Transcript Acute Care: What’s New to Reduce Damage

Acute Stroke:
Recognizing and
Reacting
Dr. Grant Stotts
Stroke Neurologist, Ottawa Hospital
Stroke and MI
• Share many common causes
– Blood pressure, smoking, cholesterol ...
• Both result in blood clots stopping
circulation
– Therefore, acute treatment may involve
similar approaches
Presentation Goals
• Review the signs of stroke
• Emphasis the crucial role fast
response plays in stroke treatment
• Recognize potential of available
treatments
– Acute
– Preventative
Warning Signs of Stroke
1. Weakness
2. Troubles Speaking
3. Vision Problems
4. Sudden Headache
5. Dizziness
Warning Signs of Stroke
• Weakness
– Sudden loss of strength or sudden
numbness in the face, arm or leg, even
if temporary
Updated October 2006
Warning Signs of Stroke
• Trouble Speaking
– Sudden difficulty speaking or
understanding or sudden confusion,
even if temporary.
Updated October, 2006
Warning Signs of Stroke
• Vision Problems
– Sudden trouble with vision, even if
temporary.
Updated October, 2006
Warning Signs of Stroke
• Headache
– Sudden severe and unusual headache.
Updated October, 2006
Warning Signs of Stroke
• Dizziness
– Sudden loss of balance, especially with
any of the above signs.
Updated October, 2006
Stroke Warning Signs
• Stroke recognition is impaired by:
– Lack of awareness
– Lack of pain
Weakness
Troubles Speaking
Vision Problems
Headache
Dizziness
A Stroke in Ottawa
A Stroke in Ottawa
• Identify possible
stroke
• Alert EMS
• Immediate
transport
• Immediate triage
(stroke code)
– Initiates calls to CT
room, neurologists
– Necessary blood
work is done
– Patient taken to
CT (computerized
Normal CT
CT With a Stroke
CT With a Bleed
Acute Stroke Treatment
tPA
• If no bleed and < 3
hours, considered
for acute treatment
• Standard is
presently tPA intravenous
– Improves relative
chance of survival
or reduced
disability by about
30%
– Risk is bleeding
(about 6% of those
who receive it)
Time is Everything
• Time is the most
important factor
– Nothing else is
more important to
open up the artery
Intra-arterial tPA
• Intraveneous tPA is limited
to being given within 3
hours
• SELECT patients from 3 to
6 hours may qualify for
intra-arterial therapy
– Guiding a catheter through
the arteries up to the clot and
giving a small dose of tPA
– Similar to heart attacks,
angioplasty and stenting can
now be done in certain
vessels
MR Angiogram
Blocked middle cerebral artery
Restored flow
MERCI DEVICE
• More recent option is to
remove the clot
(mechanical extraction)
– MERCI Device
– Currently available in
Ottawa
• Used in SELECT cases where
tPA is felt unlikely to work
• Made popular by ER
Merci Retriever
APM0097_A_1991
Merci System Animation
APM0097_A_1991
Telestroke Technology
Remote
Hospital
Base
Hospital
ISDN or VPN
VPN
Efilm
Server
Courtesy: Dr. M. Sharma
Research Presently
Taking Place
Desmoteplase
New agent for breaking up blood clots
Given IV
Similar to tPA
Desmoteplase
• Desmodus rotundus
• Vampire Bat Salivary PA
• Recombinant DSPAα1
• High Fibrin Selectivity
• sICH Low = Stringent
Dependence on Fibrin
• Therapeutic window 9hr
• Low Fibrinogenlysis
• t1/2 = 138 min
CT Perfusion Imaging in Acute Stroke – Ischemic Penumbra
10
130
30
8
104
24
6
78
18
4
52
12
2
26
6
0
0
0
CBV (ml/100g)
CBV
CBF (ml/100g/min)
CBF
MTT (sec)
MTT
How Well Are We Doing
Now?
Ontario tPA Rates by Hospital
2003
30.0
N = 4,107
25.0
20.0
15.0
Overall tPA Rate 9%
(Ischemic Patients)
10.0
5.0
0.0
A B C D E F G H I J K L M N O P Q R S T U
Courtesy: Dr. Michael Sharma, Medical
Director Stroke Program, The Ottawa
Hospital
% of N
tPA %
Improvements
• Presented here by Dr. Sharma 2003
– Increase awareness of stroke signs
• Heart and Stroke Ad Campaigns
– EMS directed to hospitals with stroke
teams
– Stroke code protocols in ER
– Neurologists on call
tPA rate July-Sept 2004
20
18
16
14
12
Rate (Ischemic
10
Stroke)
8
Series1
6
4
2
0
V
A
B
L
I
M
Site
Courtesy: Dr. M. Sharma
K
C
J
Canadian and Ontario
Stroke Strategies
The Ontario Stroke System
Best Practice across the Continuum of Care
Emergency
Prehospital
Acute
Transition
Rehab
Prevention
Stroke
recognition
Community
Stroke Strategy Principles:
•Comprehensive
•Integrated
•Evidence-based
•Province Wide
Stroke in Canada
• The leading cause of adult disability
• 4th leading cause of death
• One stroke every ten minutes in
Canada
• 50,000 strokes per year
• 20,000 new strokes in Ontario per
year
• 300,000 stroke survivors
• 28% of stroke patients are under
age 65
Cost of Stroke
• The cost of the disease is more than
$3 billion a year in Canada
• Stroke has longest LOS of any
disease
• The rate of hospitalization for stroke
is over 20 times higher for those 65
and over
• Average acute care cost estimated
at $27,500
Outcome of Ischemic
Stroke
Dead
15%
Full
Recovery
25%
Major
Disability
15%
Moderate
Disability
15%
Minor
Disability
30%
Adapted from Stegmayr B, et al. Stroke 1997;28:1367-1374
11 Regions
9 Regional Stroke Centres
2 Enhanced District Stroke Centres
16 District Stroke Centres
24 Stroke Prevention Clinics
Champlain Region
The Champlain District (1.2 million)
Impact of an integrated strategy:
The Ontario Stroke Strategy

54% increase in patients receiving referrals to stroke
prevention clinics following initial stroke/TIA to prevent more
serious event (there are now 24 prevention clinics in Ontario)

tPA: A clot-busting drug - the only proven treatment in stroke:
– Average tPA rate increased from 25% to 34% in
designated regional stroke centres

Inpatient admissions for stroke decreased by 11%, mostly
attributable to a decrease in admissions for transient ischemic
attacks (TIA) or small strokes
2005 Evaluation of the Ontario Stroke Strategy - comparisons made between 2000
(before the Ontario Stroke Strategy was implemented) and 2003 (after the
strategy was implemented)
Impact of an Integrated Strategy

Number of patients now managed on specialized stroke
units increased from 18% to 60%

Decreased utilization in inpatient resources

Physiotherapy assessments before hospital discharge have
increased from 47% to 75%, and occupational therapy
consults from 38% to 71%

85% of patients discharged on antiplatelet medications to
help prevent another stroke

8.7% of patients require admission to long-term care major decrease from two years previously
Economic impact of an integrated
stroke strategy
 Based on current Canadian population, the net benefit
of providing coordinated stroke care, over next 20 years:
– Prevent 160,000 strokes
– Prevent disability in 60,000 Canadians
– Achieve net savings of $8 billion
 Economic analysis is very conservative - does not
include:
– primary prevention interventions other than hypertension,
– secondary prevention clinics, and
– improved post-acute rehabilitation
 Projected impact would be significantly higher

Source: Dr. Mike Sharma (in partnership with Caro Research) - based on
systems changes implemented through the Ontario Stroke Strategy,
extrapolated for all of Canada, multiple data sources
Awareness of Stroke
Warning Signs
Aware of 2 or more
signs
Aware of key
warning signs
Dizziness
Vision problems
Trouble speaking
Headache
2003(%)
52
43
25
23
29
2005(%)
72
62
45
41
32
Ottawa Performance
2006
• Stroke patients arriving in ER within
2.5 hours
– 42.5%
• If patient arrives within 2.5 hours,
chance of getting tPA
– 47%
• Stroke patients arriving by
ambulance
– 57.5%
What If The Symptoms
Are Temporary?
TIA Management
• TIA is the equivalent of angina
– Warning sign of stroke
Risk of Stroke After TIA
Gladstone et al, CMAJ, 2004, Mar 30:170(7):1099
Ottawa Stroke
Prevention Clinic
• All TIA patients triaged for rapid
referral
– Carotid doppler and echocardiogram
– Placed on antiplatelet therapy
– Options for statins and BP agents
provided
Summary
• Effective treatments exist for stroke
• The key to acute treatment is TIME
– Recognition of stroke symptoms
– Activation of EMS
– Rapid triage of minor and serious
strokes/TIAs
Warning Signs of Stroke
1. Weakness
2. Troubles Speaking
3. Vision Problems
4. Sudden Headache
5. Dizziness