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Spotlight on Stroke

Larry Beresford is a freelance writer based in Oakland, Calif.

Stroke Training Resources and Opportunities

American Stroke Association International Stroke Conference

Feb. 24-26, 2010

San Antonio, Texas

http://strokeconference.americanheart.org/portal/strokeconference/sc/

The Stroke Collaborative

Give Me Five For Stroke: Resources for Health Professionals

www.givemefiveforstroke.org/healthcare/professionalResources/

National Stroke Association

Stroke Educational Materials

http://www.stroke.org/site/DocServer/MaterialsOrderFrom.pdf?docID=841

The Neurology Channel: Your Neurology Community

Stroke information at www.neurologychannel.com/stroke/index.shtml

References

  1. Glasheen J, Cumbler E, Tailoring internal medicine training to improve hospitalist outcomes. Arch Intern Med. 2009;169:204-205.
  2. Telemedicine helps experts treat stroke from afar. National Stroke Association Web site. Available at: http://www.stroke.org/site/News2?page=NewsArticle&id=8208&news_iv_ctrl=1221. Accessed Nov. 4, 2009.
  3. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3)247-254.
  4. Blacker DJ. In-hospital stroke. Lancet Neurol. 2003;2(12):741-746.
  5. Demaerschalk BM, Durocher DL. How diagnosis-related group 559 will change the US Medicare cost reimbursement ratio for stroke centers. Stroke. 2007;38:1309-1312.
  6. Freeman WD, Gronseth G, Eidelman BH. Is it time for neurohospitalists? Neurology. 2009;72:476-477.
  7. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329.
  8. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. American Heart Association Stroke Council. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40(8):2945-2948.
  9. Lyden P. Thrombolytic therapy for acute stroke—not a moment to lose. N Engl J Med. 2008;359:1393-1397.
  10. Doheny K. Few stroke patients get clot-busting drug. Business Week Web site. Available at: http://www.businessweek.com/lifestyle/content/healthday/624280.html. Accessed Sept. 23, 2009.
  11. Sacco RL, Diener HC, Yusuf S, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent strokes. N Engl J Med. 2008;359:1238-1251.
  12. Cumbler E, Glasheen J. Risk stratification tools for TIA: Which patients require hospital admission? J Hosp Med. 2009;4:247-251.
  13. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007; 369:283-292.
  14. Cumbler E, Glasheen J. Management of blood pressure after acute ischemic stroke: An evidence-based guide for the hospitalist. J Hosp Med. 2007;2:261-267.

Image Source: FORESTPATH/ISTOCKPHOTO.COM

Stroke Management Issues for Hospitalists

The management of stroke is an emergency. That theory is best reflected in the maxim “time is brain,” says Jose Biller, MD, a neurologist at Loyola University Health System in Chicago. “Appropriate treatment begins with correct diagnosis,” he says. “Misdiagnoses of strokes are not uncommon but may have serious consequences.”

Eighty-seven percent of strokes are ischemic (a blood clot blocking a vessel in the brain). The other 13% are hemorrhagic strokes or subarachnoid hemorrhages. The distinction is critical, because IV t-PA is contraindicated when there is evidence of bleeding in the brain. For the most part, it’s tough to tell at first glance if a patient has suffered an ischemic or hemorrhagic stroke. A brain scan, typically a noncontrast computed tomography (CT) scan, is needed to rule out intracerebral hemorrhage.

IV t-PA can reverse the disabling effects of stroke if administered within a narrow therapeutic window of opportunity. National stroke treatment guidelines call for IV t-PA to be administered within three hours of the known onset of symptoms. The clock starts at the time the patient was last seen normal. Intravenous t-PA is not recommended outside the time window or for such contraindications as recent major surgery, stroke, or serious head trauma within the past 30 months, history of intracranial hemorrhage, seizures at onset of symptoms, or arterial puncture at a noncompressible site within seven days.

IV t-PA can have serious side effects, but it remains the gold standard of stroke treatment within the suggested time allotment. Recent research points toward widening the time window for IV t-PA from three hours to 4.5 hours. The multinational, double-blind European Cooperative Acute Stroke Study (ECASS III), published in the Sept. 25, 2008, issue of the New England Journal of Medicine, concluded that t-PA is still beneficial up to 4.5 hours after onset of symptoms, although “sooner is better and every minute counts.”7

This finding eventually will make its way into formal guidelines, Dr. Josephson says, and some hospitals already have adopted the 4.5-hour window for IV t-PA treatment.

In May 2008, an AHA/ASA advisory recommended that IV t-PA be provided up to 4.5 hours after known onset of a stroke, unless the patient is older than 80, takes oral anticoagulants, has an assessed National Stroke Scale score greater than 25, or presents a history of both stroke and diabetes.8 In those cases, AHA/ASA recommends sticking to the three-hour ceiling.

Patrick Lyden, MD, a neurologist at the University of California at San Diego School of Medicine, noted in a September 2008 New England Journal of Medicine editorial that thrombolytic therapy can restore neurological functions if given early enough, and “has stood the test of time, shown benefit in serial community registries on multiple continents, and received approval by every major regulatory authority in the world.”9

In fact, IV t-PA is such a powerful tool for reversing stroke’s effects that the bigger question is, why is it used only for an estimated 2% to 10% of stroke patients? According to data presented at an international stroke conference in February, 64% of U.S. hospitals had not provided any IV t-PA treatments within the prior two years.10 Researchers concluded that some patients get medical help too late, but some hospitals and physicians are uncomfortable administering t-PA, and others lack sufficient protocols for responding quickly with assessment and treatment.

Hospitalists need to understand the medical management of patients who do not qualify for t-PA, approaches which have their own time windows, Dr. Josephson says. Intra-arterial administration of the therapy is supported up to six hours after the onset of stroke, while mechanical embolectomy—physically removing the clot—is recommended for as many as eight hours after onset. Newer systems for performing mechanical embolectomies include the Merci Retrieval System and the Penumbra System.

Past eight hours, stroke treatment involves appropriate choice and intensity of anti-coagulant (heparin, warfarin) and antiplatelet treatments. According to the recent PRoFESS trial, the most common antiplatelet treatment choices, clopidogrel and dipyridamole with aspirin, were found to be equal in efficacy.11

Recognizing the patients who present in the ED with evidence of TIA is critical to treatment options; many are at high risk for a full-blown stroke within the next 48 hours and should be admitted for aggressive management.12 The ABCD Score has been shown to predict which recent TIA patients are at higher risk of stroke, and thus are in need of immediate evaluation to optimize stroke prevention.1,13 “The idea that TIA and stroke are different diseases is giving way,” Dr. Josephson says. “Conceptually, they are the same disorder.”

Other treatment issues include DVT prophylaxis, identifying potential sources of embolisms, and choice of echo exam. Managing blood pressure could include permissive hypertension as high as 220/120 immediately post-stroke in patients who did not receive t-PA, or 180/105 following t-PA, then returning the blood pressure back to normal in a slow and safe manner.14—LB

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