Hemiparesis: The Emerging Role of

the Emergency Physician in Stroke

Management
Edward Sloan, MD, MPH
Associate Professor
Department of Emergency Medicine
University of Illinois College of Medicine-Chicago
Chicago, IL

Objectives

Present clinical case history

Review Emergency Department H&P
Examine tPA clinical data
Discuss tPA use in ischemic stroke
Review other therapies for ischemic stroke
Answer clinically relevant questions
Edward Sloan, MD, MPH

Case
A 70 year old female developed acute onset of left
arm weakness that lasted approximately 15
minutes and then gradually resolved. She chose to
ignore the event and did well until three weeks later
she developed complete paralysis of the left arm
and pronounced weakness of the left leg; neither
resolved and approximately 90 minutes into the
event she called EMS. Past medical history
included hypertension and COPD. Medications:
metoprolol, hydrochlorthiazide, and atrovent.
Edward Sloan, MD, MPH

Case
On exam, BP 200/120, P 68, RR 18, T 98, and pulse
oximetry showed 94% saturation. The patient
appeared alert though responses were slow. The
patient had bilateral carotid bruits, clear lungs, and
a regular rate and rhythm. There was no facial
asymmetry, upper extremity motor 5/5 on the right
and 0/5 on the left; lower extremity motor 5/5 on the
right and 3/5 on the left. Sensory was intact to light
touch and pinprick. DTRs were 2/2 on the left and
0/2 on the right. Planter reflex was downgoing on
the right and upgoing on the left.
Edward Sloan, MD, MPH

Acute Ischemic Stroke Questions

What are the epidemiology & etiology?

What are the key elements of the exam?
What is the NIH stroke scale?
What did the NINDS trial show?
How should tPA be used by the EM MD?
What about hemorrhagic conversion?
What about other therapies?
Edward Sloan, MD, MPH

Acute Stroke: Epidemiology

700,000 Cases annually

20% mortality within one year
$30 billion annual costs
Ischemic and hemorrhagic strokes

Edward Sloan, MD, MPH

Acute Ischemic Stroke:

Etiology

Thrombotic, embolic, hypoperfusion

Majority are vessel thrombosis
Clot formation on diseased vessel
20% are embolic, from heart, great vessels
Hypoperfusion with cardiogenic shock
Edward Sloan, MD, MPH

Acute Ischemic Stroke: Syndromes

Anterior cerebral
Middle cerebral
Posterior cerebral
Vertebrobasilar
Basilar artery occlusion
Cerebellar
Lacunar
Arterial dissection
Edward Sloan, MD, MPH

Acute Stroke: Historical Elements

When did symptoms begin? Onset?

Prior history of similar symptoms?
When was the patient last seen normal?
Risk factors?
Medical hx that would preclude tPA use?
Edward Sloan, MD, MPH

Acute Stroke: Physical Exam

Vital signs, pulse ox, accucheck

HEENT: Pupils, papilledema, airway
Neck: Bruits, nuchal rigidity
Chest: Rales (CHF, aspiration)
Cardiac: Gallops, murmurs

Edward Sloan, MD, MPH

Acute Stroke: Physical Exam

Abd: Evidence of AAA

Ext: Evidence of CHF, DVT
Skin: Evidence of infectious etiology
Neuro: CN, motor, sensory, reflexes,
cerebellar, visual, language,
neglect, mental status

Edward Sloan, MD, MPH

Neurologic Exam: Cranial Nerves

CN: Anterior vs. brainstem?
Anterior: Contralateral CN deficits
Brainstem: Ipsilateral CN deficits

Edward Sloan, MD, MPH

Neurologic Exam: Motor

Motor: CN, upper & lower ext
CN: Eye motor (Bells)
Upper: Pronator drift
Lower: Leg lift

Edward Sloan, MD, MPH

Neurologic Exam: Sensory

Sensory: Light touch, pinprick
Graphesthesia

Edward Sloan, MD, MPH

Neurologic Exam: Reflexes

Normal vs. pathologic
Normal: Corneal, gag, DTRs
Pathologic: Babinski, Chadduck

Edward Sloan, MD, MPH

Neurologic Exam: Cerebellar

Truncal ataxia
Ataxic gait
Rhomberg

Edward Sloan, MD, MPH

Neurologic Exam: Visual

Visual field deficit

Homonomous hemianopsia
Neglect of one side

Edward Sloan, MD, MPH

Neurologic Exam: Language

Dysarthria: Poor speech, motor dysfunction
Aphasia: Disturbed language processing
Expressive: cant speak
Receptive: cant process the spoken word

Edward Sloan, MD, MPH

Neurologic Exam: Mental Status

Level of consciousness (AVPU)

Alert
Responds to verbal
Responds to painful
Unresponsive

Edward Sloan, MD, MPH

Neurologic Exam: NIH Stroke

Scale
13 item scoring system, 7 minute exam
Integrates neurologic exam components
CN, motor, sensory, cerebellar, visual,
language, LOC
Maximum score is 31, signifying severe stroke
Minimum score is 0, a normal exam
Scores greater than 15-20 are more severe
Edward Sloan, MD, MPH

Acute Ischemic Stroke:

NINDS Clinical Trial of tPA

Treatment within 180 minutes

0.9 mg/kg of tPA
Two part study
Endpoint: favorable outcome at 3 months
Also examined mortality, hemorrhage

Edward Sloan, MD, MPH

NINDS Clinical Trial of tPA: Results

Good outcome: 30% more patients

Odds of favorable outcome: 1.7 (1.2-2.6)

10x greater hemorrhage risk: (6.4 vs. 0.6%)
Comparable 3 month mortality: (17 vs. 21%)
Conclusion: tPA worth the hemorrhage risk,
since there is clear benefit

Edward Sloan, MD, MPH

NINDS Clinical Trial of tPA:

Clinical Upshot

tPA must be considered

Patient selection is very difficult
Must maximize risk/benefit ratio
Must avoid hemorrhage, if possible
Need adequate severity, but not too severe
Less than 2% of patients will meet criteria
Edward Sloan, MD, MPH

NINDS Clinical Trial of tPA:

Timing Issues

Early EMS contact is key

Door to CT and CT read time important
Is there time for a neurologist to consult?
A stroke team helps
The 3 hour window is not the only issue
Edward Sloan, MD, MPH

NINDS Clinical Trial of tPA:

Clinically Relevant Issues

Histories are unreliable

Timing issues hard to press for stroke
Patient selection is painfully difficult
Every CT has a hypodense area
Tendency not to intervene
First do no harm
What we did vs. what was destined to be
Edward Sloan, MD, MPH

tPA in Acute Ischemic Stroke:

Clinical & Documentation Issues
Document that tPA was considered
If not used, state explicitly why the pt did
not meet criteria or why it was deferred
When explaining, tell the four key points:

30% greater chance of good outcome

10 fold greater risk of bleeding
Same mortality rate, despite bleeding risk
Explain why mortality is comparable
Edward Sloan, MD, MPH

tPA in Acute Ischemic Stroke:

Other Relevant Studies

ECASS: No efficacy, higher mortality

IA tPA: Effective, feasible
ATLANTIS: 5 hour window not possible
Cleveland: Non-supportive tPA data
2% treated, 50% standard of care deviation
16% bled, 3x higher in-hospital mortality

STARS: Favorable outcome and mortality

Edward Sloan, MD, MPH

Acute Ischemic Stroke:

Goals of Other Therapies
Recanalization
Stop ischemic cascade
Minimize hemorrhage
Minimize morbidity and mortality

Edward Sloan, MD, MPH

Acute Ischemic Stroke:

Other Therapies
LMW heparin: Possibly effective
IST study: ASA reduces death & stroke
recurrence by 1%
PROACT II: IA prourokinase improves outcome
STAT: Ancrod (pit viper venom) improves
outcome, but causes hemorrhage
Neuroprotectants: May provide benefit
Edward Sloan, MD, MPH

Acute Ischemic Stroke:

Other Issues
MR Imaging: Feasible, assists pt selection
Admission need: Still must admit TIA/CVA pts

No reason not to admit CVAs

Cant predict progression, complications
Data less clear for TIAshome observation?
Need HMO experience to be documented

Edward Sloan, MD, MPH

Acute Ischemic Stroke:

Case Management
Get the CT scan ASAP
Control the blood pressure
Start making calls: PMD, family,
neurologist
Find out the CT results
Decide risk/benefit
Discuss with pertinent decision makers
Edward Sloan, MD, MPH

Acute Ischemic Stroke:

Specific Case Outcome

CT obtained quickly
BP controlled with time & SL NTG
NIH stroke scale: 15
CT showed ?? Low density area
Neurologist not inclined to treat
Family defers tPA after consultation
Some long term deficit, physical therapy
Edward Sloan, MD, MPH

Acute Ischemic Stroke:

Conclusions

Ischemic stroke is a big problem

There is significant morbidity & mortality
tPA is effective in a narrowly defined group
Must aggressively work to get tPA used
Other therapies hold promise

Edward Sloan, MD, MPH

Acute Ischemic Stroke:

Recommendations
Better public education

More timely EMS activation

More analysis of tPA use re: optimal patients
Rapid MR imaging
Dvlp other therapies, esp neuroprotectants

Edward Sloan, MD, MPH

All are true statement about acute

ischemic stroke except:
a. There are three major categories: thrombotic,
embolic, and hypoperfusion.
b. The majority of all strokes are caused by vessel
thrombosis.
c. The symptoms of ischemic stroke develop over
minutes to hours.
d. The most common source of emboli are the heart
and major vessels.
e. Middle cerebral artery infarction is associated with
ipsilateral weakness and numbness.
Edward Sloan, MD, MPH