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The Stroke Unit & Stroke Investigations. Diane Ames Imperial College, St Mary’s Campus April 2008. Format. Stroke …. Current drivers and background for change Thrombolysis London stroke services in future Stroke investigations How we manage our patients. The drivers!.

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The stroke unit stroke investigations l.jpg

The Stroke Unit &Stroke Investigations

Diane Ames

Imperial College, St Mary’s Campus

April 2008


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Format

Stroke ….

  • Current drivers and background for change

  • Thrombolysis

  • London stroke services in future

  • Stroke investigations

  • How we manage our patients


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The drivers!


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“Faster access to better stroke care”NAO report 2005

Concluded

  • Treatment was a post-code lottery

  • Stroke - very expensive and very common

  • Key - rapid access to specialised services

  • Delays lead to  deaths/disability

  • Recognised the “abandonment” on discharge

  • Recognised need for higher priority


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“Emergency response is generally lacking”

  • NAO 2005recommendations

tPA

ICH

Better coordination

LAS / Stroke teams

ESD

More acute

treatments &

early scans

Increased

Awareness

Better Community

supports


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RCP 2006 Audit

  • Only 54% patients > 50% stay in SU

  • Too few stroke beds

  • Delays in transfers (into,through & out)

  • Few direct admissions (12%)

  • Delays in CT brain scans

    (42% only within 24 hours)

  • Patients managed on a Stroke unit had better results for all the key indicators


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Key indicators RCP 2006n=13,625

  • Screened for swallow disorder < 24 hours

  • Brain scan < 24 hours

  • Aspirin within 48hours

  • PT within 72 hours; OT within 7 days

  • Weighed, mood assessed

  • Anti-thrombotics ( AF)

  • Rehab goals documented

  • OT home visit (removed this round- 2008)


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Delays: Stroke Onset to hospital(days)

National Sentinel Stroke Audit 2006

0.9% patients took > 10days to be admitted


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More significantly…..

Stroke Onset to hospital admission

(hours)

RCP 2006 National Sentinel Audit


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The main driver for all

current developments

December 2007

Treatment delays can result in

1.9 million neurons lost /minute


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Awareness

Prevention

Carer involvement

Acting on warnings

Stroke- a medical emergency

Stroke Unit quality

Rehabilitation

Community Supports

Workforce issues

Service networks

National Strategy for Stroke2007

10 point action plan focussing on:


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Hyper-acute treatments


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Emergency stroke pathway

  • Suspect a stroke, ring 999

  • LAS use pre-assessment tool (FAST)

  • Pre-alert “hyperacute” receiving hospital

  • “24/7 thrombolysis service available”

  • Stroke team available

  • Immediate scan / decision to treat

  • Transfer to SU

  • Stroke networks emerging to channel patients to receiving centres


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  • LAS Validated tool

  • Use to triage to centre

  • Public awareness campaign


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Ischaemic penumbra

Penumbra

Poorly perfused

Core of infarction

DEAD tissue

Thrombus or embolism

Ischaemic /poorly perfused brain cells may be saved from infarction by prompt treatment


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Thrombolysis

  • rt PA i/v - on licence in Europe since 2002

  • Patients meeting inclusion criteria are able to receive treatment < 3 hours of onset of event

  • ( 6 hours IST-3 – on trial 9-5)

  • 24/7 stroke service at Imperial ( SMH & CXH sites)

  • Highly effective (only 10 people need to be treated to prevent 1 becoming dead or disabled)

  • Risk of intracerebral / other haemorrhage


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Evidence

1. NINDS rt-PA study (NEJM 1995;333(24);1581-7)

  • Showed improved outcomes but  risk of ICH

    2. 2 major reviews

    a) Cochrane (18 trials, 5727 patients, 4 drugs: rtPA, SK, UK, rpUK)

    b) rt-PA pooled data(NINDS, ECASS , ATLANTIS)

  • Cochrane 2003

  • Significant  in death & dependency

    O.R. 0.8 (95% CI 0.69%-0.93%)

  • Non Significant excess of deaths O.R 1.13 (0.86-1.48)

  • ‘The data…may justify the use of thrombolytic therapy’


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ICH in SITS-MOST register

  • Obligatory register n= 6482 treated with rtPA

  • 3/12 mortality 11.3%(cf 17.3 % in RCTs)

  • ‘Symptomatic ICH’ = 1.7%(type 2 bleed, ↓NIHSS ≥ 4)

  • ‘Fatal ICH’ @ 24 hr = 0.3%(type 2 bleed → death @ 24 hr)

  • ‘Fatal ICH’ @ 7 days = 2.2%(any bleed → death @ 7 days)

WahlgrenN et al Lancet 2007; 369: 275–282


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SITS-MOST register

  • “Mortality rates in first 3 months were

    lower in SITS-MOST (11.3%) cf RCTs (17.3%)”

  • “Functional independence at 3 months was higher in SITS-MOST (54.8%) cf RCTs(50.1%)”

  • Concluded

“The results of SITS-MOST confirm that routine

use of alteplase within 3 hours of ischaemic stroke

has a safety profile at least as good as that seen in

RCTs”


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NICE, June 2007

  • ‘Alteplase is recommended for the treatment of acute ischaemic stroke’

  • ‘within 3 hours of the onset of stroke symptoms’

  • ‘Clinically and cost effective’

  • ‘Healthcare organisations should ensure they conform to NICE technology appraisals’


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Urgent CT Brain Scan when…

  • If GCS is reduced

  • If thrombolysis considered

  • If on aspirin,other anti-platelet agent

  • If on warfarin

  • If history of falls, especially H.I. & alcohol

  • Fever, meningism, fluctuating conscious level

  • If uncertain and ?other pathology

  • Otherwise all scanned <24 hours


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CT brain scan

  • Will exclude haemorrhage

    - Acute infarcts are often NOT seen early

    - “normal” scan early does not exclude CI

  • The diagnosis of stroke is clinical….

  • Evidence exists for early anti-platelet Rx

  • Occasionally will identify structural lesions


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St Mary’s Risk Factor profile

n=1112 patients

Vulnerable population!


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General stroke management-all

  • Full clinical assessment

  • Monitor coma scale,T, P, BP ,O2, BM

  • Rehydrate i/v (or po) after swallow screen

  • Catheter not routine

  • Thrombo-prophylaxis (TEDS)

  • Ideally direct admission

  • Feed early ( po or n/g)

  • Pressure relief


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Medical

  • All assessed by Stroke SpR

  • Scan & Dopplers Day1

  • Secondary prevention early

  • Daily Consultant Neurologist or Stroke Physician

    review

  • Further Investigations

    - to clarify deficit/diagnosis

    - to identify underlying aetiology

    - to manage the comorbidity

    - Unusual not to identify a cause


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Cerebral Infarction Investigations

  • Atherothrombotic 50-60%

    RFs : DM,  BP,  lipids, PVD, smoker

  • Cardioembolic 20%

    AF, PAF, carotid disease,prosthetic valves,DCM, poor LV,aortic arch, PFO, atrial myxoma

  • Non-atherothrombotic 10%

    Vasculitides,infective incl HIV, syphilitic, recreational drugs

  • Haematological 5-10%

    HbS, thrombophilias,Anti-Phospholipids,LAC, OC pill,HRT


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Imaging

  • Multi-modal CT

  • CT perfusion/diffusion imaging

    - delineate the penumbra

  • Multi-modal MRI

  • MRI with DWI - diagnostic tool

  • MRI - posterior circulation lesions

  • MRA - looking at vessels , intra/extracranial - After intracerebral haemorrhage

    ? Aneurysm,AVM, structural lesion

  • Carotid Dopplers

    -if symptomatic stenosis – CTA/MRA arch


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MRI


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CTA


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MRA extra or intra- cerebral and carotid dopplers


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Cardiovascular Ix

  • ECG - AF important & common

    - Troponins when ECG changes

  • Echocardiogram

    - especially when suspect cardioembolic source

  • Bubble echo – young/ unexplained

  • Holter monitor

    - PAF, arrthymias common

    - PPM insertion not unusual


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Bloods

  • Routine FBC, Chemistry, Glucose,TFTs, CK

  • Clotting

  • Lipids, vasculitic screen,Treponemal serology

  • Consider

    - Troponins, ABGs

    Young Strokes- search very hard

  • Thrombophilia screen incl LAC, Anti phospholipids Homocysteine

  • Consider

  • LP, HIV


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Secondary preventionanti-platelets / anti-coagulate

  • Only after CT scan excludes haemorrhage

  • Add aspirin 300mg & Dipyridamole 25mg tds

  • Event on aspirin - add dipyridamole

  • Event on A&D - start clopidogrel

  • Aspirin intolerant - clopidogrel

    RCP 2004; Esprit; IST;

  • Usually anti-coagulate for AF @ 2-4 weeks


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Longer term BP management

  • Usually do not treat aggressively for~ 2 weeks

  • Good control > important than agent used

  • Beta -blockers – good for IHD, less beneficial in stroke

  • Diabetic patients targets lower

  • Usually use perindopril, indapamide, CCBs

60-70% patients are hypertensive


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Lipids

  • Simvastatin 40mg ( unless CK raised)

    - caution in renal failure, some drugs

  • If known IHD & on atorvastatin

    - up-titrate to 40mg

  • Concurrent ACS & Stroke - atorvastatin

  • No stroke evidence yet for ezetimibe


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Diabetes

  • ~20% stroke patients diabetic nationally

  • Frequently identify new

  • Insulin by consensus if Blood Glucose > 15

  • If on metformin- stop few days

  • Problems with NG feeding/ PEG feeds

  • HbA1C; renal function; clearance; proteinuria

  • Careful BP management


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Intracerebral haemorrhageon warfarin

  •  risk of prolonged bleeding &  mortality

  • 33% continue to bleed

  • Bleeding correlates well with GCS

  • Needs rigorous reversal of INR

  • Intensive monitoring

  • Use multiple agents /haematology advice

  • Rescan if GCS falls

Steiner S et al .ICH Associated With Anticoagulant Therapy Stroke 2006;37:256-262


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London future stroke services

  • NWT Stroke clinical reference group

  • Developing standards, pathways

    In conjunction with

  • Cardiac and Stroke Networks

  • Hub(s) –offering a comprehensive service

  • Spokes offering acute services ~ 7am-7pm

  • How many comprehensive services???


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Comprehensive Stroke CentresUS style

Outcomes

  • Increased use of lytic agents – all routes

  • Improved complex stroke management

  • Specific interventions, surgery, ITU facilities, 24/7 availability

  • Improved outcomes & decreased LOS

    AHA recommends

  • clusters of primary centres closely associated with comprehensive centres


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Chain of survival!

  • Detection -recognition of stroke

  • Dispatch -call 999 & priority LAS

  • Delivery -prompt transport & pre-hospital notification

  • Door - Immediate triage

  • Data - Assessment, bloods, imaging

  • Decision - Diagnosis & decision re therapy

  • Drug - Appropriate drug/other intervention

Adams et al. AHA Guidelines Stroke 2007;38;1655-1711


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Summary

Stroke is a medical emergency

24/7 i/v thrombolysis routine

Clot retrieval & intra-arterial Rx next

Outcomes improved with rapid assessment and treatment on a stroke unit early

Multi professional input is integral

Stringent risk factor management is key

Remember

Time lost = Brain lost


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