Feb 6, 2020
In this podcast, Dr. Mark Young, a stroke Neurologist with Abbott Northwestern Hospital, discusses current guidelines for ischemic stroke management and care.
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One large impact on stroke care 2018 is the thrombectomy window expansion time for large vessel occlusion out to 24-hours.
Current perfusion imaging
available is able to identify core infarct- establish the quantity
and mismatch ration of available brain that is
Futile reperfusion is something that should not be undertaken due to high risk of reperfusion hemorrhage which can ultimately worsen outcomes.
Last known well time means exactly that. When was the patient last seen well. So if they go to bed and then come in with a wake up stroke then LKW is when they went to bed.
Some studies on wake up strokes showed that the majority developed symptoms 2-3 hours prior to waking up.
LKW and wake up stroke are different but can often help us guide therapy. For instances pt goes to bed is LKW time and then wakes up with stroke like symptoms. Perfusion imaging is instrumental in the decision process for these patients often guiding us with further management.
The NINDS trials came out in
'95-'96. However the bottom line showed - in patients, with
ischemic stroke within 3 hours, tPA administration significantly
improved HIHSS scores but did not confer survival benefit.
Stroke neurologist typically want a call early in clinical course. Don't wait for CT prior to calling. Then when was the last known well time. Blood glucose, blood pressure, PMH and deficits (ie NIHSS), 'what are you observing'. Don't wait on labs - consideration is warfarin.
There are trials following the NINDS trial that show evidence that patient with low HIHSS with potentially disabling deficits and rapidly improving stroke improve with TPA treatment and that the hemorrhage rates are lower.
Definitely consider treating rapidly improving stroke sxs.
With stutter stroke sxs, the clock resets when the patient returns back to baseline.
Most stroke centers uses -0-4.5 hours time frame for IV thrombolytics.
Absolute and relative contraindications for thrombolytics include: greater than 2/3 MCA territory don't treat as there is little benefit. Patient on warfarin with INR greater than 1.7. Recent stroke or ICH. Endocarditis. Coagulopathy. People on DOACs. Significant thrombocytopenia. There are many more but these are the highlights.
American Stroke Association says patient must be off DOAC's for 48-hours before lytic treatment as relative contraindication.
Dr. Young's standard conversation with pt who are experiencing a stroke when discussing TPA. First, it is the standard of care, next the chance of hemorrhage is around 6-7%, but Abbott has a much lower rate of around 2.5%. We know that even with that risk patients do much better overall. At 90 days, the chance that the patient will be living independently are much better.
90-day Modified Rankin Scores are standards that we use to measure stroke outcomes. Modified Rankin Scale score of 0 is no deficit, no residual. MR of 1 can do everything you use to do although may still have mild symptoms that patient may notice. MR of 2 - you have some limitations but can live independently and do all ADLs MR of 3 - is dependent with ADLs although can walk with or without a device. MR or 4. Can't walk. MR of 5 - bed bound. MR of 6. DEAD.
Some criteria for TPA with lower HIHSS with compelling deficits are #1, what's disabling #2. Others include limb ataxia, aphasia, paresis, dominant hand problem, dysphagia, dysarthria. Controversy Hemianopsia.
Greater than or equal to NIHSS of 6 is generally recommended to get a CTA to evaluate for LVO stroke.
Imaging generally requires CT/CTA of the head and neck. Always include imaging of the neck.
Rapid perfusion imaging for LVO used in Diffuse 3 - (6-16 hours) for the window vs DAWN out to 24-hours.
So the order of imaging includes noncom CT head, CTA, CT perfusion.
When evaluating the imaging studies we want the core infarct to be less than 70ccs and the ratio of the core infarct to at risk brain penumbra to be greater than 1.8.
The use of rapid sequencing MRI has utility for post circulate symptoms, ie vertigo with/out nystagmus, abrupt onset. Generally diffusion weighted gradient echo/T2 flair images looking for blood. Other indications maybe for subacute findings/duration.
LVO's that can be intervened on include: anterior communicating, distal carotid or carotid terminus, MCA M1, M2, basilar, distal verts, maybe PCA/P1.
Important point if a patient has a LVO lesion and is within the 4.5 hour window at a small rural setting with lytic capabilities and the patient is going to a large tertiary stroke center does the patient still need to receive IV lytic therapy - knowing that the patient will require thrombectomy and answer is YES. No increased risk when using lytic with thrombectomy.
A little controversial but we maybe seeing the bypass of non-stroke hospitals specifically with LVO to tertiary stroke centers with a new scoring system that EMS can do called RACE (Rapid Arterial oCclusion Evaluation) https://neuronewsinternational.com/racecat-trial-update/
After care by the PMD what can we expect from these patients follow a LVO?
90-day Rankin 50% with modified Rankin 2 less to live independently following LVO.
50% of LVO have a 90 mortality. 70-80% will not live independently.
Discharge meds for these patients will include DOACs or Warfarin, antiplatelet agents - such as Plavix. Occasionally patient will end up on dual antiplatelet therapy depending on disease state.
Stoke mimics that have been given thrombolytics have less than 1/2% chance of hemorrhage.