gemc: stroke management in the 21st century: what do you need to know?: resident training
TRANSCRIPT
Project: Ghana Emergency Medicine Collaborative Document Title: Stroke Management in the 21st Century: What Do You Need to Know? Author(s): Rashmi Kothari (Michigan State University), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
1
Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy
Use + Share + Adapt
Make Your Own Assessment
Creative Commons – Attribution License
Creative Commons – Attribution Share Alike License
Creative Commons – Attribution Noncommercial License
Creative Commons – Attribution Noncommercial Share Alike License
GNU – Free Documentation License
Creative Commons – Zero Waiver
Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ
Public Domain – Expired: Works that are no longer protected due to an expired copyright term.
Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105)
Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain.
Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ
Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair.
To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
{ Content the copyright holder, author, or law permits you to use, share and adapt. }
{ Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. }
{ Content Open.Michigan has used under a Fair Use determination. }
2
!"#$%&$'($)*+($*,&-.$/.+&0(1$
• 2"3+%$4(*%356$)*-/($&7$%(*."$• 8(*%356$)*-/($&7$*%-4.$%3/*,343.#$• 9:;<:=$>&+.*43.#$
3
23//-(;C4*/>35&6(5$D)BE*.&+$35$
D)-.($A/)"(>3)$F.+&0($
• G&-,4(;,435%(%$• C4*)(,&$)&5.+&44(%$• :HI>6J06$
• K9L$M*B(5./$• 2+(*.(%$'3."35$<$"&-+/$
– NJ9$'3."35$I:$>35-.(/$
– NJ9$'3."35$IN;NO:$>35-.(/$
• L$P-.)&>($>(*/-+(/$
5 Reference: Tissue Plasminogen Activator for Acute Ischemic Stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group N Engl J Med 1995; 333:1581-1588. http://www.nejm.org/doi/full/10.1056/NEJM199512143332401.
QAQGF$+.;CD$F.+&0($2+3*4$R(/-4./$
• <:=$>&+($430(4#$.&$"*E($7*E&+*,4($<;>&5."$&-.)&>($
– !"#$SNH9;9HITUP%%/$R*B&$S:;I:$>35-.(/T$ $$
– !"$$SNH<;9HITUP%%/$R*B&$SIN;NO:T$$>35-.(/T$ $$
• F3653V)*5.4#$"36"(+$35.+*)(+(,+*4$"(>&++"*6($+*.($
– %"&=$C4*)(,&$– &"'=$+.;CD$
• Q&$%3W(+(5)($35$>&+.*43.#$
– (!=$C4*)(,&$– !$=$+.;CD$
6
23>($.&$2+(*.>(5.$
• )*+,-*U$$$$."(+*M(-B)$ $
$$$$$$$$$$'35%&'$
• ."$*+,-*U$>(%3*5$B>($.&$
$$$$$$$$$$XG$*++3E*4$
• )"&/*U$$$$=$.+(*.(%$35$ $$$$$$$$$$$QAQGF$SK9L$&7$ $$$$$$$$$$
NYZ<9LT$
Retro00064. Wikimedia Commons 7
F.+&0($@"*35$&7$F-+E3E*4$[$R()&E(+#$
• G(.()B&5\$X*+4#$R()&653B&5$• G3/M*.)"\$X*+4#$X?F$D)BE*B&5$
• G(43E(+#\$2+*5/M&+.$[$?*5*6(>(5.$
• G&&+\$XG$2+3*6($• G*.*\$XG$XE*4-*B&5$[$?*5*6(>(5.$
• G()3/3&5\$FM()3V)$2"(+*M3(/$• G+-6\$2"+&>,&4#B)$[$Q(-+&M+&.()BE($2"(+*M#$
9
G(.()B&5$
• !"*.$*+($F365/$[$F#>M.&>/1$
– L<=$6(5(+*4$M-,43)$%3%5’.$05&'$*5#$– <I=$&7$*)-.($/.+&0($M*B(5./$%3%5’.$05&'$*5#$
• !"*.$*+($R3/0$]*).&+/1$
– <9=$6(5(+*4$M-,43)$%3%5’.$05&'$*5#$– L<=$&7$*)-.($/.+&0($M*B(5./$%3%5’.$05&'$*5#$
Pancioli JAMA 1998;279 Kothari Stroke 1997;28 10
!"*.$%&$#&-$5((%$.&$05&'$*,&-.$/.+&0(1$
• F365/$[$F#>M.&>/$
– &5(;/3%(%$(^.+(>3.#$
'(*05(//$
– &5(;/3%(%$5->,5(//$
– %3_)-4.#$/M(*0356$
– E3/-*4$M+&,4(>/$
• R3/0$]*).&+/$– "#M(+.(5/3&5$– %3*,(.(/$>(443.-/$
– />&0356$
– "(*+.$%3/(*/($– M+3&+$/.+&0(/$– &4%(+$*6($– +*)($SD7+3)*5;D>(+3)*5/T$
11
@35)355*B$C+("&/M3.*4$F.+&0($F)*4($
Facial Droop
Normal: Both sides of face move equally Abnormal: One side of face does not move at all
Arm Drift
Normal: Both arms move equally or not at all Abnormal: One arm drifts compared to the other
Speech
Normal: Patients use correct words with no slurring Abnormal: Slurred or inappropriate words or mute
Shantoo, Wikimedia Commons
Gonad, Wikimedia Commons
St Bartholomew's Hospital Archives & Museum, Wellcome Images
12
`(5(+*4$C-,43)/’$C(+)(MB&5$&7$!"*.$.&$%&$35$
@*/($&7$*$F.+&0($
• I:=$'&-4%$/((0$>(%3)*4$*a(5B&5$
– L<=$)*44$INN$3>>(%3*.(4#$
– 9K=$)*44$."(3+$7*>34#$%&).&+$
– NN=$6&$/.+*36".$.&$."($XG$
NSA/Gallop Poll 1996 14
A53B*4$?(%3)*4$@&5.*).$E(+/-/$23>($&7$XG$
D++3E*4$
2.61.4
6.3
4.55.6
3.5
01234567
911 Private MD ED
MeanMedian
Ons
et to
ED
Arr
ival
(hou
rs)
Barsan Arch Intern Med. 1993 15
G(43E(+#\$2+*5/M&+.$[$?*5*6(>(5.$
• Db@/$• F.+&0($+()&653B&5$• 23>($&7$&5/(.$
• Q(-+&4&63)*4$(E*4-*B&5$• @"()0$64-)&/($• X*+4#$"&/M3.*4$5&BV)*B&5$• R*M3%$2+*5/M&+.cccccc$
EyOne, Wikimedia Commons 16
X>(+6(5)#$G(M*+.>(5.$?*5*6(>(5.$
• G&&+\$XG$2+3*6($• G*.*\$XG$XE*4-*B&5$$• G()3/3&5\$FM()3V)$2"(+*M3(/$• G+-6\$2"+&>,&4#B)$2"(+*M#$
Russell Lee, Wikimedia Commons 17
X^)4-/3&5$@+3.(+3*$
• 01-23*4)*+56,-*• 784!9.:!!%*• d(>&++"*6($&5$@2$
• ;2<=6,2*>3*51-23$• F-+6(+#$NL$%*#/$• 2+*->*$<$>&5."/$
• F.+&0($$<$>&5."/$
• ?353>*4$&+$+(/&4E356$
/#>M.&>/$
• `AJ`e$,4((%$9N$%*#/$• C+3&+$A@d$&+$FDd$• ?2@213*AB*• P5$@&->*%35$C2fNHg$
• 01*+2C>,<1*8DD4(!$• C4*.(4(./$hN::Z:::$• EF6@5-2*4'%%$
22
G&/356$
• :HI$>6J06$S>*^HUI:$>6T$
• N:=$,&4-/$S&E(+$N$>35-.(T$
• N$"&-+$357-/3&5$
Mass Communication Specialist Seaman Andrew Skipworth, Wikimedia Commons 24
C*B(5.$?&53.&+356$
• A@e$*%>3//3&5$S9L$"&-+/T$
• Q(-+&$)"()0/$$– j$Ng$>35-.($k$K$"&-+/$
– j$N$"&-+$k$NO$"&-+/$• bC$)"()0/$$
25
b4&&%$C+(//-+($?*5*6(>(5.$
• Q&5;2"+&>,&4#B)$@*5%3%*.(/$
• 2"+&>,&4#B)$@*5%3%*.(/$
– M+(;.+(*.>(5.$SNOgJNN:$>>d6T$
– %-+356$[$M&/.;.+(*.>(5.$
26
bC$?*5*6(>(5.$
• Q&5;2"+&>,&4#B)$@*5%3%*.($
– G&5’.$2+(*.ccc$• C+(;2"+&>,&4#/3/$
– b($`(5.4(ccc$• G-+356$[$C&/.;2"+&>,&4#/3/$
– b($D66+(//3E(ccc$
27
QAQGF;R()&>>(5%(%$2*+6(./$
• G&&+;.&;%&).&+ $ $ $N:$>35-.(/$
• G&&+;.&;@2$ $ $ $$$$$$9g$>35-.(/$
• G&&+;.&;@2$+(*%356 $$$$$$Lg$>35-.(/$
• G&&+;.&;.+(*.>(5. $ $K:$>35-.(/$
28
F.+&0($@"*35$&7$F-+E3E*4$[$R()&E(+#$
• G(.()B&5\$X*+4#$R()&653B&5$• G3/M*.)"\$X*+4#$X?F$D)BE*B&5$
• G(43E(+#\$2+*5/M&+.$[$?*5*6(>(5.$
• G&&+\$XG$2+3*6($• G*.*\$XG$XE*4-*B&5$[$?*5*6(>(5.$
• G()3/3&5\$FM()3V)$2"(+*M3(/$• G+-6\$2"+&>,&4#B)$[$Q(-+&M+&.()BE($2"(+*M#$
29
<;?&5."$]*E&+*,4($P-.)&>($
31
20
0 10 20 30 40
rt-PA
Placebo
Number of Patients ((N Engl J Med 1995:333) 30
A@d$G(*."/$*5%$?&+.*43.#$
0 5 10 15 20 25
rt-PA
Placebo
ICH DeathsMortality
21
17 3
0.3
Number of Patients (N Engl J Med 1995:333) 31
b*/(435($QAdFF$*5%$A@d$35$."($QAQGF$2+3*4$
2 35 4
17
02468
1012141618
0-5 6-10 11-15 16-20 >20
Baseline NIH Stroke Scale Score
Percentage of t-PA Patients with Symptomatic ICH
(Broderick, Stroke 1997) 32
G3/M&/3B&5$R(/-4./$7+&>$QAQGF$2+3*4$
rt-PA n=312
Placebo n=312
p Value
LOS (mean days +SD)
10.88+10.04 12.41+11.10 0.02
Disposition 0.002*
Home 151 (48%) 112(36%)
Rehab unit 91 (29%) 115 (37%)
Nursing home 22 (7%) 39 (13%)
Dead 35 (11%) 40 (13%)
Other 13 (4%) 6 (2%)
* compared home to all other dispositions Neurology 1998;50 33
X^.(5%356$."($2"(+*M(-B)$!35%&'$
! ! "#$%&'(!
)*'&+$,-!
./0!
12'34!
5&6$789$2!
)*'&+$,!
:;<:=;.>! !"#$
%&'()*+$
))?!
))?!
@4A?B!
C4C?B!
CD4E?!
@4E?!
F/:>>! !"#$
%&'()*+$
)@?!
GE?!
GD?B!
A?B!
CH?B!
C)?B!
F/:>>!..! !"#$
%&'()*+$
ID4)?!
)@4@?!
H4H?B!
)4I?B!
CD4J?!
CD4A?!
§ % mRankin 0-1 for ECASS I & II, NIHSS<1 for ALANTIS at 3-months 34