Transcript Stroke fast track and complications

Stroke fast track and
complications
Khwanrat 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 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 rtPA
(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 Thrombolytics
• Stroke or head trauma in
3 mo
• Major surgery within 14
days
• Any history of intracranial
hemorrhage
• SBP > 185 mm Hg
• DBP > 110 mm Hg
• Rapidly improving or minor
symptoms
• Symptoms suggestive of
subarachnoid hemorrhage
• Glucose < 50 or > 400
mg/dl
• GI hemorrhage within 21 days
• Urinary tract hemorrhage within
21 days
• Arterial puncture at noncompressible site past 7 days
• Seizures at the onset of stroke
• Patients taking oral anticoagulants
• Heparin within 48 hours and
elevated PTT
• PT >15 / INR >1. 7
• Platelet count <100,000
rtPA Treatment Based on CT
Findings
•
•
•
•
•
CT Findings
None
Subtle < 1/3 MCA
Subtle > 1/3 MCA
Hypodensity < 1/3
MCA
• Hypodensity > 1/3
MCA
Recommendations
>>Treat
>>Treat
>>Probably treat
>>Probably treat
>>Don’t treat
NINDS 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
occurred in 6.4 percent of the patients given tPA, as compared with 0.6 percent of those
given placebo ( 36 hrs)
N Engl J Med 1995;333:1581-1587
Factors Associated
with 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
By ?
Stroke Fast Track; Treatment
Stroke Unit
vs
General neurological ward or General ward
Home, Home care, …
Consensus time-frames criteria
for effective hospital stroke response system by
National Institute of Neurological Disorders & Stroke
Time frames
Time to first physician
Time to CT
Time to Lab
Time to CT result
Time to Lab result
Time to Treatment (rtPA cases)
Time to Monitor bed (rtPA cases)
NINDS times
(min)
10
25
N/A
45
N/A
60
180
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
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
ER NURSE
ASSESSMENT
Notify Neurologist
4. Trouble walking, dizziness, loss of
coordination of balance, especially if
combined with other signs
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
SU; Neurologist & Nurses
1. Thrombolytic check lists
2. Consent form resident / Staff neurology
3. Notify neurosurgeon before start intravenous Thrombolytic
HEMORRHAGE
Consult neuroSurgeon
Step by step for rtPA
Step
Step
Step
Step
1
2
3
4
–
–
–
–
Screening at ER by Nurse
Clinical; Lab Screening by doctor
IV Thrombolysis
Post Thrombolysis care (24 hrs;
> 24 hrs)
Step 1 – Screening at ER
by Nurse
ั
• พยาบาลต้องซกถามอาการที
่
ั าเป็นโรคหลอดเลือดสมอง
สงสยว่
ได้แก่
@ แขนขา ชา อ่อนแรง ข้างใด
@
@
@
@
ข้างหนึง่ ท ันที
ั พูดไม่ได้
้ ว พูดไม่ชด
ปากเบีย
หรือฟังไม่เข้าใจท ันทีท ันใด
เดินเซ เวียนศรี ษะท ันทีท ันใด
้ นหรือมืดม ัว
ตามองเห็นภาพซอ
ข้างใดข้างหนึง่ ท ันที
ปวดศรี ษะรุนแรงท ันที
ระยะเวลาทีเ่ ป็นต้องไม่เกิน 3
ช.ม พยาบาลต้องแจ้งแพทย์เพือ
่
ยืนย ันการเข้า 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 Screening
by doctor
• พยาบาล Notify แพทย์ เมือ
่ แพทย์ ได ้รับแจ ้งต ้องไป
ดูผู ้ป่ วยทันทีเพือ
่ ประเมินอาการและระยะเวลาทีเ่ กิด
อาการ
• Blood for Coagulogram, E’lyte ,CBC, BS,
BUN, Cr, (Blood Clot 1 tube), Stool occult
blood
• CT Brain, EKG
• แพทย์ ประเมิน Exclusion & Inclusion Criteria
for IV Thrombolysis
THROMBOLYSIS CHECK LIST
Name……………………Age .......HN…………..AN…………..
Date:……………Attending staff…………..
Time: 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
Symptoms rapidly improving or minor symptoms (NIHSS = 0-6)
Coma or severe obtundation (or NIHSS>25)
Seizure at onset
Symptoms of SAH (diffuse headache, stiffness of neck)
Prior stroke or head trauma within 3 months
Major surgery within 14 days
Prior intracranial hemorrhage
GI hemorrhage or urinary tract hemorrhage within 21 days
Arterial puncture at a noncompressible site or LP within 7 days
Recent Myocardial infarction
Patients receiving heparin within 48hrs and with an elevated PTT
PT >15 or INR > 1.7
Platelet count < 100,000
Plasma glucose < 50 or >400
Hematocrit < 25%
Pregnant (Note: menstruation is NOT a contraindication)
Hypodense > 1/3 MCA territory
Stroke from other causes
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  N
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Step 3 – IV rtPA
(Recombinant Tissue Plasminogen Activator)
Stroke Lysis
Box
(rt-PA 50mg
Total 2 Set)
Dosage calculation and How to infuse
 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 …………………
Checklist prior to rt-PA
•
•
•
•
•
•
•
Time of stroke onset: < 180 min
Check Head CT – completed
Check Lab – completed
Physician order set completed
Contraindication checklist completed
Patient and Family Consent completed
Notify neurosurgeon
 done
 done
 done
 done
 done
 done
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
การประเมินทีส
่ าค ัญ
1. ก่อนและขณะให้ยา BP ต้อง < 185/110
mmHg
ั ามี ICH
2. อาการและอาการแสดงทีส
่ งสยว่
•
•
•
•
อาการทางระบบประสาททีเ่ ลวลงอย่างฉ ับพล ัน
ปวดศรี ษะ
BP> 185/ 110 mmHg อย่างฉ ับพล ัน
N/V
Step 4 – Post Thrombolysis care (> 24
hrs)
่
ผูป
้ ่ วยควรได้ร ับการดูแลร ักษาทว่ ั ไป เชน
o ได้ร ับยาต้านการแข็งต ัวของเกล็ดเลือด
o การดูแลทว่ ั ไป การทากายภาพบาบ ัด
o การประเมินอาการทางระบบประสาท
้ นเป็นระยะ
o การป้องก ันภาวะแทรกซอ
ี่ งและการป้องก ัน
o การสอนให้ความรูป
้ จ
ั จ ัยเสย
o การกล ับเป็นซา้
MONITORING AND THROMBOLYTIC
TREATMENT
DATE
ORDER FOR ONE DAY
- 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 minute
Then 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
DATE
ORDER FOR CONTINUATION
- NPO except medications for 24
hrs.
-IV fluid as appropriate
- Bed rest
- Record l /O
- Medication consider
1. H2 receptor blocker / Proton
Pump
Inhibitor
2. Antihypertensive drugs
If BP >185 /110 mm Hg
(Page 10 GUIDELINE OF ACUTE
ISCHEMIC STROKE TREATMENT
BY INTRAVENOUS
THROMBOLYTIC
WARD
NAME
LAST NAME
AGE
H.N
ALLERG
Y
DIAGN
OSIS
MONITOR AND THROMBOLYTIC TREATMENT
DATE
ONE DAY
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.
DATE
CONTINUATION
WARD
NAME
LAST NAME
AGE
H.N
ALLERGY
DIAGNOS
IS
ศักยภาพของโรงพยาบาลทีส่ ามารถดาเนินการรักษาโรคหลอด
เลือดสมองตีบด้ วยการให้ ยาละลายลิม่ เลือดทางหลอดเลือดา
สถานบริการต้ องสามารถให้ บริการ 24 ชั่วโมง ในหัวข้ อดังต่ อไปนี้
• ประสาทแพทย์ หรื อแพทย์ เวชศาสตร์ ฉุกเฉิน/อายุรแพทย์ ที่ได้ รับ
ประกาศนียบัตรฝึ กอบรมในการให้ สารละลายลิม่ เลือด
• ประสาทศัลยแพทย์
• CT brain
• มีห้องปฏิบัติการที่สามารถตรวจ BS, CBC, Coagulogram, E’lyte, BUN, Cr
• สามารถหาเลือดและส่ วนประกอบของเลือดได้ เช่ น FFP, CP, PC และ PRC
• มี ICU หรื อ stroke unit ทีส่ ามารถให้ การดูแลผู้ป่วยในระหว่ างหรื อภายหลัง
การให้ ยาได้
• มีการสารองยา rt-PA ไว้ ในบริเวณทีใ่ ห้ การรักษา
STROKE
COMPLICATION !!!
Complications 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
acute 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 progression
•
•
•
•
•
•
•
•
Age
Hx of DM
Elevated SBP on admission
Prior antiplatelets
Hyperthermia
Hyperglycemia
High Hct
Early positive CT brain
2.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
thrombolysis; tx
hold drug infusion
emergency CT
blood component check &prepare
cryo ppt,PRC,Platelet
neurosurgical option for selected case
3.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 onset
24 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
stroke
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 is
described by Monro-Kellie doctrine,
v.intracranial (constant) = v.brain + v.CSF + v.blood +
v.mass
4.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
in 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 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
Multidisciplinary in Stroke
Neurologist
Medical
Doctors
Nerosurgeon
Nurses
Physiotherapists
Phamacologist
Patient
Occupational
Therapists
ญาติ
Case
Managers
Nutritionists
Social
Workers
Thank you for
your attention