K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD1 (rev. 01.18.08)

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STROKE: The Brain MattersModule I

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Prevalence and incidence: From 1970s to early 1990s, non-

institutionalized stroke survivors increased from 1.5 million to 2.4 million

On average, every 45 seconds someone in the U.S. has a stroke

Each year 700,000 people experience a new or recurrent stroke

Blacks have almost twice the risk of first-ever stroke compared with whites

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Impact of stroke

Stroke accounted for about one of every 15 deaths in the U.S. in 2003

Stroke ranks No. 3 among all causes of death 8-12% of ischemic strokes and 37-38% of

hemorrhagic strokes result in death within 30 days

Top cause of disability

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Estimated Direct and Indirect Costs of Major Cardiovascular Diseases and StrokeUnited States: 2006

Source: Heart Disease and Stroke Statistics – 2006 Update

142.5

57.9 63.5

29.6

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What is Stroke? BRAIN ATTACK Clinical diagnosis supported by testing Abrupt onset of neurologic deficit

attributable to a focal vascular cause Sudden loss of blood, with subsequent loss

of nutrients and oxygen to a part of the brain, causing cell death

Ischemic vs. Hemorrhagic

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Ischemic strokes: 80% of all strokes

Ischemic strokes occur if blood flow is blocked locally in an artery supplying the brain or if the entire circulation fails so that all organs, including the brain, are inadequately perfused

What might block a brain artery? 1. Pathology such as atherosclerotic plaque in the vessel's wall that narrows or even obliterates its lumen or produces complete collapse of the wall 2. A "plug" in its lumen formed by material carried in the blood 3. Abnormally high pressure in brain tissue surrounding the vessel that compresses its wall to the point of squeezing shut its lumen

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Ischemic stroke

Cerebral thrombosis most common and occurs in arteries narrowed by cholesterol plaque

Cerebral embolism occurs when a wandering clot or other particle forms away from the brain (usually the heart or aorta) and this clot occludes an artery leading to the brain

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Hemorrhagic stroke: 20% of all strokes

Half involve rupture of either aneurysms which initially bleed into the subarachnoid space or of arteriovenous malformations which are often located within the brain and therefore tend to bleed into the brain itself.  Both of these pathologies are thought to be the consequence of developmental abnormalities and are characterized by thinned vascular walls

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Intracerebral Hemorrhage Caused by rupture of the walls of small penetrating

arteries serving deep structures, with bleeding directly into the brain and its ventricles

These vessels are at particular risk because of their thin muscular walls and narrow lumens.  It is thought that the cumulative effects of untreated hypertension and atherosclerosis or other kinds of pathologic changes weaken their walls and put them at special risk for rupture

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Lobar hemorrhages Small arteries supplying the superficial regions of

the cerebral hemispheres may develop deposits of an abnormal protein called amyloid in the extremely elderly

In some cases, this material can weaken the walls of these vessels to the extent that they rupture and cause hemorrhages in the superficial regions of the hemispheres 

Unlike the intracerebral hemorrhages involving midline penetrating vessels, superficial lobar hemorrhages can occur in individuals who have had normal blood pressure throughout

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Transient Ischemic Attack (TIA) Symptoms and causes similar to stroke Important RISK FACTOR; about 15% of all

strokes are heralded by a TIA TIAs are produced by transient blockage of the

cerebral or retinal circulation. Typical duration of symptoms is 5-15 minutes

By definition, neurologic deficits that resolve in <24 hours

Evaluation parallels that of stroke

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Risk factors for stroke after TIA

Age over 60 years Diabetes mellitus Symptom duration more than 10 minutes Residual weakness or speech disturbance

N Eng J Med 4/17/03

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Brain anatomy:

www.tbts.org/assets/ images/brainmap.gif

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Different parts of the brain: Cerebrum ~ The cerebrum (supratentorial or front of brain) is

composed of the right and left hemispheres. Functions of the cerebrum include: initiation of movement, coordination of movement, temperature, touch, vision, hearing, judgment, reasoning, problem solving, emotions, and learning.

Brainstem ~ The brainstem (midline or middle of brain) includes the midbrain, the pons, and the medulla. Functions of this area include: movement of the eyes and mouth, relaying sensory messages (hot, pain, loud, etc.), hunger, respirations, consciousness, cardiac function, body temperature, involuntary muscle movements, sneezing, coughing, vomiting, and swallowing.

Cerebellum ~ The cerebellum (infratentorial or back of brain) is located at the back of the head. Its function is to coordinate voluntary muscle movements and to maintain posture, balance, and equilibrium.

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More specific areas of the brain: Pons ~ A deep part of the brain, located in the brainstem, the pons contains many of

the control areas for eye and face movements.

Medulla ~ The lowest part of the brainstem, the medulla is the most vital part of the entire brain and contains important control centers for the heart and lungs.

Frontal lobe ~ The largest section of the brain located in the front of the head, the frontal lobe is involved in personality characteristics and movement.

Parietal lobe ~ The middle part of the brain, the parietal lobe helps a person to identify objects and understand spatial relationships (where one's body is compared to objects around the person). The parietal lobe is also involved in interpreting pain and touch in the body.

Occipital lobe ~ The occipital lobe is the back part of the brain that is involved with vision.

Temporal lobe ~ The sides of the brain, these temporal lobes are involved in memory, speech, and sense of smell.

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Cerebrovascular circulation

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Stroke Symptomso Sudden numbness or weakness of face, arm or leg

especially on one side of the body

o Sudden confusion, trouble speaking or understanding

o Sudden trouble seeing in one or both eyes

o Sudden trouble walking, dizziness, loss of balance or coordination

o Sudden severe headache with no known cause

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Neurologic symptoms of occluded vessels will vary depending on location

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Vessels typically effected and an overview of possible symptoms

Middle cerebral artery

Vertebrobasilar artery

Anterior cerebral artery

Posterior cerebral artery

Carotid artery

Aphasia, visual field defects, hemi paresis, hemiplegia, hemi sensory loss, inattention, apraxia.

Diplopia, dysarthria, ataxia, poor motor coordination, vertigo, nausea/vomiting.

Personality changes, confusion, weakness usually> distally, hemiplegia.

Cortical blindness, dyslexia, visual field defects if occipital.

Altered level of consciousness, weakness, numbness.

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American Heart Association’s 7 “D’s” of Stroke Care

Detection, early recognition of the signs and symptoms and determination of onset time. If the patient awakened with signs and symptoms of a stroke, the onset time is considered the last time he was seen awake without them.

Dispatch, rapidly getting the patient emergency medical care.

Delivery, transporting him to the nearest stroke center or a hospital capable of following the latest stroke guidelines.

Door, rapid triage in the ED.

Data, documenting or collecting information about the patient's history, lab work, imaging studies, examinations, physical assessments, and time of onset of signs and symptoms. Needs to undergo a noncontrast computed tomography (CT) scan of the brain within 25 minutes of arrival at the ED, and it must be interpreted within 45 minutes of arrival to determine if an acute ischemic stroke occurred.

Decision, answering the inclusion and exclusion criteria for t-PA therapy and reviewing treatment options with the patient and family.

Drug, starting t-PA treatment within 3 hours of onset of symptoms if all conditions are met; Nursing care at the door.

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Diagnostics Lab work: Complete blood cell count, glucose

and electrolyte levels, renal and liver function studies, prothrombin and partial thromboplastin times, and cardiac biomarkers

12-lead electrocardiogram

CT of brain (w/angiography IF indicated and does not delay administration of t-PA)

CT of brain with angiography

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Timing is critical!!Three (3) hour window of time to receive

acute treatment for ischemic stroke.

ED Ischemic stroke pathway:

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t-PA (Tissue Plasminogen Activator) Inclusion / Exclusion Criteria

Inclusion Criteria: Clinical diagnosis of stroke Age 18 or older Time of stroke onset (i.e. last time pt witnessed to be well) < 3 hours BP Systolic <= 185, diastolic <= 110 (can receive 1-3 doses of BP agent for control) Pro time <= 15 seconds or INR <= 1.7 Platelet count >= 100,000 Blood Glucose => 50 and <= 400 mg/dl Exclusion Criteria: Minor stroke or rapidly resolving stroke Seizure at onset of stroke Heparin treatment during the past 48 hours with an elevated PTT Evidence of acute myocardial infarction Exclusion Criteria (Relative Contraindications): History of prior intracranial hemorrhage, neoplasm, AVM or aneurysm Major surgical procedures within 14 days Stroke or serious head injury within 3 months Gastrointestinal or urinary bleeding within last 21 days Lactation or Pregnancy within 30 days

Modified from NINDS criteria

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t-PA dose and administrationTissue Plasminogen Activator (t-PA)

Alteplase (Activase®)

Drug class = Fibrinolytic used to treat acute ischemic stroke. Clot-specific binding to fibrin-bound plasminogenallowing conversion to plasmin, which digests the fibrin.

Onset of action occurs in 60-90 minutes.

LOADING dose = 0.09 mg/kg IV push over 1 minute (dose not to exceed 9 mg)

Followed by: INFUSION dose = 0.81 mg/kg IV infusion over 1 hour (dose

not to exceed 81 mg)

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Order sets used by the ED:

Link: ??

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Post-thrombolytic order set Key issues: ASA, heparin, Coumadin

contraindicated up to 24 hrs. after t-PA administered

NPO until swallow evaluated

Assess for changes in neuro status that may indicate post t-PA complication of bleeding

Assess any other abnormal bleeding

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Other ED pathways: TIA and Hemorrhagic

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Stroke Patient Placement Patient placement is planned with use of

designated stroke unit beds unless other factors determine otherwise

After t-PA, patients are monitored in CICU 18-24 hrs (or SCU). If stable, they are then transferred to P3CD (R4, if tele needed)

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Stroke Bed Aggregation:

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Act F.A.S.T.If you think someone may be having a stroke, act F.A.S.T. and do thissimple test:

FACE    Ask the person to smile.Does one side of the face droop?

ARMS    Ask the person to raise both arms.Does one arm drift downward?

SPEECH  Ask the person to repeat a simple sentence.Are the words slurred?  Can he/she repeat the sentence correctly?

TIME    If the person shows any of these symptoms, time is important. 

Call 911 or get to the hospital fast. Brain cells are dying. TIME LOST IS BRAIN LOST!

NINDS