Transcript Latest trends in Care of the Stroke Patient

Latest Trends in Care
of the Stroke Patient
William J. Meurer, MD
Clinical Lecturer and Stroke Fellow
University of Michigan Stroke Program
Departments of Emergency Medicine
and Neurology
Objectives
 Review
concise clinical pearls in
caring for the acute stroke patient
 Review results of past research that
may influence your practice
 Discuss recently announced acute
stroke research
 Provide overview of ongoing research
which may influence your practice in
future
Disclosures
 My
salary is provided by the
University of Michigan
 No other financial support
 I WILL discuss some off label uses of
medications
Overview
 Review
scope and disease process of
stroke
 Review clinical guidelines and pearls
 Discuss recent advances
 Discuss ongoing national and local
research
Stroke Facts
• Third leading cause of death
– Over 160,000 deaths per year
• 750,000 strokes per year
• Over 4 million stroke survivors
• Leading cause of adult disability
– Of those who survive, 90% have deficit
1. Williams GR, Jiang JG, Matchar DB, et al. Stroke 1999; 30:2523-28.
2. Hoyert DL, Kochanek KD, Murphy SL. National Vital Statistics Report 1999; 47:19.
24.7
25.0
23.3
Per 1,000 Persons
21.8
20.0
16.8
15.0
11.8
16.5
13.5
11.3
10.4
9.8
10.0
6.7
4.9
5.0
0.0
0.0 0.0 0.0 0.1
0.1 0.1 0.1 0.4
0-34
35-44
1.4
2.12.5
4.6
4.2
2.6
1.6
0.8
45-54
55-64
65-74
75-84
85+
Ages
White Males
White Females
Black Males
Black Females
Annual rate of first cerebral infarction by age, sex and race
(Greater Cincinnati/Northern Kentucky Stroke Study: 1993-94).
Source: Unpublished data from the GC/NKSS; Kissela et al., Stroke. 2004;35:426-31.
Smoothed County Stroke Death Rates:
Adults 35 and Older, 1991-98
Source: CDC. Atlas of Stroke Mortality: Racial, Ethnic and Geographic Disparities in the United States, Jan. 2003
Michigan’s Stroke Belt
Source : The Atlas of Stroke Mortality
Acute Stroke / ASA Guidelines
 tPA
if indicated and exclusions
absent
 Anti-platelet within 48 hours (do not
give with tPA)
 Permissive hypertension
 No IV anticoagulants (i.e. heparin) –
DVT prophylaxis okay (after 48 hr if
tPA given)
 CT remains standard acute imaging
ASA guidelines – ischemic stroke
 If
not receiving thrombolytics
– Do not treat unless SBP > 220 or DBP >
120
 If
receiving thrombolytics treat if
– PreRx SBP > 185 DBP > 110
– PostRx SBP > 180 DBP > 105
Doesn’t ACEP also have a
guideline?
 Has
practice guideline
 www.acep.org – type acute stroke
into search box
 I recommend you read it yourselves
if interested
Copied from ACEP website
verbatim
 EDs
and hospitals should work with
emergency medical services and the
community so that all parties know
what the hospital's capabilities are
regarding acute stroke care.
 Further studies are needed to define
more clearly those patients most
likely to benefit from fibrinolytic
therapy in acute ischemic stroke.
Copied from ACEP website
verbatim
 Intravenous
tPA may be an
efficacious therapy for the
management of acute ischemic
stroke if properly used incorporating
the guidelines established by the
National Institute of Neurological
Disorders and Stroke (NINDS).
Copied from ACEP website
verbatim (bolding mine)

There is insufficient evidence at this time to
endorse the use of intravenous tPA in clinical
practice when systems are not in place to
ensure that the inclusion/exclusion criteria
established by the NINDS guidelines for tPA
use in acute stroke are followed. Therefore,
the decision for an ED to use intravenous tPA for
acute stroke should begin at the institutional
level with commitments from hospital
administration, the ED, neurology, neurosurgery,
radiology, and laboratory services to ensure that
the systems necessary for the safe use of
fibrinolytic agents are in place.
tPA
A. Hernandez, M.I. Rochera, R. Angles, M. Farre, J. Caballero:
Hemorrhagic Transformation And A New Ischemic Accident During
Thrombolysis Treatment With rtPA. The Internet Journal of Emergency
and Intensive Care Medicine. 2006. Volume 9 Number 1
Acute stroke - summary
 Time
is brain (notify, notify, notify)
 tPA is your friend
 Watch for fluctuation
 Treat fever
 Consider treating hyperglycemia
 Use crystalloid (think perfusion)
 Avoid dropping BP in ischemic stroke
 Acute Stroke Protocol in place and
ready to go!
Important advance – primary stroke
centers
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
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Acute Stroke Teams
Written Care Protocols
Emergency Medical Services
Emergency Department
Stroke Unit
Neurosurgical Services
Support of Medical Organization
Neuroimaging
Laboratory Services
Outcomes/Quality Improvement
Education Programs
Primary Stroke Centers (JCAHO)
Bixby Medical Center
Borgess Medical Center
Bronson Methodist Hospital
Detroit Receiving Hospital/University Health Center
Henry Ford Hospital and Health Network
Herrick Memorial Hospital
Metro Health Hospital
Northern Michigan Hospital
Providence Hospital and Medical Centers
Saint Mary’s Health Care - Grand Rapids, Mich.
Sparrow Hospital
Spectrum Health - Blodgett Campus
Spectrum Health-Butterworth Campus
St. Joseph Mercy Oakland
St. Mary’s of Michigan Medical Center
University of Michigan Health System – MMC
William Beaumont Hospital
Florida Stroke Act
 Required
EMS to take patients to
primary stroke centers (JCAHO or
state certified)
 Resulted in significantly increased
utilization of tPA at certified centers
 Resulted in increased stroke volume
at certified centers
Important Advance – Stroke Units
 Outcomes
improved (trends)
– Decreased disability
– Reduced discharges to nursing homes
– Reduced mortality
 Behavior
changed
– Increased use of tPA
Important advance –
telemedicine
Disclaimer
 Discussion
from this point (other
than summary) is regarding
experimental therapies
 Some of these may be offered to
patients at centers in Michigan
currently
 Some may not
 Some may turn out not to work…
Options other than tPA
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Intra-arterial tPA (up
to 6 hours)
MERCI retrieval (up to
6-8 hours)
Either could be
considered in selected
cases when systemic
tPA contra-indicated
or outside 3 hr
window
Severity requirement
Source: Imaging
Economics, November
2005
MERCI Device
Source: St. Petersburg Times, October 2003
Recent Negative Research
 NXY-059
(SAINT II)
– Neuro-protective agent
– Primary outcome not reached
 NovoSeven
– Recombinant Factor VIIa
– Hemostatic agent (ICH)
– Primary Outcome Not Reached
– No longer seeking FDA approval
Activated Factor VIIa
NXY-059 (SAINT-II)
Ongoing Acute Stroke Research at
UMHS

Multi-center
–
–
–
–
CLEAR
TNK
INSTINCT
NETT
TNK / CLEAR
 Studying
alternate thrombolytic
regimens to tPA
 Similar inclusion
 Similar outcome measures
 Proposed as potentially safer agents
INSTINCT
 Multi-center
trial
 Targeted educational intervention
 Involves 24 hospitals in Michigan
 Primary endpoint is appropriate use
of tPA
NETT
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A multi-center
network to engage in
acute treatment trials
in Neurologic
Emergencies
System of hubs and
spokes
U of M is clinical
coordinating center
Henry Ford and Wayne
State are hubs
What is being studied
elsewhere
 Encouraging
pilot / safety studies
 Highlighting therapies which may
have impact on acute care in future
IMS-2
 2/3
of standard dose tPA given (0.6
mg/kg)
 Cerebral angiogram
 Additional bolus and infusion at
embolism site
CLOTBUST
Therapeutic hypothermia
Recommended therapy for comatose
survivors of out of hospital cardiac arrest
 Feasibility study done in stroke – further
work ongoing

Prehospital Magnesium
Novel system in LA county
 IV magnesium sulfate given to patients
identified in the field with severe acute
ischemic stroke
 www.fastmag.info

Summary – take home points
 Time
to treatment is key
 Treat fever / hyperglycemia
 Permissive HTN in acute ischemic
stroke
 There are options beyond 3 hours
 A great deal of exciting research is
going on in Michigan and around the
world
The University of Michigan
Comprehensive Stroke Program
Neurology
Neurosurgery
Lewis B. Morgenstern, MD
Director
Julian T. Hoff, MD
Devin L. Brown MD, MS
Michael M. Wang MD PhD
Kate Maddox, RN
Darin Zahuranec, MD
Jennifer Majersik, MD
William Meurer, MD
Epidemiology
Physical Medicine
& Rehabilitation
Lisa DiPonio, MD
B. Gregory Thompson, MD
Lynda D. Lisabeth PhD
Mary N. Haan, PhD
Cardiology
Kim A. Eagle, MD
Radiology
Ellen Hoeffner, MD
Dheeraj Gandhi, MD
Joe Gemette, MD
Emergency Medicine
William G. Barsan, MD
Phillip A. Scott, MD
Robert Silbergleit, MD
Shirley Frederiksen, MS, BSN
Annette Sandretto, MSN
William Meurer, MD
University of Michigan Stroke
Program
 Website
– www.med.umich.edu
 My email – [email protected]
 Please feel free to contact me if you
would like an educational program at
your site!