Acute Ischemic Stroke: Overcoming Barriers by Improving ...
Acute Ischemic Stroke: Overcoming Barriers by Improving Systems of Care
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Current Tools for the Diagnosis and Treatment of Acute Ischemic Stroke
Andy Jagoda, MD, FACEP
Professor and Chair of Emergency Medicine Mount Sinai School of Medicine New York, NY
Objectives
? Discuss clinical evaluations and the use of stroke scale tools in decision-making
? Discuss neuro-imaging tools in the assessment of patients with TIA and acute stroke
? Discuss care map / protocol tools in facilitating quality stroke care
? 2015 Vindico Medical Education
Acute Ischemic Stroke: Overcoming Barriers by Improving Systems of Care
CT Insensitive for Stroke
CT is often normal for gross signs of infarction for the first 6-12 hours, though subtle, early changes are seen in up to 67%
Latchaw RE, et al. Stroke. 2009;40:3646-3678.
Clinical Diagnosis
Stroke Assessment Tools
Stroke Mimic in about 3% of Patients Treated with tPA
Winkler DT, et al. Stroke. 2009;40:1522-1525. Scott PA, Silbergleit R. Ann Emerg Med. 2003;42:611-618.
ROSIER Scale: Stroke Recognition Tool
Symptom onset: Date
Time
GCS E= M= V
BP / BS: If BS < 60 treat urgently and reassess
Has there been loss of consciousness or syncope? Y (-1) N (0) Has there been seizure activity? Y (-1) N (0) Asymmetric facial weakness Y (+1) N (0) Asymmetric arm weakness Y (+1) N (0) Asymmetric leg weakness Y (+1) N (0) Speech disturbance Y (+1) N (0) Visual field defect Y (+1) N (0) Total Score _____ (-2 to +5) Provisional diagnosis: Stroke Non-stroke (specify) ___________________ * Stroke is likely if total scores are > 0. Scores of 0 have a low possibility of stroke but not completely excluded.
Nor AM, et al. Lancet Neurol. 2005;4:727-734.
TIA: ABCD2 Assessment Tool
Predictor
? 20% to 50% of strokes
Age > 60 y
preceded by a TIA
? 75% resolve in 140/90 mm Hg
minutes; 97% 60 min (2)
10-59 min (1)
20 severe
? Stroke scales help quantify the deficit, facilitate communication, identify location, provide prognosis, direct testing
? Severe strokes are associated with increased risk of sICH ? "Minor" strokes are a relative contraindication for tPA
? Studies suggest that patients with minor or rapidly improving deficits may benefit from treatment**
** Smith EE, et al. Stroke. 2005;36:2497-2499.
Posterior Circulation Strokes
? CT misses 60%-90% of acute ischemic strokes in the brainstem or cerebellum
? MRI with diffusion-weighted imaging is more reliable than CT, but is still misses 15%-20% of patients with posterior circulation stroke in the early period
? HINTS is reported to be up to 99% sensitive when performed by an experienced clinician
? emcrit/misc/posterior-stroke-video/
Newman-Toker DE, et al. Acad Emerg Med. 2013;20:986-996. Kattah JC, et al. Stroke. 2009;40:3504-3510.
Non-Contrast CT
? Sensitive ? Available ? Fast ? Findings on CT
related to:
? Size of infarct ? Severity of ischemia ? Time of onset
? Hypodensity or mass effect associated with 8x increase risk of sICH
Miller DJ, et al. Neurohospitalist. 2011 Jul;1(3):138?147.
? 2015 Vindico Medical Education
Acute Ischemic Stroke: Overcoming Barriers by Improving Systems of Care
Alberta Stroke Program Early CT Score (ASPECTS)
? 10 points quantitative topographic CT score
? Defined scan protocol ? Developed to provide a reliable
grading system ? Early ischemic change predict
outcome and risk
? Focal parenchymal hypodensity ? Cortical swelling with sulcal effacement /
loss of gray white differentiation ? Hyperdense MCA sign
? Scoring is limited to MCA strokes ?
MRI ? DWI
? 88%-100% sensitivity
? Better than CT (Level IA)
? Takes 6 minutes
? Visible minutes after infarct
? Better than CT for distinguishing acute vs chronic lesions
? Better than CT for small CVAs, posterior fossa
MRI ? Gradient Echo
? Blood dependent on age and pulsing sequences used
? As accurate as CT for acute hemorrhage
? Micro-hemorrhages ? Relevance?
Jauch EC, et al. Stroke. 2013;44:870-947.
Vascular Imaging
? Digital Subtraction Angiography
Gold standard Risks, time-consuming
? CT w/o contrast + CTA
Equivalent to DSA (Level IB evidence)
? MRI (DWI, FLAIR, GRE/SWI +/- PWI) +/- MRA
Equivalent to DSA (Level IB evidence)
American Society of Neuroradiology, the American College of Radiology, and the Society of NeuroInterventional Surgery, 2013
? 2015 Vindico Medical Education
Acute Ischemic Stroke: Overcoming Barriers by Improving Systems of Care
Imaging in Acute Ischemic Stroke
? P's of acute stroke imaging: Parenchyma (brain), Pipes (vasculature), Perfusion (blood flow), and Penumbra (at-risk tissue).
? Multimodal imaging ? Sequence studies: Image, angiography perfusion, diffusion ? Enhances the sensitivity of emergent neuroimaging for acute ischemic processes ? Identifies patients who may benefit from endovascular interventions
Sa de Camargo EC, Koroshetz WJ. NeuroRx. 2005 Apr; 2(2): 265?276.
Does the Penumbra Matter?
Downloaded from
Indications/Contraindications
? Contraindications:
? Relative Contraindications:
? Current intracranial bleeding/SAH
? Active internal bleeding
? Head or spine surgery or severe TBI within 3 months
? History of serious intracranial conditions
i.e., AVM, neoplasm, aneurysm
? Bleeding diathesis
? Minor or rapidly improving symptoms
? Pregnancy
? Seizure at onset
? Major surgery or serious trauma within previous 14 days
? Recent GI or urinary tract hemorrhage within 21 days
? Recent AMI within previous 3 months
? Current uncontrolled hypertension
Alteplase [package insert]. Genentech. South San Francisco, CA. 2015.
? 2015 Vindico Medical Education
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