Acute Stroke: Recognizing and Reacting

1. Acute Stroke:Recognizing and Reacting Dr. Grant Stotts Stroke Neurologist, Ottawa Hospital

2. 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

4. Presentation Goals • Review the signs of stroke • Emphasis the crucial role fast response plays in stroke treatment • Recognize potential of available treatments • Acute • Preventative

5. Warning Signs of Stroke • Weakness • Troubles Speaking • Vision Problems • Sudden Headache • Dizziness

6. Warning Signs of Stroke • Weakness • Sudden loss of strength or sudden numbness in the face, arm or leg, even if temporary Updated October 2006

7. Warning Signs of Stroke • Trouble Speaking • Sudden difficulty speaking or understanding or sudden confusion, even if temporary. Updated October, 2006

8. Warning Signs of Stroke • Vision Problems • Sudden trouble with vision, even if temporary. Updated October, 2006

9. Warning Signs of Stroke • Headache • Sudden severe and unusual headache. Updated October, 2006

10. Warning Signs of Stroke • Dizziness • Sudden loss of balance, especially with any of the above signs. Updated October, 2006

11. Stroke Warning Signs • Stroke recognition is impaired by: • Lack of awareness • Lack of pain Weakness Troubles Speaking Vision Problems Headache Dizziness

12. A Stroke in Ottawa

13. 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 tomography) scanner

14. Normal CT

15. CT With a Stroke

16. CT With a Bleed

17. Acute Stroke TreatmenttPA • 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)

18. Time is Everything • Time is the most important factor • Nothing else is more important to open up the artery

19. 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

20. MR Angiogram

21. Blocked middle cerebral artery Restored flow

22. 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

23. Merci Retriever

24. Merci System Animation

25. Telestroke Technology RemoteHospital Base Hospital ISDN or VPN VPN Efilm Server Courtesy: Dr. M. Sharma

26. Research Presently Taking Place

27. Desmoteplase New agent for breaking up blood clots Given IV Similar to tPA

28. Desmoteplase • Desmodus rotundus • Vampire BatSalivary PA • Recombinant DSPAα1 • High Fibrin Selectivity • sICH Low = Stringent • Dependence on Fibrin • Therapeutic window 9hr • Low Fibrinogenlysis • t1/2 = 138 min

29. 10 130 30 8 104 24 6 78 18 4 52 12 2 26 6 0 0 0 CBV (ml/100g) CBF (ml/100g/min) MTT (sec) CT Perfusion Imaging in Acute Stroke – Ischemic Penumbra CBV CBF MTT

30. How Well Are We Doing Now?

31. Ontario tPA Rates by Hospital2003 N = 4,107 Overall tPA Rate 9% (Ischemic Patients) Courtesy: Dr. Michael Sharma, Medical Director Stroke Program, The Ottawa Hospital

32. 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

33. Courtesy: Dr. M. Sharma

34. Canadian and Ontario Stroke Strategies

35. The Ontario Stroke System Best Practice across the Continuum of Care Emergency Acute Prehospital Transition Prevention Rehab Community Stroke recognition • Stroke Strategy Principles: • Comprehensive • Integrated • Evidence-based • Province Wide

36. 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 Statistics Canada Kiely DK, et al. Stroke 1993;24:1366-1371

37. 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

38. Outcome of Ischemic Stroke Adapted from Stegmayr B, et al. Stroke 1997;28:1367-1374

39. 11 Regions 9 Regional Stroke Centres 2 Enhanced District Stroke Centres 16 District Stroke Centres 24 Stroke Prevention Clinics

40. Champlain Region

41. 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)

42. 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 Impact of an Integrated Strategy

43. 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

44. Aware of 2 or more signs Aware of key warning signs Dizziness Vision problems Trouble speaking Headache 2003(%) 2005(%) 52 72 43 62 25 45 23 41 29 32 Awareness of Stroke Warning Signs

45. Ottawa Performance2006 • 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%

46. What If The Symptoms Are Temporary?

47. TIA Management • TIA is the equivalent of angina • Warning sign of stroke

48. Risk of Stroke After TIA Gladstone et al, CMAJ, 2004, Mar 30:170(7):1099