Stroke fast track and Stroke fast track and complicationscomplications

Khwanrat Wangphonphatthanasiri,MDKhwanrat Wangphonphatthanasiri,MD

When cerebral artery occlude

DWI and ADC map demonstrate an area of diffusion restriction in the right MCA territory consistent with acute infarction.CBF and MTT map (PWI) demonstrate the infarct penumbra which is larger than the core, indicating the presence of salvageable tissue.CBV map (PWI) demonstrates infarct core which is slightly smaller than the area of diffusion restriction. 

Patient imaged pre-tPA treatment at 1.5 hours, with large left MCA occlusion (MRA), and a penumbral pattern with a large PWI lesion and small DWI lesion. Subacute studies post- tPA (day 5) show recanalisation, reperfusion and minimal expansion of the infarct core on DWI.

Intravenous Thrombolytic TherapyIntravenous Thrombolytic Therapy

• National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study ( NINDS rt-PA Stroke Study)

• European Cooperative Acute Stroke Study ( ECASS I, ECASS II,)

• Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS trial)

Administration of Administration of rrtPA tPA (Protocol Guidelines(Protocol Guidelines))

I. Inclusion criteria

Age 18 years or older

Signs of a measurable neurologic deficit from

an ischemic stroke on examination

Time of onset < 3 hours

Exclusions to ThrombolyticsExclusions to Thrombolytics• Stroke or head trauma in 3 mo• Major surgery within 14 day

s • Any history of intracranial h

emorrhage • SBP > 185 mm Hg • DBP > 110 mm Hg • Rapidly improving or minor

symptoms • Symptoms suggestive of sub

arachnoid hemorrhage • Glucose < 50 or > 400 mg/d

l

• GI hemorrhage within 21 days • Urinary tract hemorrhage within 2

1 days • Arterial puncture at non-compress

ible site past 7 days • Seizures at the onset of stroke • Patients taking oral anticoagulants • Heparin within 48 hours and elev

ated PTT • PT >15 / INR >1. 7• Platelet count <100,000

rrttPA Treatment Based on CT FinPA Treatment Based on CT Findingsdings

• CT Findings  • None • Subtle < 1/3 MCA • Subtle > 1/3 MCA • Hypodensity < 1/3 MC

A • Hypodensity > 1/3 MC

A

Recommendations

>>Treat

>>Treat

>>Probably treat

>>Probably treat

>>Don’t treat

NINDS rtPA Stroke StudyNINDS rtPA Stroke Study

• 31 to 50% had a complete or near-complete recovery at three months, as

• compared with 20 to 38 %of the patients given placebo

• Motarity rate was similar at one year• Symptomatic brain hemorrhage, which occurre

d in 6.4 percent of the patients given t-PA, as compared with 0.6 percent of those given placebo ( 36 hrs)

N Engl J Med 1995;333:1581-1587

Factors Associated Factors Associated with Increased Risk of ICHwith Increased Risk of ICH

• Treatment initiated > 3 hours

• Increased thrombolytic dose

• Elevated blood pressure

• NIHSS > 20 *

• Acute hypodensity or mass effect

Modified Rankin Scale scores at 3 and 12 months in patients treated in Cologne compared with patients from the NINDS rtPA Stroke Trial placebo and treatment groups (3 and 12 months) and with the ECASS I and ECASS II 3 h rtPA cohorts (3 months).

• Stroke is a "Brain Attack"

• Stroke is an emergency!

• Time is brain

Onset Emergency Room

Stroke Fast Track; Treatment

Stroke Unit vs

General neurological ward or General ward

Home, Home care, …

By ?

Time frames NINDS times(min)

Time to first physicianTime to CTTime to LabTime to CT resultTime to Lab resultTime to Treatment (rtPA cases)Time to Monitor bed (rtPA cases)

1025

N/A45

N/A60

180

Consensus time-framesConsensus time-frames criteriacriteriafor effective hospital stroke response system by for effective hospital stroke response system by

National Institute of Neurological Disorders & StrokeNational Institute of Neurological Disorders & Stroke

Rapid Identification and Treatment of Acute Stroke. Arlington, VA.

National Institute of Neurological Disorders and Stroke; 1997

GUIDELINE OF ACUTE ISCHEMIC STROKE TREATMENT BY INTRAVENOUS THROMBOLYTIC

SUSPECTED ISCHEMIC STROKE ONSET WITHIN 3 hrs

ER NURSE ASSESSMENT

1.Sudden of either weakness, numbness, paralysis of the face, arm or leg, especially on one side of the body.

2. Confusion, trouble speaking or understanding

3. Loss of vision in one or both eyes

4. Trouble walking, dizziness, loss of coordination of balance, especially if combined with other signs

Notify Neurologist

CHECK V/S, N/S and basic life support, stool occult blood ,blood examination Coagulogram, Electrolyte ,CBC, BS, BUN,Cr, (Blood Clot 1 tube)

Notify CT

Contract SU

Non contrast CT

NON HEMORRHAGE

HEMORRHAGE

Consult neuro-

Surgeon

SU; Neurologist & Nurses 1. Thrombolytic check lists2. Consent form resident / Staff neurology 3. Notify neurosurgeon before start intravenous Thrombolytic

Step by step for rtPAStep by step for rtPA

Step 1 – Screening at ER by NurseStep 2 – Clinical; Lab Screening by

doctorStep 3 – IV Thrombolysis Step 4 – Post Thrombolysis care (24

hrs; > 24 hrs)

Step 1 – Screening at ER Step 1 – Screening at ER by Nurseby Nurse

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การเข�า Stroke fast track

1. Sudden of either weakness, numbness, paralysis of the face, arm or leg, especially on one side of the body.

2. Confusion, trouble speaking or understanding

3. Loss of vision in one or both eyes

4. Trouble walking, dizziness, loss of coordination of balance, especially if combined with other signs

Step 2 – Clinical; Lab Step 2 – Clinical; Lab Screening by doctorScreening by doctor

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• Blood for Coagulogram, E’lyte ,CBC, BS, BUN, Cr, (Blood Clot 1 tube), Stool occult blood

• CT Brain, EKG • แพที่ย1 ป็ระเม*น Exclusion & Inclusion

Criteria for IV Thrombolysis

THROMBOLYSIS CHECK LISTTHROMBOLYSIS CHECK LIST

Name……………………Age .......HN…………..AN…………..Name……………………Age .......HN…………..AN…………..Date:……………Attending staff…………..Date:……………Attending staff…………..

TimeTime: Symptom Onset …………rtPA given:………..NIHSS………: Symptom Onset …………rtPA given:………..NIHSS………

INCLUSION criteria (must all be YES)• Age ≥ 18 years Yes No• Time of onset well established to be < 3 hours

Yes No• Clinical diagnosis of ischemic stroke causing a measurable

neurological deficit Yes No• CT without hemorrhage or significant edema

Yes No

EXCLUSION criteria (must all be No) SBP>185 or DBP>110 Yes No• Symptoms rapidly improving or minor symptoms (NIHSS = 0-6) Yes No• Coma or severe obtundation (or NIHSS>25) Yes No• Seizure at onset Yes No• Symptoms of SAH (diffuse headache, stiffness of neck) Yes No• Prior stroke or head trauma within 3 months Yes No• Major surgery within 14 days Yes No• Prior intracranial hemorrhage Yes No• GI hemorrhage or urinary tract hemorrhage within 21 days Yes No• Arterial puncture at a noncompressible site or LP within 7 days Yes No• Recent Myocardial infarction Yes No• Patients receiving heparin within 48hrs and with an elevated PTT Yes N• PT >15 or INR > 1.7 Yes No• Platelet count < 100,000 Yes No• Plasma glucose < 50 or >400 Yes No• Hematocrit < 25% Yes No• Pregnant (Note: menstruation is NOT a contraindication) Yes No

Hypodense > 1/3 MCA territoryStroke from other causes

(rt-PA rt-PA 50mg

Total 2 Set)

Stroke Stroke Lysis Lysis

Box Box

Step 3 – IV rtPA

(Recombinant Tissue Plasminogen (Recombinant Tissue Plasminogen Activator)Activator)

Weight (kg) : __× 0.9 mg = __ mg Give 10% bolus over 1 minute __ mg (ml) Give remaining 90 % constant infusion over 60 minutes __ mg (ml)

Total maximum dose 90

mg. M.D. Physician Signature …………………

Dosage calculation and How to infuse

Checklist prior to rt-Checklist prior to rt-PAPA

• Time of stroke onset: < 180 min done• Check Head CT – completed done• Check Lab – completed done• Physician order set completed done• Contraindication checklist completed done• Patient and Family Consent completed done• Notify neurosurgeon

Signature of Incharge nurse……………………… Date…/…………./…………. Time …………………

A checklist prior to rt-PA has to be made, including time of stroke onset lesser than 3 hrs, a complete check of head CT, Lab and Physician Order set, not to mention the completeness of contraindication checklist and concent.

Step 4 – Post Thrombolysis care (in 24 hrs)

Complication form rtPA

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• อาการที่างระบบป็ระสาที่ที่��เลว่ลงอย�างฉั�บพล�นอาการที่างระบบป็ระสาที่ที่��เลว่ลงอย�างฉั�บพล�น• ป็ว่ดศี�รษะ ป็ว่ดศี�รษะ• BP> 185/ 110 mmHg BP> 185/ 110 mmHg อย�างฉั�บพล�อย�างฉั�บพล�นน• N/VN/V

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Step 4 – Post Thrombolysis care (> 24 hrs)

MONITORING AND THROMBOLYTIC MONITORING AND THROMBOLYTIC TREATMENTTREATMENT

DATE ORDER FOR ONE DAY DATE ORDER FOR CONTINUATION WARD

- Prior on rt – PA Check NIHSS ,V/S ,N/S and basic life support, stool occult blood , blood examination Coagulogram, Electrolyte ,CBC, FBS, BUN,Cr (Blood Clot 1 tube)- CT brain non contrast - On rt – PA …. mg IV bolus in 1 minuteThen rt – PA … mg IV drip in 60

minute-Check vital sign , neurological sign &NIHSS after infusion q 15 mins. for 2 hrs. then q 30 mins. for 6 hrs. then q 60 mins. until 24 hrs.- If SBP >185 or <110 mm Hg DBP >110 or < 60 mm Hg if BP out of ranges please notify doctor

- NPO except medications for 24 hrs.-IV fluid as appropriate- Bed rest- Record l /O- Medication consider1. H2 receptor blocker / Proton Pump Inhibitor2. Antihypertensive drugs If BP >185 /110 mm Hg (Page 10 GUIDELINE OF ACUTE ISCHEMIC STROKE TREATMENT BY INTRAVENOUS THROMBOLYTIC

NAMELAST -NAMEAGEH.NALLERGYDIAGNOSIS

DATE ONE DAY DATE CONTINUATION WARD

If Hemorrhage is suspected - Stop infusion of the Thrombolytic drug- Repeat CBC, platelet, INR, PTT, PT - CT brain stat- Prepare FFP or platelet count, Cryo-precipitate.- Notify Neurologist Neurosurgeon and Team for discussion.

NAMELAST -NAMEAGEH.NALLERGYDIAGNOSIS

MONITOR AND THROMBOLYTIC TREATMENTMONITOR AND THROMBOLYTIC TREATMENT

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เล�อด2าเล�อด2า สถานบร*การต้�องสามารถให�บร*การ 24 ช��ว่โมง ในห�ว่ข�อด�งต้�อไป็น�%

• ป็ระสาที่แพที่ย1หร�อแพที่ย1เว่ชศีาสต้ร1ฉั0กเฉั*น/ อาย0รแพที่ย1 ที่��ได�ร�บป็ระกาศีน�ยบ�ต้รฝึ:กอบรมในการให�สารละลายล*�มเล�อด

• ป็ระสาที่ศี�ลยแพที่ย1• CT brain• ม�ห�องป็ฏิ*บ�ต้*การที่��สามารถต้รว่จ BS, CBC,

Coagulogram, E’lyte, BUN, Cr• สามารถหาเล�อดและส�ว่นป็ระกอบของเล�อดได� เช�น

FFP, CP, PC และ PRC• ม� ICU หร�อ stroke unit ที่��สามารถให�การด&แลผู้&�ป็7ว่ยในระหว่�างหร�อภายหล�งการให�ยาได�

• ม�การส2ารองยา rt-PA ไว่�ในบร*เว่ณที่��ให�การร�กษา

STROKECOMPLICATION !!!

Complications of strokeComplications of stroke

• Neurological deterioration in acute stroke;

- decrease of level of consciousness

- motor deficit progression

• General medical complications

• Prospectively collected data; suggest direct effect of ischemic stroke account for

most deaths within first week after stroke

mortality resulting from medical complications predominate there after

Neurological deterioration in Neurological deterioration in acute strokeacute stroke

1.Recurrent stroke - The International Stroke Trial (IST) show recurrence

rate (first 14 days) 2.8 % in those tx with aspirin 3.9% in those not receive aspirin

- ASA (160-325 mg) begin within 24 hrs after stroke is recommended to lower risk of early ischemic stroke recurrence(IST,CAST)

Lancet 1997;349:1569-1581 Lancet 1997;349: 1641-1649

risk factors/predictors for stroke progressionrisk factors/predictors for stroke progression

• Age• Hx of DM• Elevated SBP on admission• Prior antiplatelets• Hyperthermia• Hyperglycemia• High Hct• Early positive CT brain

2.Hemorrhagic transformation2.Hemorrhagic transformation

symptomatic (headache,worsening of focal deficit,decreased

level of consciousness)

asymptomatic

- prospective study; assess 65 pts. with acute supratentorial infarct - serial CT

in 4 weeks 43%(28/65) found hemorrhagic transformation 5% (3/65) or 10% of pts.hemorrhagic

transformation have neurological deterioration

correlation between size of infarct and present of hemorrhagic transformation

Stroke 1986;17:179-185

Rate of hemorrhagic transformation (total and symptomatic) according to time to treatment

In case suspected ICH associated with In case suspected ICH associated with thrombolysis; txthrombolysis; tx

hold drug infusion

emergency CT

blood component check &prepare

cryo ppt,PRC,Platelet

neurosurgical option for selected case

3.Cerebral edema3.Cerebral edema

- related to large infarct & tend to have delayed clincial deterioration

most serious rising ICP – brain herniation- As ICP rises CPP&CBF are reduced local increase in tissue pressure interfere

local microcirculation -; worsening ischemia & 2’ cerebral damage

- maximal edema occurs between day 2-5 - cause mainly by cytotoxic brain edema

2 hr after onset24 hrs later with clinical deterioration

CT brain show subfalcial herniation , massive ACA+ MCA infarction with brain swelling and hemorrhagic conversion

treatment of elevated ICP in treatment of elevated ICP in strokestroke

1. elevate head of bed 15-30’; both ICP & CPP are lowest while head elevate by 30’

2. hyperventilation act almost immediately to lower ICP

by leading to vasoconstriction 2’ to alkalosis of CSF

hyperventilation pCO2 below 30 mmHg can induced ischemia via vasoconstriction

J Neurosurgery 1991;75:731-739

3.pharmacological treatment 3.1 manitol ; almost immediate decrease In whole blood

viscosity leadind to vasoconstriction and decrease ICP(non infarcted brain)

- maximal duration of effect on ICP range 20-360 min (mean 88 min)

- dose 0.25-0.5 g/kg over 20 min repeat q 6 hr monitor fluid input/output,serum osmolarity typical maximum daily dose 2g/kg Circulation 1994;90:1588-1601 J Neurosurgery 1981;55:550-553 J Neurosurgery 1983;59:822-828 Acta Neurochir 1977;36:189-200 Neurology 2001;57:2120-2122

4.Surgical intervention- specific condition hemicreniectomy in case massive MCA

infarction

craniotomy or suboccipital craniectomy in case large cerebellar infarct & depressed level of consciousness secondary to BS compression

Right middle cerebral artery infarction

cranial vault is closed, fixed bony box, its volume is constant. This volume i

s described by Monro-Kellie doctrine,

v.intracranial (constant) = v.brain + v.CSF + v.blood + v.intracranial (constant) = v.brain + v.CSF + v.blood + v.massv.mass

4.Seizure and epilepsy4.Seizure and epilepsy

- seizure & post ictal state lead to depressed level of consciousness & worsening focal neurological deficit

- incidence of seizure after stroke ~ 8.6% early onset (</=2wks) occur 4.8% 40% occurred within 24 hrs late onset ( >2 wks) occur 3.8% ; predictor of recurrent seizure 55% of pts.late onset seizure developed epilepsy

- status epilepticus – uncommon(9%) - AED recommended for seizure in acute stroke setting long term AED individualized Arch Neurol 2000;57:1617-1622 Neurology 1996;46:1029-1035

5. Unknown causes of deterioration 5. Unknown causes of deterioration in small &large vessel infarctin small &large vessel infarct

early deterioration (within 7 days onset ) occurs in ~ 25% of pts.

Stroke 2000;31:2049-2054

excluded of consciousness change ,progressive motor deficit --- cause mostly by lacunar infarct esp .DM

Stroke 2002;33:1510-1516

- mechanism – not well understood - hypothesis 1.thrombos propagation 2. microemboli or low perfusion from large vessel 3. excitotoxicity ; elevated serum glutamate &

depressed serum GABA found associated with motor deterioration in first 48 hrs

Neurology 1996;47:884-888

Stroke 2001;32:1154-1161

4. inflammatory contribute; inflammatory marker ex.IL6,TNF alfa elevate in case early deterioration

5.hypoperfusion, lower blood pressure

Stroke 2002;33:982-987

6. Systemic conditions6. Systemic conditions

-systemic process affect neurological status in stroke pts. by furthering cerebral ischemia or leading to neuronal dysfunction

- transient worsening or recurrence of original symptom - ex. Fever ; potential mechanism – release of excitatory

amino acid & hydroxyl radicals sedative medications J Neurochem1995;65:1250-1256

Neuroscience 1998;83:1239-1243

Nutritionists

Social Workers

CaseManagers

Occupational Therapists

Nurses

Medical Doctors

Physiotherapists

Neurologist

Phamacologist

Patient

Nerosurgeon

Multidisciplinary in Multidisciplinary in StrokeStroke

ญาต้*

Thank you for your attention