STROKE TELEMEDICINERyan Heyborne, MDIdaho Emergency Physicians – June 2009

“Telemedicine can be an effective method to

provide expert stroke care to patients located in rural

areas.”

- 2007 AHA/ASA Stroke Guidelines

Stroke Telemedicine

Stroke Centers limited in Idaho Time critical Many facilities not comfortable with

diagnosis and/or treatment without support

Visual diagnosis helpful Guidance in treatment

Thrombolytics

Stroke Telemedicine (cont)

Stroke Telemedicine. Mayo Clin Proc. 2009;84 ~20 telestroke networks worldwide – CA,

NY, GA, AZ, MI, MA, MD, TX, PA, UT, NV, CO, Canada, Europe

Hub and spoke hospitals Communication established within 40 min of

arrival (initial assessment begun and tests ordered)

Treatments recommended and started within 60 min.

Primary Stroke Center

~200 Hospitals in US

Overview

Tools to provide direction Not meant to be an esoteric lecture

TIA’s Stroke Protocol Thrombolytics Interventional Radiology

TIA’s

TIA defined AHA: “A TIA is a "warning stroke" or "mini-

stroke" that produces stroke-like symptoms but no lasting damage.”

Some controversy regarding “duration” Most < 30 min. Many over 60 min. (never more than 24 h) Practical purposes – only having this discussion

if already resolved.

Kimura K. The duration of symptoms in transient ischemic attack. Neurology 1999

TIA Workup

Predictor of Stroke Angina of the Brain Risk Stratification

Inpatient v. Outpatient Risk Factor Based – ABCD2 Resource Based – Many hospitals can’t do

workup

ABCD2

A (Age); 1 point for age >60 years,

B (Blood pressure > 140/90 mmHg); 1 point for hypertension at the acute evaluation,

C (Clinical features); 2 points for unilateral weakness, 1 for speech

disturbance without weakness, and

D (symptom Duration); 1 point for 10–59

minutes, 2 points for >60 minutes.

D (Diabetes); 1 point

ABCD2 (cont)

ABCD2 Score Guideline only – Clinical Judgment Trumps Validated in Multiple Studies – “Best” for ED Use

Recent Study – Neurology; June 2009 (half in first 24 h)

Stroke risk at 2 days, 7 days, 30 days, and 90 days: Scores 0-3: low risk   (1-4%) Scores 4-5: moderate risk (4-14%) Scores 6-7: high risk (8-23%) Admit Moderate/High risk – Low risk MAY be worked

up as outpatient and started on antiplatelet therapy.Johnston SC. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007.

TIA Workup

Cardiac Monitoring, EKG Head CT Physical Examination Labs, Consider Hypercoag. Carotid Duplex US Consider MRI/MRA Consider Echocardiogram

Treatment

AHA/ASA 2006 – Guidelines for Prevention of Stroke in TIA/Ischemic Stroke Risk Factor Modification: DM/HTN/Tob/etc. Non-cardiogenic ischemic stroke or TIA:

Aspirin Alone – Low dose (81-325 mg/day) adequate Aspirin and Dipyridamole Plavix Alone – increased bleeding risk with Aspirin and

Plavix Cardiogenic – arrhythmia, vascular disease, PFO

Consider Coumadin, referral for cardiology intervention

TIA Summary

Decision of inpatient v. outpatient Resource-based May need stroke center, may not

Stroke

Stroke Protocol

Preparation Maintain patient safety (escort/fall

precautions) Obtain VS, Pulse-ox Monitor, O2 @ 2L (Sat 95%)

History Event History – Time of Onset, affected

function PMH – Recent Trauma or Procedures

Stroke Protocol (cont)

Assessment Respiratory Status – patent airway,

secretions Neurological Status

LOC Speech Clarity and Pattern Facial Symmetry Hand Grip, foot push/pull Paresthesia/Paralysis Blood Glucose Check

NIH Stroke Scale

Within 10 minutes Level of Consciousness Visual – Gaze/Fields Motor –

Facial/Extremities/Ataxia

Sensory – Pinprick Speech Neglect

http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

Stroke Protocol (cont)

Brain Attack Team Activate if symptoms < 3 hours Includes

Emergency Physician Emergency Nurse Phlebotomist CT Tech ED Tech Brain Attack Radiologist Stroke Service

The telemedicine Emergency Physician

Stroke Protocol (cont)

2 IV Sites Labs – Cardiac Panel,

Coags EKG CXR? (2007) Brain Attack Protocol

Head CT Noncontrast Head CT CT angiogram of

carotid artery and Circle of Willis

Intervention

IV t-PA IA t-PA Clot retrieval Admission

ICU if Thrombolytics Telemetry if not

IV t-PA

Studies NEJM 1995 – National Institute of Neurological

Disorders and Stroke (NINDS) Overall, for every 100 patients treated within the first 3

hours, 32 had a better outcome as a result and 3 a worse outcome.

Lancet 2004 – Pooled analysis of multiple studies (ATLANTIS, ECASS, NINDS) 2775 Patients Favorable 3-month outcome

Multiple measures – common - Modified Rankin Scale: Shifting a grade compared to placebo

Odds Ratio 2.81 if < 90 min. Odds Ratio 1.55 90-180 min. Odds Ratio 1.40 180-270 min.

Improved Outcomes

Modified Rankin Score 0 - No symptoms at all 1 - No significant disability despite symptoms; able to

carry out all usual duties and activities 2 - Slight disability; unable to carry out all previous

activities, but able to look after own affairs without assistance 3 - Moderate disability; requiring some help, but able to

walk without assistance 4 - Moderately severe disability; unable to walk without

assistance and unable to attend to own bodily needs without assistance

5 - Severe disability; bedridden, incontinent and requiring constant nursing care and attention

6 - Dead

IV t-PA continued

From St. Al’s t-PA Information sheet: “1 out of 9 received benefit and 1 out of 16 had a

serious bleeding complication…” ECASS 3 (NEJM 2008) - consider out to 4.5 hours

– need more data, may consider in some cases – discuss with neurologist. Risk of Hemorrhage increases from 1.1% to 5.9%

with no significant difference in mortality rate Not FDA Approved – Recommended by ASA with

qualifications Stroke Scale < 25, age <80, anticoagulation, H/O CVA

and DM

Sorting through the Criteria…

Evolving Always at

your fingertips online.

Clinical judgment and open discussion…

IV t-PA Inclusion Criteria

Stroke onset less than 3 hours Age > 18 Informed Consent Neurologic deficit measurable on NIH

stroke scale No specific cut off (around 5 to 22)

CT scan of the brain showing no evidence of intracranial hemorrhage

Labs Reviewed

IV t-PA Exclusion

Evidence of intracranial hemorrhage, mass-efffect or edema on noncontrast head CT, or history of ICH   

High suspicion of subarachnoid hemorrhage (if CT nl)

History of intracranial neoplasm, arteriovenous malformation, or aneurysm

Active internal bleeding (e.g., GI or urinary bleed-21d) Asymptomatic, non-anemic guiac + not absolute

contraindication Within 3 months of previous stroke, intracranial

surgery, serious head trauma Recent acute myocardial infarction (around a

week)

IV t-PA Exclusion (cont)

SBP > 185 or DBP > 110 repeatedly or requiring agrressive Tx to keep below Labetalol 10 mg repeated x 1 OR Nitropaste 1-2” OR Nicardipine infusion 5-15 mg/hr

Major Surgery within 14 days Known bleeding diathesis such as (not limited to)

Platelet count <100,000/mm Heparin/Lovenox within 48 hours and had an elevated

pTT Recent use (48 h) of anticoagulant (e.g., warfarin sodium)

and elevated PT (INR > 1.5) Glucose is <50 mg/dL or >400 Witnessed seizure at stroke onset  

IV t-PA Exclusion (cont)

Only minor (sensory loss, ataxia, dysarthria alone) or rapidly improving stroke symptoms   

Patient has a large stroke/MCA Infarct In consultation with Neurologist NIHSS 22-25 or more

Recent arterial puncture at non-compressible site

Severe complicated condition that may confound treatment (Neuro, Psych, Cancer, AIDS, etc)

Pregnant  

IV t-PA Criteria (cont)

Relative Contraindications Age > 80 Pericarditis/Endocarditis Liver/Kydney Dysfunction Diabetic Hemorrhagic Retinopathy Occluded/Infected AV cannula

(hemodialysis) Lumbar puncture within 7 days Within 14 days of serious trauma

IV t-PA Criteria (cont)

Summary of Indications/Contraindications Requires an open, in-depth discussion with the

patient and family members IF you’re going to do it, do it right… ED “Stroke Packet”

ED orders Thrombolytic Checklist for stroke / Order Sheet

Risk and benefits information sheet Admission Order Sheet So you don’t have to commit it all to memory…

All available on telemedicine web-site

Safe in a Telemedicine Setting

Telemedicine for Safe and Extended Use of Thrombolysis in Stroke: The Telemedic Pilot

Project for Integrative Stroke Care (TEMPiS) in Bavaria

Stroke 2005;36;287-291

“The present data suggest that systemic thrombolysis indicated via stroke experts in the setting of teleconsultation exhibits similar complication rates to those reported in the NINDS and Stroke trial. Therefore, tPA treatment is also safe in this context and can be extended to nonurban areas.”

Giving IV t-PA

“Alteplase” 0.9 mg /kg up to 90 mg 10% as a bolus and the rest to be infused

over one hour. Start at Outside Facility During Transport

Need Paramedic Lifeflight

Giving t-PA (cont)

Q 15 min. BP measurements No Heparin, aspirin, clopidogrel, etc. for

24 hours Standard treatments if having seizure

but prophylaxis not routinely given ICU monitoring Monitor for Bleeding

Post t-PA Blood Pressure Mgmt. 2007 AHA/ASA Stroke Guidelines

Measure Q 15 minutes Don’t treat below ~180/105 Systolic 180-230; Diastolic 105-120

Labetalol – boluses to max of 300 mg v. infusion 2-8 mg/hr

Systolic >230; Diastolic >120 Labetalol as above Nicardipine 5-15 mg/hr (titrate by 2.5 every 5

minutes) Consider nitroprusside

t-PA Reversal

Intracranial Hemorrhage Acute neurologic deterioration, new headache, BP

spike, nausea/vomiting Stop t-PA infusion Stat Head CT Stat Pt, PTT, fibrinogen, Platelet count Prepare for administration of

6-8 units of cryoprecipitated fibrinogen Platelets Factor VII

Neurosurgical consultation Don’t need to have this all available to start

infusion

t-PA Summary

Risk/Benefit Discussion Blood pressure management to 180/110

Labatelol first line 0.9 mg /kg up to 90 mg ICU Admission Follow closely for deterioration

Intra Arterial Thrombolytics

Interventional Radiology Direct Injection Similar Exclusion Criteria

Dissection/Stenosis/Poor Visualization PROACT II (JAMA 1999)

Acute strokes less than 6 hours duration caused by middle cerebral artery occlusion.

180 patients in 54 centers Patients given 9 mg of IA r-proUK PLUS IV

heparin VS IV heparin alone

IA Thrombolytics (cont)

Results Positive

Treatment group – 40% Rankin score of 2 or less Control group – 25% Rankin score of 2 or less

Negative Increase in intracranial hemorrhage with

neurologic deterioration within 24 hours 10% of IA r-proUK vs 2% of control

Overall mortality at 90 days was 25% for IA r-proUK vs 27% of control

IA Thrombolytics Summary

IA t-PA considered equivalent to r-proUK Consider if < 6 hours and lesion

amenable on CTA Decision in consultation with

Neuroradiologist/ Neurologist

Mechanical Retreival

MERCI Retriever (Mechanical Embolus Removal in Cerebral Ischemia)

Consideration up to 6-8 hours

Can be safely combined with IV-tPA – Am J Neuroradiol 2006

Mechanical (cont)

Inclusion Acute large vessel stroke NIHSS ≥ 8 8 hours of symptom onset for MERCI and

Penumbra devices 6 hours of symptom onset for IA tPA

Exclusions Significant cytotoxic edema Blood on Head CT

Allow consideration of the post trauma, post partum, and post surgical patient.

Summary

TIA Risk Factor Stratification Risk management

Stroke Time sensitive treatments St. Al’s is Stroke Center NIH Stroke Scale Appropriate Initial Work-up/Evaluation prior

to transfer/Stroke Team Activation

Summary (cont)

Stroke Treatments IV Thrombolytics

Symptoms less than 3 hours Careful discussion of

indications/contraindications IA Thrombolytics

Symptoms less than 6 hours with favorable lesion

Mechanical Retreival Symptoms less than 8 hours with favorable

lesion

Discussion / Questions