The Continuum of Stroke Care

Transcript

1 The Continuum of Stroke Care 1

2 NINDS TPA Stroke Study: Time to Treatment e Odds Ratio per Outcome Favorevole 8 Odds Ratio Outcome Favorevole Benefit for rt-pa No Benefit for rt-pa TIME IS BRAIN!!! m Minuti Inizio dei sintomi - Inizio del trattamento

3 Ictus acuto: Fase di ricovero Grado A L ictus è una urgenza medica che merita un ricovero immediato in ospedale come suggerito dal documento di Helsingborg e da molte linee guida. Il paziente con ictus va sempre ricoverato perché è solo con gli accertamenti eseguibili in regime di ricovero che si può rapidamente diagnosticare sede, natura ed origine del danno cerebrale, oltre che evidenziare e curare eventuali complicanze cardiache, respiratorie e metaboliche.

4 Emergency start at community level: Prehospital care Acute stroke is emergency condition regardless of severity of neurological deficit The priority is the same level as MI, serious trauma Transfer the patients to hospital in the shortest time possible ASA Guidelines. Stroke

5 Prehospital management of potential stroke patients Recommended Assess & manage ABC Initiate cardiac monitoring Supplement O 2 to maintain O 2 saturation > 94% Establish IV access Determine blood glucose and treat accordingly ASA Guidelines. Stroke

6 Prehospital management of potential stroke patients Recommended Determine time of symptom onset or last known normal Rapidly transport patient to nearest most appropriate hospital Notify hospital of pending stroke patient arrival ASA Guidelines. Stroke

7 Action Emergency Department Based Care Time Door to physician 10 minutes Door to stroke team 15 minutes Door to CT initiation 25 minutes Door to CT interpretation 45 minutes Door to drug (rtpa) 60 minutes Door to stroke unit admission 3 hours ASA Guidelines. Stroke

8 Management of acute ischemic stroke ABCs Diagnosis & differential diagnosis General management Acute specific treatment Treatment of neurological complication 8

9 Management of acute ischemic stroke ABCs Diagnosis & differential diagnosis General management Acute specific treatment Treatment of neurological complication 9

10 Acute ischemic stroke Diagnosis Sudden onset, focal deficit, risk factors Investigation Brain imaging (CT/ MRI) Blood glucose Oxygen saturation BUN/ Creatinine/ Electrolytes CBC Prothrombin time, INR aptt Cardiac test Others 10

11 Differential diagnosis: Condition mimicking stroke Psychogenic Seizure Hypoglycemia Migraine with aura Hypertensive encephalopathy Wernicke s encephalopathy CNS abscess CNS tumor Drug toxicity 11

12 Management of acute ischemic stroke ABCs Diagnosis & differential diagnosis General management Acute specific treatment Treatment of neurological complication 12

13 Acute ischemic stroke General management Airway, Breathing, Circulation Fever Blood glucose Hypertension IV fluid Treatment of underlying diseases 13

14 Hypertension DBP > 140 mmhg X 2 5 min apart Sodium nitroprusside µg/ kg/ min IV Nitroglycerine 5 mg IVand 1-4 mg/ h SBP > 220 mmhg, DBP mmhg X 2 20 min apart Captopril mg oral Nicardipine 5-15 mg/ hr IV drip Labetalol 10 mg IV in 1-2 min q min if need OR 2-8mg/ min IV drip Nitroglycerine patch Do not use Nifedipine sublingual 14

15 Management ischemic stroke ABCs Diagnosis & differential diagnosis General management Acute specific treatment Treatment of neurological complication 15

16 Acute ischemic stroke 16

17 Intravenous thrombolysis FDA approved 1996 based on NINDS rt- PA Stroke Study Treatment within 3 hours of symptom onset Complete neurological improvement or improvement >= 4 points on NIHSS at 24 hours Complete or nearly complete recovery at 3 months Symptomatic brain hemorrhage is major risk (6.4% VS 0.6%) 17

18 Intravenous thrombolysis Presence of brain edema, mass effect associated with hemorrhage NIHSS < 20, age < 75 years had greatest possibility for good outcome NIHSS >22 had very poor prognosis whether or not rt-pa Low attenuation > 1/ 3 of MCA territory less likely to had good outcome Good response were highest among patients with NIHSS <10 normal baseline CT 18

19 Exclusion criteria Patients with ischemic stroke within 3 hours who could be treated with rt-pa 1. Significant head trauma or prior stroke in previous 3 months 2. Symptoms suggest SAH 3. Arterial puncture at non compressible site in previous 7 days 4. History of previous intracranial hemorrhage 5. Intracranial neoplasm, AVM, or aneurysm 6. Recent intracranial or intraspinal surgery ASA Guidelines. Stroke

20 Exclusion criteria Patients with ischemic stroke within 3 hours who could be treated with rt-pa 7. Elevated BP (systolic > 185 or diastolic >110 mmhg) 8. Active internal bleeding 9. Acute bleeding diathesis, including but not limited to platelet < 100,000 /mm Heparin received within 48 hours, resulting in elevated aptt 11. Current use of anticoagulant with INR > 1.7 0r PT >15 seconds ASA Guidelines. Stroke

21 Patients with ischemic stroke within 3 hours who could be treated with rt-pa Exclusion criteria 12. Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (ie. aptt, INR, platelet count, ECT, TT or appropriate factor Xa activity assay) 13. Blood glucose concentration < 50 mg% 14. CT shows multilobar infarction (hypodensity > 1/3 cerebral hemisphere) ASA Guidelines. Stroke

22 Patients with ischemic stroke within 3 hours who could be treated with rt-pa Relative exclusion criteria* 1. Only minor or rapid improving stroke symptoms 2. Pregnancy 3. Seizure at onset 4. Major surgery or serious trauma within previous 14 days 5. Recent GI or Urinary tract hemorrhage within previous 21 days 6. Recent acute MI within previous 3 months *Patients may received rtpa despite 1 or more relative contraindication, consider risk to benefit carefully ASA Guidelines. Stroke

23 Additional criteria for patients with ischemic stroke within hours Inclusion criteria 1. Measurable neurological deficit 2. Onset of symptoms within hours ASA Guidelines. Stroke

24 Additional criteria for patients with ischemic stroke within hours Relative exclusion criteria 1. Age > 80 years 2. Severe stroke (NIHSS > 25) 3. Taking an oral anticoagulant regardless of INR 4. History of both DM and prior ischemic stroke 5. Ischemic injury > 1/3 of MCA territory ASA Guidelines. Stroke

25 Regimens for IV rt-pa treatment Infusion 0.9 mg/ kg (max 90 mg) over 1 hour, 10 % of the dose given as bolus dose over 1 minute Admit to stroke unit If severe headache, acute hypertension, nausea, vomiting, or worsening neurological signs, discontinue infusion, and emergency CT brain BP measurement & Neurological assessments every 15 minutes during & after infusion for 2 hours every 30 minutes next 6 hours every hour until 24 hours 25

26 Regimens for iv rt-pa treatment If BP S > 180 mmhg or BP D > 105 mmhg, increase frequency of BP measurement, administer antihypertensive drugs to maintain BP at or below this level Delayed placement of NG tube, bladder catheters, intra- arterial catheters Anticoagulants and antiplatelet agents should be delayed for 24 hours after treatment 26

27 Regimens for iv rt-pa treatment Obtain a follow-up CT or MRI at 24 hours after IV rtpa before starting anticoagulants or antiplatelet agents Staffs, CT, Neurosurgeon, Laboratory test available 24 hours Cryoprecipitate or fresh frozen plasma, platelet concentration 27

28 Acute Care in Ischemic Stroke Intravenous fibrinolytic therapy is recommended in the setting of early ischemic changes (other than frank hypodensity) on CT, regardless of their extent (IA) revised from previous recommendation in 2009 Frank hypodensity on non-contrasted CT may increase the risk of hemorrhage with fibrinolysis & should be considered, If frank hypodensity involves > 1/3 of MCA territory, IV rtpa should withheld (IIIA) revised from previous recommendation in 2009 ASA guidelines, Stroke 2013; 44: xxx- xxx (published online Jan 31, 2013) 28

29 Acute Care in Ischemic Stroke IV-rtPA (0.9mg/kg, max dose 90 mg) is recommended for selected patients who may be treated within 3 hours of onset (IA) In patients eligible for IV-rtPA, treatment with rtpa should be initiated as quickly as possible, door-to-needle time should be with in 60 minutes (IA) revised from previous recommendation in 2009 ASA guidelines, Stroke 2013; 44: xxx- xxx (published online Jan 31, 2013) 29

30 Acute Care in Ischemic Stroke IV-rtPA (0.9mg/kg, max dose 90 mg) is recommended for administration to eligible patients with hours after stroke onset (IB) Additional exclusion criteria: Age > 80 years Taking oral anticoagulants Baseline NIHSS score > 25 Imaging evidence of ischemic injury > 1/3 of MCA territory History of both stroke and DM revised from previous recommendation in 2009 ASA guidelines, Stroke 2013; 44: xxx- xxx (published online Jan 31, 2013) 30

31 Treatment of neurological complication Cerebral edema and increased intracranial pressure Seizures Hemorrhagic transformation 31

32 Conclusions Acute stroke is an emergency condition, is the same level as MI, serious trauma Emergency management is need rt-pa & Stroke unit, are the major advances Appropriate general care are also need To improve the quality of care : Multidisciplinary/ network approach CQI activities are very importance 32

33 Stroke Team Ictus acuto Sommario dei compiti diagnostica clinica diagnostica neuroradiologica diagnostica per ultrasuoni valutazione cardiovascolare assessment delle funzioni vitali interventi terapeutici primari

34 K values and item reliability for NIHSS Stroke 2002 NIHSS Item Name Comparison per item, n Weighted Value 95% CIs 1a LOC * b LOC questions * c LOC commands * Gaze * Visual fields * Facial palsy * a Left arm motor * b Right arm motor * a Left leg motor * b Right leg motor * Limb ataxia * Sensory * Language * Dysarthria Neglect * Total *

35 Ulteriori aspetti rilevanti sul piano diagnostico e prognostico Definizione del sottotipo patologico di ictus: aterotrombotico, cardioembolico, lacunare, altre cause Quadri neurologici selettivi

36 STROKE TEAM AOU Careggi Definizione (Delibera Aziendale Dic 2003) Gruppo multiprofessionale (neurologo, cardiologo, internista, neuroradiologo, chirurgo vascolare, infermiere professionale) motivato e addestrato per la gestione del paziente con ictus cerebrale acuto [ ] lo stroke team viene attivato dai medici del DEA in pazienti affetti da ictus che arrivano entro 3 ore dall esordio dei sintomi, salvo estensione della finestra terapeutica in casi selezionati.

37 codice rosso Percorso del paziente con ictus acuto Medico DEA Lettura TAC Doppler/angioTC Prelievo? Attiva NR Attiva TAC Criteri incl/escl internistici Inizio TAC Fine TAC Prende visione risultato TAC NIHSS TEA CV 118 Preallarme DEA infermiere paziente prelievo Attiva team < 3 ore esordio sintomi Risultato prelievo team Prende visione risultato prelievo Controllo criteri incl/escl Richiede consenso Doppler/angioTC TS TLR SU SU/ TINC terapia Tempo dall arrivo in DEA (minuti) Legenda: NR: neuroradiologo; TEA: tromboendarterectomia; TS: trombolisi sistemica; TLR: Trombolisi locoregionale; CV: chirurgia vascolare; SU: Stroke Unit; TINC: Terapia intensiva neurochirurgica 90

38 Selezione dei vari trattamenti nei pazienti con ictus acuto entro 4 ore (tra 3 e 4 ore studio ECASS III) tra 4 e 6 ore oltre le 6 ore NIHSS < 6 Ecodoppler carotidi + TCD o angiotc NIHSS tra 6 e 25 NIHSS > 25 Valutare per trombolisi sistemica (TS) (protocollo SITS-MOST) Valutare per trombolisi locoregionale (TLR) NIHSS > 6 con prognosi funzionale grave valutazione per TLR solo nel sospetto di occlusione dell arteria basilare/vertebrale Stenosi carotidea significativa no STOP si Controindicazione alla TS secondo i criteri SITS-MOST no Controindicazioni assolute alla TLR no Angio-TC si STOP si Controindicazioni alla TEA no TS Occlusione vascolare utilmente trattabile con TLR (carotide interna, cerebrale media, vertebrale e basilare) no si TEA STOP Valutazione controindicazioni relative TLR

39 Flessibilità dell approccio endovascolare Differenziare la terapia a seconda del tempo di ischemia, sede e tipo di occlusione, fattori di rischio emorragico Terapia farmacologica Terapia meccanica Terapia combinata Flessibilità dell intervento endovascolare

40 American Accademy of Emergency Medicine Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke having an expert in neuroradiology read the CT scan first, having a neurologist directly involved

41 30 days risk adjusted fatality by organized care index in patients with moderate/severe stroke (CNS score <7). The organized care index (OCI) was classified as having received 0, 1, 2, or 3 of the following services: occupational therapy or physiotherapy, stroke team assessment, or admission to a stroke unit. Saposnik G et al. Stroke 2009;40:

42 General ward care with team support versus dedicated SU Care. 164 pts with moderately severe large vessel occlusion stroke randomly allocated to. Major 3 month outcomes. OR (C.I.) Death 5.0 ( ) Death or institutionalization 3.5 ( ) Rankin s score ( ) Barthel Index < ( ) Andrew E el al, Stroke 2002