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The Stroke Unit Stroke Investigations

2. Format. Stroke

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The Stroke Unit Stroke Investigations

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    1. 1 The Stroke Unit & Stroke Investigations Diane Ames Imperial College, St Mary’s Campus April 2008

    2. 2 Format Stroke …. Current drivers and background for change Thrombolysis London stroke services in future Stroke investigations How we manage our patients

    3. 3 The drivers!

    4. 4 “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

    5. 5 “Emergency response is generally lacking”

    6. 6 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

    7. 7 Key indicators RCP 2006 n=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)

    8. 8

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    11. 11 National Strategy for Stroke 2007 Awareness Prevention Carer involvement Acting on warnings Stroke- a medical emergency Stroke Unit quality Rehabilitation Community Supports Workforce issues Service networks

    12. 12 Hyper-acute treatments

    13. 13 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

    14. 14

    15. 15 Ischaemic penumbra PENUMBRA AREA OF ISCHAEMIC TISSUE SURROUNDING AREA OF CELL DEATH. 50% DETERIOATE WITHIN FIRST FEW HOURS.PENUMBRA AREA OF ISCHAEMIC TISSUE SURROUNDING AREA OF CELL DEATH. 50% DETERIOATE WITHIN FIRST FEW HOURS.

    16. 16 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 1IN 50 FATAL !!1IN 50 FATAL !!

    17. 17 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’

    18. 18

    19. 19 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)

    20. 20 “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

    21. 21 ‘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’

    22. 22 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

    23. 23 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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    26. 26 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

    27. 27 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

    28. 28 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

    29. 29 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

    30. 30

    31. 31 CTA

    32. 32 MRA extra or intra- cerebral and carotid dopplers

    33. 33 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

    34. 34 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

    35. 35 Secondary prevention anti-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

    36. 36 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

    37. 37 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

    38. 38 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

    39. 39 Intracerebral haemorrhage on 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

    40. 40 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???

    41. 41 Comprehensive Stroke Centres US 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

    42. 42 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

    43. 43 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

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