Acute Ischemic Stroke - ... Acute Ischemic Stroke Objectives •Recognize the signs and symptoms of

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  • Acute Ischemic Stroke

    W. David Freeman, MD

    Professor of Neurology and Neurosurgery

    Mayo Clinic

    No conflicts of interest or disclosures

    Mayo Clinic Flagler Education Day May 3rd 2019

  • Acute Ischemic Stroke

    Yes

    Neurocrit Care. 2015 Dec;23 Suppl 2:S94-102. doi: 10.1007/s12028-015- 0159-0.

    TISSUE-BASED SELECTION (PENUMBRAL CTP IMAGING DAWN Protocol 6-24hr window)

    TIME-BASED SELECTION

    https://www.ncbi.nlm.nih.gov/pubmed/26438453

  • Acute Ischemic Stroke

    Objectives

    • Recognize the signs and symptoms of acute stroke with emphasis on the time of onset to guide therapy

    • Know the steps in pre-hospitaland 1st hour evaluation of acute stroke symptoms

    • Obtain brain imaging in determining the cause of stroke

    • Recognize Time and Tissue-based selection criteria

  • Stroke

    Clinical diagnosis

    Sudden onset of neurological deficit that can be explained by vascular cause

    Unable to distinguish between a hemorrhagic and ischemic stroke until imaging obtained

  • Prehospital Evaluation

    • Initial prehospital evaluation by EMS:

    • History & Physical

    • Determine LKW (Last Known Well) or LSN (Last Seen Normal)

    • ABC’s

    • Glucose check

    • Stroke Screen Exam

    • Obtain IV access (preferably 16-18g antecubital)

    • Call and transport to nearest Stroke Center

  • ED Evaluation

    Checklist

    ☐ Activate stroke code system (if available)

    ☐ Vital signs

    ☐ Maintain oxygen saturation >94%

    ☐ Determine time of onset / LKW

    ☐ Determine NIHSS score

    ☐ CT or other brain imaging study

    ☐ Medication list

    ☐ IV access – 18g

    ☐ Labs: capillary glucose, CBC with platelets, PT/INR, PTT, and beta-HCG

    ☐ EKG

  • Acute Ischemic Stroke

    Yes

  • Transient Ischemic

    Attack

  • ABCD2 Score

    ABCD2 Criteria Points

    Age ≥ 60 years 1

    BP ≥ 140/90 mmHg at initial evaluation 1

    Clinical Features of the TIA: • Speech Disturbance without

    Weakness, or • Unilateral weakness

    1 2

    Duration of Symptoms: • 10-59 minutes, or • ≥ 60 minutes

    1 2

    Diabetes Mellitus in Patient's History 1

  • Transient Ischemic Attack

    • Start antithrombotic agent – ASA, clopidogrel, ASA/dipyridamole • Start high-intensity statin (moderate intensity in age >75 yrs) • Carotid Imaging • Consider Transthoracic echocardiogram • Consider 30-day ambulatory cardiac monitor • Encourage smoking cessation

  • Acute Ischemic Stroke

    Yes

    TISSUE-BASED SELECTION (PENUMBRAL CTP IMAGING DAWN Protocol 6-24hr window)

  • Case

    • 79 y/o man presents to ED with:

    • Left face and arm weakness, neglect

    • Onset 1hour ago (witnessed, LSN, LKN)

    • PMH: diabetes, hypertension, sleep apnea, hyperlipidemia

    • Meds: amlodipine

    • Vitals: Afebrile; BP 184/75 mmHg; P 100/min irreg irreg rhythm; RR 18/min; O2sat 100%

    • NIHSS 20

    • General physical exam unremarkable

    • Bedside blood sugar check 120 g/dl

  • Noncontrast head CT Right MCA L.V.O. Large Vessel Occlusion

  • Contraindications for use of IV t-PA

    0-3 hrs

    AHA/ASA 2013 guidelines 2015 FDA guidelines

    Prior stroke within 3 months Removed

    Seizure at onset Removed

    Bleeding Diathesis Platelet count < 100,000/mm Abnormal PTT on heparin Anticoagulant with INR > 1.7 Current use of DOAC

    Bleeding diathesis remains a contraindication, but all laboratory values and specific examples removed

    History of ICH Warning for recent ICH

    SBP > 185/110 mmHg Remains a warning, but specific BP values removed

    Blood glucose < 50 mg/dL (2.8mmol/L)

    Removed

    Severe Stroke Removed

    Mild or rapidly improving symptoms

    Removed

    Symptoms suggestive of SAH Confirmed SAH

  • ECASSIII: IV t- PA 3.0 – 4.5

    hrs

    Additional inclusion between 3 - 4.5 hrs

    Meet all criteria of < 3 hour since onset of stroke

    Age ≤ 80 years of age

    No anticoagulant use, regardless of INR

    NIHSS ≤ 25

    No combined history of prior stroke and diabetes

  • Case

    • < 3 hours from onset

    • NIHSS 20

    • Bedside blood sugar check normal

    • Noncontrast head CT without hemorrhage

    • No contraindications

    • BP < 185/110

    Neurocrit Care. 2015 Dec;23 Suppl 2:S94-102. doi:

    10.1007/s12028-015-0159-0.

    https://www.ncbi.nlm.nih.gov/pubmed/26438453

  • IV t-PA Delivery

    Two peripheral IV lines (one for TPA, one for PRNs)

    Calculate actual body weight

    can be estimated by two experienced providers, or scale in ED minus stretcher weight

    0.9 mg/kg (MAX 90 mg)

    10% given in bolus over 1st minute

    The rest given over a 1 hour infusion

    Stop immediately if neurological deterioration

    Think hemorrhagic conversion

  • Risk of Intracerebral Hemorrhage with IV t-PA 0-3 hrs

    NIHSS Risk of ICH

    0-10 2-3%

    11-20 4-5%

    >20 17%

    The higher the NIHSS the higher the risk of ICH

  • Deterioration During or After IV t- PA

    STOP t-PA infusion

    Vital signs every 15 mins

    Consider non-invasive interventions to lower ICP (e.g., mannitol)

    Obtain STAT non-contrast CT scan

    Notify the neurosurgeon on call If not available, begin the process of transfer

    Stat Labs: PT, PTT, platelets, fibrinogen, type and cross

    Give cryoprecipitate if confirmed hemorrhage

    Consider one unit of platelets

  • Endovascular Treatment

    Intra-arterial thrombolysis or thrombectomy

    • Large vessel occlusion

    • Allows later time window of therapy up to 6 – 8 hours

    • Continually defining best patient inclusion and exclusion

    • Continually developing newer devices

    Yes

    Neurocrit Care. 2015 Dec;23 Suppl 2:S94-102. doi:

    10.1007/s12028-015-0159-0.

    TISSUE-BASED SELECTION (PENUMBRAL CTP IMAGING DAWN Protocol 6-24hr window)

    https://www.ncbi.nlm.nih.gov/pubmed/26438453

  • Thombectomy Devices

  • Trevo

  • Trevo

  • Solitaire

  • Recommendations for Thrombectomy (LVO)

    Give IV t-PA if eligible

    Endovascular Therapy indicated if the following criteria are met:

    Prestroke mRS score 0 to 1

    LVO of the ICA or proximal MCA (M1)

    Age ≥ 18 (no upper age limit)

    NIHSS ≥ 8

    ASPECTS score ≥ 6

    Groin puncture within 6 hours of LKW

  • Case • He received IV t-PA

    • CTA confirms right MCA-M1 LVO

    • He is taken for thrombectomy

  • CBF CBV

    TTP TTD MTT

    CBF= CPP/CVR Thus CBF= CBV/MTT

    Neuroimaging Clin N Am.

    2011 May ; 21(2): 259–283.

  • Pre intervention Angio

    Post intervention Angio

    Red Clot embolus

    Freeman WD, Brott TG. Neurovascular Surgery. 2nd Ed. Thieme; 2015. p. 337-350.

  • Case of Reperfusion Therapy

    • Patient NIHSS went from 20 to 3

    • Admitted to the ICU for post IV t-PA and endovascular care protocols

    Yes

  • PENUMBRA

    MCA model, CBF values = ml/100g/min

    Red= core infarct, Blue = Penumbra, Grey=normal

  • Ischemic Core

    • Nonsalvagable tissue (

  • Recent Trials: CT Penumbral Selection vs Time- Based Selection or both

    More Selective LVO

    Small core infarct

    Less Selective LVO

    MR CLEAN: 13% REVASCAT: 15% THRACE: 11%

    EXTEND-IA: 31% SWIFT PRIME: 24% ESCAPE: 25%

    Effect size

  • Late Window Treatment

    DWI/PWI and CTP Assessment in the Triage of

    Wake-Up and Late Presenting Strokes Undergoing

    Neurointervention (DAWN) Multicenter randomized controlled trial, funded by industry

    6-24 hours, NIHSS 10+ Perfusion evaluation for core volume, graded by age

    Primary outcome: 90 day mRS

    Stopped early due to pre-specified endpoint

    Endovascular Therapy Following Imaging

    Evaluation for Ischemic Stroke 3 (DEFUSE 3) Multicenter randomized controlled trial, funded by StrokeNet

    6-16 hours, NIHSS 6+ RAPID software for automated evaluation of penumbra

    Primary outcome: 90 day mRS

    Completed

    http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiyqIqRso_PAhVBPD4KHagZCdcQjRwIBw&url=http://www.kumed.com/neurosciences/stroke-center/dawn-trial&psig=AFQjCNEFQkS4cyxuZR2WNwcMSipxMtA3SQ&ust=1473960828786208 https://www.googl