The Continuum of Stroke Care

1
The Continuum of Stroke Care

• Justin A. Sattin, M.D.
• Assistant Professor
• UW Department of Neurology
• Medical Director
• UW Health Comprehensive Stroke Program

2
The Chain of Survival

• Healthful Choices
• Public Recognition
• EMS Access
• ED Recognition
• Radiology / Lab
• Neurologist
• Pharmacy

• ICU Nursing Care
• General RN Care
• More Radiology / Lab
• Inter-D Care
• Rehabilitation
• Re-Integration

3
Stroke Symptoms
4
Cincinnati Prehospital Stroke Scale
Facial Droop Instruction Ask patient to smile o
Normal Both sides of face move equally o
Abnormal One side of face does not move as well
Arm Drift Instruction Ask patient to close eyes
and extend both arms straight out for 10
seconds o Normal Both arms move the same or not
at all o Abnormal One arm does not move or
drifts down
Speech Instruction Ask patient to say You cant
teach an old dog new tricks. o Normal Patient
says correct words without slurring o
Abnormal Patient slurs words, says wrong words,
or is unable to speak
Kothari RU, et al. Cincinnati Prehospital Stroke
Scale reproducibility and validity. Ann Emerg
Med. 199933373-8.
5
Ischemic or Hemorrhagic?
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Ischemic or Hemorrhagic?
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NINDS tPA Trial
The National Institute of Neurological Disorders
and Stroke rt-PA Stroke Study Group. Tissue
plasminogen activator for acute ischemic stroke.
N Eng J Med. 199533315881593.
8
39 26 13 13 ---- 50 relative benefit 26
39 26 13 absolute difference 100 -----
8 needed to treat 13
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Time is of the Essence
Hacke W, et al. Association of outcome with early
stroke treatment pooled analysis of ATLANTIS,
ECASS, and NINDS rt-PA stroke trials. Lancet
2004363768-74.
10
Furlan A, Higashida R, Wechsler L, et al.
Intra-arterial prourokinase for acute ischemic
stroke. The PROACT II Study A randomized
controlled trial. JAMA. 19992822003-2011.
11
Mechanical Embolectomy
Leary MC, et al. Beyond tissue plasminogen
activator mechanical intervention in acute
stroke. Ann Emerg Med. 200341838-46.
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Courtesy of Concentric Medical, Inc.
13
Mechanical Embolectomy
14
Annual Stroke Mortality 2001-2004
Avg of deaths per county per year (total for
all counties in group)
lt10 (64)
50-100 (1,067)
10-50 (1,033)
gt100 (1,186)
Yuan, H. and Brue, C. Wisconsin Heart Disease and
Stroke Surveillance Summary Update 2007 PPH
43040 (01/07). Wisconsin Department of Health and
Family Services, Division of Public Health.
The Joint Commission. Available at
http//www.jointcommission.org/CertificationProgra
ms/Disease-SpecificCare/DSCOrgs/ Accessed
10/14/07
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General Management Principles

• Hypoxic pts. should receive O2
• SpO2 gt 92
• Cardiac monitoring for at least 24 hrs.
• Treat HTN conservatively for 24 hrs.
• Ischemic SBP lt 220 mmHg
• Hemorrhagic SBP lt 160 mmHg

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General Management Principles

• Minimize urinary catheterization
• Fevers should be evaluated and treated
• Hyperglycemia should be treated
• Optimal threshold is not established
• lt 140 mg/dL? lt 185 mg/dL?

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General Management Principles

• Dysphagia screening
• Early mobilization
• DVT prophylaxis
• LMWH

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Stroke
Hemorrhagic
Ischemic
Cardioembolic Large artery athero. Small vessel
dz. Other Unknown
ICH
SAH
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J,
Love BB, Gordon DL, Marsh EE 3rd. Classification
of subtype of acute ischemic stroke. Definitions
for use in a multicenter clinical trial. TOAST.
Trial of Org 10172 in Acute Stroke Treatment.
Stroke. 199324(1)35-41.
19
Stroke
Ischemic
Cardioembolic Large artery athero. Small vessel
dz. Other Unknown
http//www.florida-oxygen.com/treatment.htm
20
Stroke
Ischemic
Cardioembolic Large artery athero. Small vessel
dz. Other Unknown
http//www.cardioliving.com/consumer/Stroke/AF_Cau
ses.shtm
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Cardioembolic Stroke
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Stroke
Ischemic
Cardioembolic Large artery athero. Small vessel
dz. Other Unknown
http//biocomp.stanford.edu/3dreconstruction/movie
s/haveri/stenosis_ica_angio26ssd.jpg
23
Stroke
Ischemic
Cardioembolic Large artery athero. Small vessel
dz. Other Unknown
24
Stroke
Ischemic
Cardioembolic Large artery athero. Small vessel
dz. Other Unknown
http//bbh.hhdev.psu.edu/courses/368/slide.21.(164
).htm
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Stroke
Ischemic
Cardioembolic Large artery athero. Small vessel
dz. Other Unknown
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Risk Factor Modification

• Hypertension
• Diabetes
• Dyslipidemia
• Metabolic Syndrome
• Tobacco Dependence

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Antithrombotic Therapies

• Aspirin
• Aspirin/Dipyridamole (Aggrenox)
• Clopidogrel (Plavix)
• Warfarin (Coumadin)

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Important Collaborators

• PT
• OT
• Speech
• Swallow
• Rehab
• Neuro ?

• Health ?
• Case Managers!
• Social Work
• Pastoral Care
• Palliative Care
• ACE Team

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Discharge Dispositions

• Home
• often with outpt. or home health therapies)
• Acute Rehab
• Subacute Rehab
• Skilled Nursing Facility
• Hospice
• (Celestial Discharge)

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Vascular CognitiveImpairment
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How to Reach Us

• Emergent Referrals
• UW Access Center
• Phone [phone]

• Office Referrals
• UW Stroke Clinic
• Phone [phone]
• Fax [phone]