Beruflich Dokumente
Kultur Dokumente
July 2012
Volume 14, Number 7
In The Emergent Treatment Authors
800,000 patients each year. The physical, emotional, and financial Peter D. Panagos, MD, FAHA, FACEP
Associate Professor, Department of Emergency Medicine and
toll stroke inflicts on patients and their families cannot be overstat- Neurology, Washington University School of Medicine, St. Louis, MO
ed. At the forefront of acute stroke care, emergency clinicians are Matthew R. Reynolds, MD, PhD
positioned to have a major impact on the quality of care that stroke Department of Neurological Surgery, Washington University School of
Medicine, St. Louis, MO
patients receive. This issue outlines and reviews the literature on
J Mocco, MD, MS, FAANS, FAHA
4 evolving strategies reflecting developing advancements in the Associate Professor of Neurological Surgery, Radiology, and Radiological
care of acute ischemic stroke and their potential to impact patients Sciences, Vanderbilt University Medical Center, Nashville, TN
in the emergency department setting: (1) the expanding window Peer Reviewers
for intravenous rt-PA, (2) the use of multimodal computed tomo- Andrew Asimos, MD
graphic scanning in emergent diagnostic imaging, (3) endovascu- Director of Emergency Stroke Care, Carolinas Medical Center,
lar therapies for stroke, and (4) stroke systems of care. Whether Charlotte, NC
practicing in a tertiary care environment or in a remote emergency Joshua S. Broder, MD, FACEP
Associate Professor, Residency Program Director, Division of
department, emergency clinicians will benefit from familiarizing Emergency Medicine, Duke University Medical Center, Durham, NC
themselves with these advancements and should consider how Christopher Lewandowski, MD
these new approaches might influence their management of pa- Residency Program Director, Vice Chair, Department of Emergency
Medicine, Henry Ford Hospital; Clinical Professor of Emergency
tients with acute ischemic stroke. Medicine, Wayne State University, Detroit, MI
Editor-in-Chief Carolina School of Medicine, Chapel Charles V. Pollack, Jr., MA, MD, Stephen H. Thomas, MD, MPH International Editors
Andy Jagoda, MD, FACEP Hill, NC FACEP George Kaiser Family Foundation
Peter Cameron, MD
Professor and Chair, Department of Chairman, Department of Emergency Professor & Chair, Department of
Steven A. Godwin, MD, FACEP Academic Director, The Alfred
Emergency Medicine, Mount Sinai Medicine, Pennsylvania Hospital, Emergency Medicine, University of
Associate Professor, Associate Chair Emergency and Trauma Centre,
School of Medicine; Medical Director, University of Pennsylvania Health Oklahoma School of Community
and Chief of Service, Department Monash University, Melbourne,
Mount Sinai Hospital, New York, NY System, Philadelphia, PA Medicine, Tulsa, OK
of Emergency Medicine, Assistant Australia
Editorial Board Dean, Simulation Education, Michael S. Radeos, MD, MPH Jenny Walker, MD, MPH, MSW
University of Florida COM- Assistant Professor of Emergency Assistant Professor, Departments of Giorgio Carbone, MD
William J. Brady, MD
Jacksonville, Jacksonville, FL Medicine, Weill Medical College Preventive Medicine, Pediatrics, and Chief, Department of Emergency
Professor of Emergency Medicine,
of Cornell University, New York; Medicine Course Director, Mount Medicine Ospedale Gradenigo,
Chair, Resuscitation Committee, Gregory L. Henry, MD, FACEP
Research Director, Department of Sinai Medical Center, New York, NY Torino, Italy
University of Virginia Health System, CEO, Medical Practice Risk
Emergency Medicine, New York
Charlottesville, VA Assessment, Inc.; Clinical Professor Ron M. Walls, MD Amin Antoine Kazzi, MD, FAAEM
Hospital Queens, Flushing, New York
of Emergency Medicine, University of Professor and Chair, Department of Associate Professor and Vice Chair,
Peter DeBlieux, MD
Michigan, Ann Arbor, MI Robert L. Rogers, MD, FACEP, Emergency Medicine, Brigham and Department of Emergency Medicine,
Louisiana State University Health
FAAEM, FACP Women’s Hospital, Harvard Medical University of California, Irvine;
Science Center Professor of Clinical John M. Howell, MD, FACEP
Assistant Professor of Emergency School, Boston, MA American University, Beirut, Lebanon
Medicine, LSUHSC Interim Public Clinical Professor of Emergency
Medicine, George Washington Medicine, The University of Scott Weingart, MD, FACEP
Hospital Director of Emergency Hugo Peralta, MD
University, Washington, DC; Director Maryland School of Medicine, Associate Professor of Emergency
Medicine Services, LSUHSC Chair of Emergency Services,
of Academic Affairs, Best Practices, Baltimore, MD Medicine, Mount Sinai School of
Emergency Medicine Director of Hospital Italiano, Buenos Aires,
Faculty and Resident Development Inc, Inova Fairfax Hospital, Falls Alfred Sacchetti, MD, FACEP Medicine; Director of Emergency Argentina
Church, VA Assistant Clinical Professor, Critical Care, Elmhurst Hospital
Francis M. Fesmire, MD, FACEP Dhanadol Rojanasarntikul, MD
Department of Emergency Medicine, Center, New York, NY
Director, Heart-Stroke Center, Shkelzen Hoxhaj, MD, MPH, MBA Attending Physician, Emergency
Chief of Emergency Medicine, Baylor Thomas Jefferson University, Medicine, King Chulalongkorn
Erlanger Medical Center; Assistant Senior Research Editor
College of Medicine, Houston, TX Philadelphia, PA Memorial Hospital, Thai Red Cross,
Professor, UT College of Medicine,
Scott Silvers, MD, FACEP Joseph D. Toscano, MD Thailand; Faculty of Medicine,
Chattanooga, TN Eric Legome, MD
Chair, Department of Emergency Emergency Physician, Department Chulalongkorn University, Thailand
Nicholas Genes, MD, PhD Chief of Emergency Medicine, King’s of Emergency Medicine, San Ramon
Medicine, Mayo Clinic, Jacksonville, FL
Assistant Professor, Department of County Hospital; Associate Professor Regional Medical Center, San Suzanne Peeters, MD
Emergency Medicine, Mount Sinai (Visiting), SUNY Downstate College of Corey M. Slovis, MD, FACP, FACEP Ramon, CA Emergency Medicine Residency
Medicine, Brooklyn, NY Professor and Chair, Department Director, Haga Hospital, The Hague,
School of Medicine, New York, NY
Keith A. Marill, MD of Emergency Medicine, Vanderbilt Research Editor The Netherlands
Michael A. Gibbs, MD, FACEP University Medical Center; Medical
Assistant Professor, Department of Matt Friedman, MD
Professor and Chair, Department Director, Nashville Fire Department and
Emergency Medicine, Massachusetts Emergency Medicine Residency,
of Emergency Medicine, Carolinas International Airport, Nashville, TN
General Hospital, Harvard Medical Mount Sinai School of Medicine,
Medical Center, University of North
School, Boston, MA New York, NY
Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Thurman, Dr. Reynolds, Dr. Broder, and their
related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. The following
disclosures of potentially relevant financial interests were made: Dr. Jauch, Chair, American Heart Association Stroke Council; Dr. Panagos, NIH, NINDS, Genentech, Inc.; Dr. Mocco,
Officer, Lazarus Effect; Dr. Asimos, Genentech, Inc.; Dr. Lewandowski, Medical Dialogues Group, Inc.; Dr. Jagoda, Executive Committee, Brain Attack Coalition. Commercial Support: This
issue of Emergency Medicine Practice did not receive any commercial support.
Case Presentations Strokes may be classified as ischemic (87%),
hemorrhagic (10%), or subarachnoid hemorrhage
A 64-year-old male presents to the ED with the acute (3%). The distinction between these stroke subtypes
onset of profound right-sided motor weakness and expres- is paramount, given the distinctly different diagnos-
sive aphasia. The patient has no headache, no history of tic imaging modalities, treatment paradigms, and
trauma, and no other problems upon presentation. His preventative measures used in their management.
only chronic medical problem is hypertension that is well The important role played by emergency clinicians
controlled on his medications. His wife witnessed the in the care of acute ischemic stroke cannot be over-
onset of his symptoms while they were eating dinner 3.5 emphasized. Because they are always on the front
hours prior to arrival. He has normal vital signs, and lines of acute illness, emergency clinicians serve a
a stat CT scan of the head is normal as are his labora- critical role in the appropriate triage, workup, man-
tory studies. His deficits have persisted throughout his agement, and disposition of acute stroke patients.
expedited workup and he is now 4 hours into an acute Without the expertise and skill of emergency medi-
ischemic stroke (an hour beyond the FDA-approved treat- cine providers, patients affected by stroke have little
ment window for intravenous rt-PA), with a calculated hope of receiving an expedited workup, much less
NIHSS score of 16. What emergent treatment options, if the rapid and appropriate treatment decision that
any, do you have for this patient? offers their best hope for neurological recovery.
A 56-year-old male presents to the ED with a dense Recent years have seen an explosion of advance-
right-sided hemiparesis along with global aphasia and a ments in the care of acute ischemic stroke patients.
leftward gaze deviation. He appears anxious, but other- This article reviews 4 of the major evolving key ele-
wise he is in no acute distress and has normal vital signs. ments that are changing the emergent management
He was last seen normal approximately 9 hours ago, as of acute ischemic stroke and are forming the basis of
he and his wife were going to bed. Upon awakening in the emergent stroke care for the future. Sections include:
morning, he exhibited symptoms and was rushed to your • Section I: The Expanding Window Of Opportu-
hospital. His significant neurologic deficits persist, and nity In Acute Stroke: The Extended Window For
his head CT shows only a hyperdense MCA sign on the Intravenous rt-PA Use (page 3)
left. What further diagnostic and therapeutic measures • Section II: The Use Of Multimodal Computed
can be utilized to manage this patient’s severe ischemic Tomography In Acute Stroke Imaging (page 6)
stroke? • Section III: Endovascular Therapies For Acute
A 72-year-old female presents to your ED with a se- Ischemic Stroke (page 12)
vere left-sided hemiparesis, rightward gaze deviation, and • Section IV: Stroke Systems Of Care (page 16)
hemineglect. She is a highly functioning lady and very ac-
tive in her community. She had originally presented to an Whether practicing in a major tertiary care
outside clinic and was then transferred to your ED. Her center or in a remote emergency department (ED)
witnessed onset of symptoms occurred 6.5 hours prior to setting, emergency clinicians must be familiar with
arrival, and her workup is negative other than a slight advances in stroke care and how to best apply these
loss of grey-white differentiation in her right middle cere- advances to their practice setting.
bral artery distribution on noncontrasted head CT. What There continue to be many controversies related
therapeutic options might you employ to best emergently to acute stroke care, and the authors recognize that
manage this woman’s condition? there is significant regional and local variation in
practice. Many considerations must be taken into
Introduction account when tailoring a management strategy for
the individual patient. The authors recommend that
Stroke is the fourth leading cause of death in the every hospital proactively develop protocols that ad-
United States and the leading cause of long-term dress likely scenarios and thus maximize the deliv-
disability in adults.1 Every year in the United States, ery of care and minimize liability.
approximately 795,000 individuals experience a
new or a recurrent stroke.2 Of these episodes, 77% Abbreviations
(610,000) are initial attacks; 23% (185,000) are re-
current attacks. The risk of stroke is higher in men A list of abbreviations can be found on page 28.
than in women, in blacks than in whites, and in
older than in younger individuals. Stroke imparts a Review Of The Literature
tremendous medical, emotional, and fiscal burden
to society; annual costs for stroke care in the United The literature was searched using Ovid MED-
States alone exceed $73 billion.1 Clearly, improve- LINE® and PubMed from 1990 to present. Areas
ments in early stroke care may reduce not only the of focus and key words included acute ischemic
morbidity and mortality of this devastating disease stroke, computed tomographic angiography, computed
but also the significant financial cost. tomographic perfusion, multimodal computed tomogra-
Abbreviations: ATLANTIS, Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke; ECASS, European Cooperative Acute Stroke
Study; IST-3, Third International Stroke Trial; mRS, modified Rankin Scale; NA, not available; NINDS, National Institute of Neurological Disorders and
Stroke; rt-PA, recombinant tissue plasminogen activator; sICH, symptomatic intracerebral hemorrhage; SITS-ISTR, Safe Implementation of Treatments
in Stroke-International Stroke Thrombolysis Registry.
Patient presents within 0 to 3 hours Patient presents within 3 to 4.5 hours Patient presents within 8 hours from
from symptom onset from symptom onset symptom onset OR patient with clinical
failure of IV thrombolytic therapy who
remains within 8-hour window
Utilize inclusion and exclusion criteria
Utilize inclusion and exclusion criteria
for IV thrombolytic therapy (following
for IV thrombolytic therapy (following
established local guidelines founded
established local guidelines founded in
in NINDS criteria) with the following Consider endovascular therapy
NINDS criteria)
exceptions:
Additional inclusion criterion:
• 3 to 4.5 hours from symptom onset
Discuss risk/benefit with patient and/or
family, when feasible Additional exclusion criteria:
• Age > 80
Discuss risk/benefit with patient and/or
• NIHSS score > 25
family, when feasible
• Use of any anticoagulants regardless
of INR
Give IV rt-PA to appropriately selected • History of stroke AND diabetes
patients (Class I)*
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright ©2012 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.
Diagnostic Techniques
• MRI with diffusion • MR perfusion
• MRA/MRV • CT perfusion
• CTA • Xenon CT
• Digital subtraction cerebral catheter angiography • SPECT
• Transcranial Doppler • PET
• Carotid duplex ultrasound
• Transesophageal echocardiography
Infrastructure
• Stroke unit** • Stroke clinic
• Intensive care unit • Air ambulance
• Operating room staffed 24/7 • Neuroscience intensive care unit
• Interventional services coverage 24/7
• Stroke registry
Educational/Research Programs
• Community education • Clinical research
• Community prevention • Laboratory research
• Professional education • Fellowship program
• Patient education • Presentations at national meetings
*Although these therapies are currently not supported by Grade IA evidence, they may be useful for selected patients in some clinical settings.
Therefore, a Comprehensive Stroke Center that does not offer these therapies should have an established referral mechanism and protocol to send
appropriate patients to another facility that does offer these therapies.
**Stroke unit may be part of an intensive care unit.
Abbreviations: 24/7, 24 hours a day, 7 days a week; CT, computed tomography; CTA, computed tomographic angiography; MRA, magnetic resonance
angiography; MR, magnetic resonance; MRI, magnetic resonance imaging; MRV, magnetic resonance venography; PET, positron emission tomogra-
phy; SPECT, single-photon emission computed tomography.
Adapted with permission from Alberts MJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: a consensus statement
from the Brain Attack Coalition. Stroke. 2005;36(7):1597-1616.
Conclusion
The present time is an exciting one in the stroke
community, as the cutting edge of acute stroke care
continues to evolve. With advancements in the emer-
gent management of stroke, emergency clinicians
may be encouraged by increasingly more opportu-
nities to positively affect the care of patients with
acute ischemic stroke. As the study and refinement
of these new treatment strategies continues, hope
grows stronger that more and more patients will be
eligible for and more effectively selected for state-of-
the-art reperfusion therapies. As a result, the poten-
tial to decrease the terrible morbidity and mortality
associated with acute stroke serves as a driving force
1. “I realized that the patient met criteria for throm- 6. “I really thought it was conversion disorder.”
bolytics, but I was afraid she would have a hem- A robust knowledge of the signs and symptoms
orrhage if I gave thrombolytics, and I would get of stroke as well as insight into more unusual
sued.” presentations for stroke, coupled with a thorough
There are far more lawsuits filed against emergency and expert neurological examination, are critical
physicians for failure to administer thrombolytic in avoiding the misdiagnosis of an acute stroke
therapy than for complications of the treatment. as a manifestation of psychiatric illness. Beware
Adherence to a well-developed acute stroke of cognitive biases, and make sure that all
protocol agreed upon by local practice is the best patients with any alterations in baseline function
defense in any malpractice scenario. receive very careful consideration.
2. “I didn’t realize the patient was anticoagulated 7. “It seemed like benign positional vertigo to
before I gave thrombolytic therapy.” me.”
A thorough review of the patient’s medication Vertigo can be very difficult to differentiate in
and allergy list is always indicated prior to the its etiology. When in doubt, consider posterior
administration of any drug. If a patient is on circulation ischemia as an etiology, especially
warfarin, the patient’s INR must be known before when additional symptoms (double vision,
thrombolytics are administered. If the patient is coordination problems, difficulty walking, etc.)
on warfarin and is beyond the 3-hour treatment are present.
window, IV thrombolytics are contraindicated, per
ECASS III guidelines. 8. “The patient came into the ED 5 hours into his
acute stroke. It was too late to do anything.”
3. “I gave the patient thrombolytics for the stroke, Be aware of surrounding resources in acute
but the patient had a massive gastrointestinal stroke care. If you do not practice in a center
hemorrhage. I didn’t realize he had a significant that offers endovascular therapies that can be
gastrointestinal bleed a week ago.” deployed long after IV thrombolytic windows
A thorough review of the indications and close, know whether or not surrounding facilities
contraindications of thrombolytic therapy is always offer such therapies. Some lawsuits arise because
indicated prior to the initiation of treatment. of a failure to consider transferring a patient to
Careful attention to the contraindications for a higher level of care when the patient remains
therapy will help the practitioner avoid pitfalls. within endovascular therapeutic windows but
does not receive an opportunity for treatment.
4. “I didn’t see the hemorrhage on the CT scan.”
Rapid interpretation of the noncontrasted head 9. “Everything was going fine, but it took too long
CT for hemorrhage is essential to successful to get the CT done.”
thrombolytic therapy. The expertise to identify Time targets for the completion of emergent studies
acute hemorrhage is paramount when interpreting are well-established. Delays in the acquisition of
this study prior to the administration of emergent studies are commonly cited as deviations
thrombolytic therapy. If one is uncomfortable in the standard of care by plaintiffs. Well-designed
making this determination, rapid access to acute stroke protocols — in place and rehearsed
adequate radiologic expertise must be a part of any prior to patient arrival — serve to streamline
acute stroke treatment protocol. the care of stroke patients, optimizing care and
minimizing delays.
5. “We didn’t realize the patient was having a stroke
until it was too late. The symptoms were mild, 10. “I can’t believe she had a stroke. The neck pain
and the patient was in our waiting room for 3 seemed musculoskeletal.”
hours before he was brought back.” Remember that cerebrocervical arterial
In the era of significant ED overcrowding, accurate dissections may occur following blunt trauma
and timely triage is paramount. Easy-to-follow to the neck as well as spontaneously. Know
information on the signs and symptoms of stroke the risk factors for carotid and vertebral artery
should be made available to all triage personnel, dissections and consider the diagnosis in any
with an understanding to immediately bring any case of headache, neck pain, or vertigo or with
patient meeting suspicion for acute stroke to the any neurologic symptoms, especially following
attention of the attending ED physician. trauma to the head or neck or in any other risk-
associated scenario.
CT scanning is to:
a. Identify patients suffering a wake-up stroke
Emergency
who might still benefit from reperfusion
b. Identify patients who might benefit from Medicine Practice
therapy despite an INR > 3
c. Identify patients who might benefit from
hypothermia treatments
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CT: Computed tomography ACEP Accreditation: Emergency Medicine Practice is approved by the American College of
Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
CTA: Computed tomographic angiography AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice,
DRAGON: Dense cerebral artery sign/early infarct has been reviewed and is acceptable for up to 48 Prescribed credits per year by the
American Academy of Family Physicians. AAFP Accreditation begins July 31, 2011. Term
sign, Rankin Scale score, Age, Glucose level at base- of approval is for 1 year from this date. Each issue is approved for 4 Prescribed credits.
Credits may be claimed for 1 year from the date of each issue. Physicians should claim
line, Onset-to-treatment sign, baseline NIHSS score only the credit commensurate with the extent of their participation in the activity.
ECASS: European Cooperative Acute Stroke Study AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American
IA: Intra-arterial Osteopathic Association Category 2A or 2B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a survey
IAT: Intra-arterial thrombolysis of medical staff, including the editorial board of this publication; review of morbidity and
ICH: Intracerebral hemorrhage mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities
for emergency physicians.
IMS: Interventional Management of Stroke Target Audience: This enduring material is designed for emergency medicine physicians,
IST-3: Third International Stroke Trial physician assistants, nurse practitioners, and residents.
Objectives: Upon completion of this article, you should be able to: (1) understand the
IV: Intravenous expanded time window for IV rt-PA therapy and the literature supporting this practice, (2)
MCA: Middle cerebral artery describe the use of multimodal CT scanning and its potential impact on clinical practice,
(3) describe different endovascular therapies and how they are employed for reperfusion
MERCI: Mechanical Embolus Removal in Cerebral therapy, and (4) describe the features of PSCs and CSCs and understand your role in
Ischemia stroke care within your individual clinical practice.
Discussion of Investigational Information: As part of the newsletter, faculty may be
MRA: Magnetic resonance angiography presenting investigational information about pharmaceutical products that is outside
mRS: modified Rankin Scale Food and Drug Administration-approved labeling. Information presented as part of
this activity is intended solely as continuing medical education and is not intended to
MTT: Mean transit time promote off-label use of any pharmaceutical product.
NIHSS: National Institutes of Health Stroke Scale Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance,
independence, transparency, and scientific rigor in all CME-sponsored educational
NINDS: National Institute of Neurological Disor- activities. All faculty participating in the planning or implementation of a sponsored
ders and Stroke activity are expected to disclose to the audience any relevant financial relationships
and to assist in resolving any conflict of interest that may arise from the relationship.
PSC: Primary Stroke Center In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for
this CME activity were asked to complete a full disclosure statement. The information
rt-PA: Recombinant tissue plasminogen activator received is as follows: Dr. Thurman, Dr. Reynolds, Dr. Broder, and their related parties
sICH: Symptomatic intracerebral hemorrhage report no significant financial interest or other relationship with the manufacturer(s) of
any commercial product(s) discussed in this educational presentation. The following
SITS-ISTR: Safe Implementation of Thrombolysis in disclosures of relevant financial interest with a potentially financially interested entity
Stroke – International Stroke Thrombolysis Registry were made: Dr. Jauch, Chair, American Heart Association Stroke Council; Dr. Panagos,
NIH, NINDS, Genentech, Inc.; Dr. Mocco, Officer, Lazarus Effect; Dr. Asimos, Genentech,
SITS-MOST: Safe Implementation of Thrombolysis Inc.; Dr. Lewandowski, Medical Dialogues Group, Inc.; Dr. Jagoda, Executive Committee
for the Brain Attack Coalition.
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