The document discusses acute stroke, including that it is a leading cause of death and disability. It describes the two main types, ischemic and hemorrhagic stroke, and warning signs. Treatment has advanced from supportive care in 1990 to include therapies like IV tPA and endovascular procedures. Prehospital systems aim to rapidly identify and transport stroke patients to appropriate facilities.

1. Stroke & The EMS Response 07/08/2009 Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC, Mercy Air, San Bernardino County FD, Barstow FD

4. Acute Ischemic Stroke

5. Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage

7. Cerebrovascular Disease Pathogenesis Cardioembolic (30%) Lacunar (25%) (small vessel disease) Ischemic Stroke (83%) Hemorrhagic Stroke (17%) Subarachnoid Hemorrhage (30%) Cryptogenic (5%) Atherothrombotic Cerebrovascular Disease (30%) Intracerebral Hemorrhage (70%) Other (vasculitiis, dissection, hypercoagulable, etc (10%)

12. Emergent Stroke Care & The Chain of Survival Patient Calling EMS ED Stroke Stroke Knowledge 911 System Staff Team Unit

18. The 6 Major Stroke Clinical Syndromes Syndrome Symptoms/Signs Cerebral Hemisphere Ischemia Contralateral hemiparesis, hemisensory Contralateral visual field defect Aphasia (left) / Hemispatial neglect (right) Brainstem Ischemia Decreased LOC Unilateral or bilateral weakness, sensory Dysconjugate gaze, dysarthria, dysphagia, vertigo Cerebellar Ischemia Ataxia, nystagmus Lacunar (small vessel) Ischemia Motor/sens/ataxia without language, neglect, visual Intracerebral Hemorrhage One of above focal syndromes, plus Headache, N/V, decreased LOC Subarachnoid Hemorrhage Thunderclap headache Neck stiffness Decreased LOC

21. How Did we Get Here? The NINDS Trail

22. IV TPA FOR STROKE 3-4.5 HR’s? ECASS 3

23. Prehospital Trails- Fast-Mag

29. Stroke Treatment In The Emergency Department < 3 Hrs = Hyperacute therapy when nearly all patients have penumbra

30. The Ischemic Penumbra Core Infarct Ischemic Penumbra: zone of salvageable tissue surrounding core infarct

31. Strategies to Identify Patients with Salvageable Ischemic Penumbra < 3 Hrs = > 3 Hrs Hyperacute therapy when nearly all patients have penumbra Time From Onset (Hours) % Patients with Penumbra Imaging required to assess pathophysiology

41. Intra-arterial Recanalization Therapies

42. Intra-arterial Recanalization Approaches Thrombolytics Mechanical Techniques

44. Merci Retriever Devices X5, X6 Five helical loops, conical, X6 more resistant to stretching L5, L6 Helical loops, cylindrical, arcading filaments K-mini Helical loops with counter-twist, cylindrical, smaller diameter V-Series 7 helical loops (2 small distal loops), filaments, variable spring rate

45. Merci ® Retrieval System Balloon Guide Flexible, helical shaped, tapered tip made of nitinol wire Merci = mechanical embolus retrieval in cerebral ischemia

46. Find it, Engage it, Retrieve it

47. UCLA – MCA Occlusion 30-Year-Old Female – Baseline NIHSS 24 Symptom Onset to Final Angiogram – 5:37 NIHSS 24 hours 1 mRS 5 days post 0 30 days post 0 90 day post 0

52. Multimodal Diffusion-Perfusion MRI Tissue Status Bioenergetic Compromise Perfusion Status Hemodynamic Compromise Vessel Status Occlusions or Stenoses DWI PWI MRA

53. Multimodal CT Imaging Tissue Status Bioenergetic Compromise Perfusion Status Hemodynamic Compromise Vessel Status Occlusions or Stenoses CT PCT CTA

54. Intracerebral Hemorrhage Therapies BP control Ventriculostomy for Hydrocephalus Hemorrhage evacuation Cerebellar, cortical

59. Noncontrast CT – L MCA hyperdense sign

60. Noncontrast CT – L MCA hyperdense sign

67. DWI PWI MRA

76. DWI PWI Day 5 Pre

78. Acute Ischemic Stroke Care in the 21 st Century Symptoms Primary Stroke Center Neuroprotectants EMS 911 Comp Stroke Center EMS IV Lytic Imaging Imaging IA Mechanical or Lytic Angiogram Cath Lab Neuroprotectants Stroke Unit

79. • EMS play a critical role in the emergency care of acute stroke patients. • Over 400,000 acute stroke patients are being transported annually by EMS providers. • Just over half of all stroke patients use EMS, but those who do comprise the majority of patients presenting within the 3 hour window for acute treatment. • EMS use decreases time to hospital arrival, physician exam, CT imaging, neurologic evaluation, and ability to implement acute stroke intervention Key Points

80. • There are more than 750,000 strokes per year. • 163,000 die from stroke every year in america • stroke is the third leading cause of death • stroke is the leading cause of disability in adults • 4.4 million survivors; only 50-75% of stroke survivors regain functional independence • estimated direct/indirect costs for 2007- $62.7 billion • 14% of persons who survive a first stroke or TIA will have another within one year The Impact of Stroke

81. A pea sized piece of brain dies for every 12 minutes that treatment is delayed. Each minute you wait you lose close to 2 million brain cells. Time is Brain

82. TPA For Stroke 3 hours of symptom onset (NINDS trial) 4.5 hours of symptom onset (ECASS 3) 7 D’s detection, dispatch deliverly, door, data, decision, drug Stroke & The EMS Response

83. Use of TPA for acute stroke 1999-2004 treatment rates for ischemic stroke: 1% Schumacher C et al: use of thrombolysis in Acute Ischemic Stroke. ANN Emerg Med. 2007;50:99-107 Stroke & The EMS Response

84. Stroke mimics cortical vs noncortical stroke cranial nerves awake breathing Stroke & The EMS Response

85. Left side right side at threshold of new therapies that require us as an EP to statify…in the same way we do with mi patients Stroke & The EMS Response

86. For the first time in a decade it will matter what type of stroke syndrome they have lacunar or cortical cortex..Big vessels mca, cath lab get rid of clot language involved you have just localized to the cortex… angiogram, cta, mra ventriculosotomy massive territory stroke do they need a ventriculostomy risk stratification…language on the left sensory exam more likely to be cortical lacunar infarcts characterized small vessel disease less likely to get edema Stroke & The EMS Response

87. Lacunar different treatment arm lacunar vs cortical You only have one ICU bed, which is more likely to have complications the cortical is! Stroke mimics dissection, infective endocarditis, ekg, vegitations, intermittent afib, cardiac cerebral axis… Stroke & The EMS Response

88. Mimics: Encephalopathy Endocrine Dissection Endocarditis MRI What do the Neurologist want? What is the right risk stratification test noncontrast ct Stroke & The EMS Response

89. Types of Specialized Studies: Tissue Groups ct perfusion studies…contast studies with special protocols that show blood flow, be able top ick out the dead the core infarct vs the pneumbra poor The Vessels diffusion weighted- MRI picks up a dead core of an infarct, picks up early changes in cell death dead core of an infarct perfusion weighted- shows us the blood flow… will help us hone our therapies Stroke & The EMS Response

90. CT…about the vasculature, can we see where the obstruction is CTA vs MRA MR…. Stroke & The EMS Response

91. ABC’s, tube em, what if they have a fever should we cool em fever associated with poorer outcomes, increase temp increase metabolic demmand, so do we cool them, tylenol, whats causing the fever ? Pneumonia one of the biggest killer of people having a stroke, keep patients NPO…is the fever because they aspirated… TPA candidate Blood pressure control under 185/110 220/120 it could be harmful to lower the blood pressure in these individuals acclimated to the higher blood pressures Stroke & The EMS Response

93. BP Control Nipride less popular toxicity concern difficult to use problem in renal failure dilates cerebral vessels steal phenomenon with some Labetolol 10mg iv….up to about 300mg longer half life no concern about cocaine Nicardipine titratable less toxic effects Stroke & The EMS Response

94. Hyperglycemia trend towards tighter control trauma, sepsis, stroke most of this literature of an association type 80-140 UK study flies in the face of that should we use heparin, doesn’t appear to have any of the benefits of TPA not indicated in acute ischemic stroke…so if you have a cardio embolic source they have been waiting 72 hours to a week to put them on anticoagualtion. hypotension Stroke & The EMS Response

95. Don’t combine the ASA with TPA what about plavix? 7mg 5 days to steady state many are loading 300mg….jury still out moderate hypothermia does it work for stroke, most neuroprotective therapies have failed in human trials vasodilators…no carotid endarectomy…no doesn’t work, its too late endovascular interventions…look promising up to 8 to 9 hours Neuroprotective agents…don’t really have a good one yet 2007 Stroke & The EMS Response

96. Attention to the basics swallow eval, pneumonia, dvt, sepsis, head of the bed up, npo in the ed. Treatment of acute neurological complications lie at the nexus between medical and surgical disease, dense hemiparesis cortical- sensory, language, spatial, perception problem along with it. Get drowsy likely to go down hill. Cerebellar infarct- posterior strokes, bleed is a surgical emergency, infarct may also be surgical patient need decompression, your swelling in a confined space. Stroke & The EMS Response

97. Malignant MCA syndrome Roy was attached by montecue the tiger hemicraniectomy, they realized that he would die without it. Venticulostomy to relieve pressure hemorrhagic transformation seizures- treat them, they generally don’t recommend prophylaxis, latter with scaring they then tend to generate the epilogenic foci. Stroke & The EMS Response

98. Stokes Mimics 24 hour cardiac monitoring from time of onset think about the heart brain axis cortical vs noncortical vs lacunar imaging noncontrast dead vs not quite dead is there an ischemic pneumbra that would could save treat pain, drain bladder, npo, keep hob elevated good BP control get all your specialist involved tight glycemic control ? What do we want to do? Stroke & The EMS Response