Ischemic Stroke – Acute - Revision history

JenniferH: /* YKHC Stroke Clinical Guideline Development */

2023-02-13T18:42:18Z

YKHC Stroke Clinical Guideline Development

← Older revision		Revision as of 18:42, 13 February 2023
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	Drs. Jeremy Wood and Peek Ehlinger created the YKHC stroke guideline with the goal of improving care for our patients treated both in the YKHC hospital and nearby region. One of the goals was to encourage earlier identification of strokes that may be amenable to thrombectomy. The emergence of an intervention for large vessel occlusion strokes has changed the diagnostic pathway and treatment algorithm for stroke. It is an area of active development that we should expect will change over the next few years.		Drs. Jeremy Wood and Peek Ehlinger created the YKHC stroke guideline with the goal of improving care for our patients treated both in the YKHC hospital and nearby region. One of the goals was to encourage earlier identification of strokes that may be amenable to thrombectomy. The emergence of an intervention for large vessel occlusion strokes has changed the diagnostic pathway and treatment algorithm for stroke. It is an area of active development that we should expect will change over the next few years.

	Thrombectomy for appropriate ~~LVO~~ strokes appears to have a much more hopeful risk versus benefit ratio than does thrombolytics for the undifferentiated ischemic stroke, however, in general the area of stroke treatment has a fair bit of controversy and you will likely hear different things from different people. We tried to emphasize the importance of bringing neurology along in this decision, and it’s OK to defer to them.		Thrombectomy for appropriate large vessel occlusion strokes appears to have a much more hopeful risk versus benefit ratio than does thrombolytics for the undifferentiated ischemic stroke, however, in general the area of stroke treatment has a fair bit of controversy and you will likely hear different things from different people. We tried to emphasize the importance of bringing neurology along in this decision, and it’s OK to defer to them.

	Thrombolytics have been shown to provide net benefit in a select group of patients, however, they also can harm at rates that increase due to a number of factors, such as time from stroke onset (i.e. data stronger for <3 hours than between 3 and 4.5) and patient specific risk factors. Be sure to take your time with the exclusion criteria and consideration of stroke mimics.		Thrombolytics have been shown to provide net benefit in a select group of patients, however, they also can harm at rates that increase due to a number of factors, such as time from stroke onset (i.e. data stronger for <3 hours than between 3 and 4.5) and patient specific risk factors. Be sure to take your time with the exclusion criteria and consideration of stroke mimics.
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	*In large series of stroke patients, 6.8% of them had bleeding in their brain after receiving alteplase for stroke, versus 1.3% of those stroke patients who did not receive the drug. If we give this drug 18 times, chances are it will make one person have bleeding in their brain.		*In large series of stroke patients, 6.8% of them had bleeding in their brain after receiving alteplase for stroke, versus 1.3% of those stroke patients who did not receive the drug. If we give this drug 18 times, chances are it will make one person have bleeding in their brain.
	*2% of people given this drug die from a hemorrhage (absolute risk) however by 3-6 months out those that receive the drug within 3 hours have a 10% (absolute increase) increased chance of disability-free survival, and that drops to 5% between 3 and 4.5 hours.		*2% of people given this drug die from a hemorrhage (absolute risk) however by 3-6 months out those that receive the drug within 3 hours have a 10% (absolute increase) increased chance of disability-free survival, and that drops to 5% between 3 and 4.5 hours.



	===Resources/References===		===Resources/References===

JenniferH at 15:34, 31 January 2023

2023-01-31T15:34:47Z

← Older revision		Revision as of 15:34, 31 January 2023
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	Patients who decline transfer, particularly those without hemorrhage who have returned to neurologic baseline, could be monitored for 1-2 days at YKHC to monitor for worsening, screen for arrhythmia on telemetry, and work with our physical therapy colleagues. These patients should then be referred to ANMC neurology for MRI, echo, and carotid imaging (if not done in Bethel).		Patients who decline transfer, particularly those without hemorrhage who have returned to neurologic baseline, could be monitored for 1-2 days at YKHC to monitor for worsening, screen for arrhythmia on telemetry, and work with our physical therapy colleagues. These patients should then be referred to ANMC neurology for MRI, echo, and carotid imaging (if not done in Bethel).

			===YKHC Stroke Clinical Guideline Development===
			Drs. Jeremy Wood and Peek Ehlinger created the YKHC stroke guideline with the goal of improving care for our patients treated both in the YKHC hospital and nearby region. One of the goals was to encourage earlier identification of strokes that may be amenable to thrombectomy. The emergence of an intervention for large vessel occlusion strokes has changed the diagnostic pathway and treatment algorithm for stroke. It is an area of active development that we should expect will change over the next few years.

			Thrombectomy for appropriate LVO strokes appears to have a much more hopeful risk versus benefit ratio than does thrombolytics for the undifferentiated ischemic stroke, however, in general the area of stroke treatment has a fair bit of controversy and you will likely hear different things from different people. We tried to emphasize the importance of bringing neurology along in this decision, and it’s OK to defer to them.

			Thrombolytics have been shown to provide net benefit in a select group of patients, however, they also can harm at rates that increase due to a number of factors, such as time from stroke onset (i.e. data stronger for <3 hours than between 3 and 4.5) and patient specific risk factors. Be sure to take your time with the exclusion criteria and consideration of stroke mimics.

			We currently have stocked tenectaplase in the ED, which is the direction that most stroke centers are going.

			====Shared Decision Making====
			Shared decision making is often difficult in a patient with a disabling stroke and may not be necessary or possible in all patients. As the patient may not have capacity to participate in decisions, you may need to enlist the help of a surrogate decision maker or proceed under presumed consent in such cases when the benefits clearly outweigh the harms. The included consent form is a suggested reference to review anticipated risks and benefits. There is an online resource that has been clinically validated ([http://www.sorcan.ca/iscore/ iScore]) which also may be of some use.

			'''Verbal Consent example from UpToDate'''
			*"There is a treatment for your stroke called alteplase that must be given within 4.5 hours after the stroke started. It is a 'clot-buster' drug. Getting alteplase reduces your risk of being disabled. People who get alteplase for stroke have a better chance of recovering without disability and getting back to the activities they enjoy compared to people who do not receive the treatment. All medicines have some risk. With alteplase, there is a risk of serious bleeding. However, time is important as well. We know that the sooner we start treatment with alteplase, the greater the chance that patients will have a good outcome."

			====Revision of Written Consent form—numbers from Lancet 2014 article====

			'''Benefits:'''
			*< 3 hours: 33% of stroke patients given alteplase had good outcome, whereas 23% of stroke patients controls (no alteplase) also got better. 10 people would have to get the drug to help 1 person have a good outcome.
			*Between 3 and 4. 5 hours from stroke onset: 35% of patients receiving alteplase had a good outcome, and 30% of patients who didn’t get the drug also got better. You would have to treat 20 people to help 1 person have a good clinical outcome.

			'''Risks:'''
			*In large series of stroke patients, 6.8% of them had bleeding in their brain after receiving alteplase for stroke, versus 1.3% of those stroke patients who did not receive the drug. If we give this drug 18 times, chances are it will make one person have bleeding in their brain.
			*2% of people given this drug die from a hemorrhage (absolute risk) however by 3-6 months out those that receive the drug within 3 hours have a 10% (absolute increase) increased chance of disability-free survival, and that drops to 5% between 3 and 4.5 hours.



	===Resources/References===		===Resources/References===

JenniferH: /* Resources/References */

2022-09-20T19:33:17Z

Resources/References

← Older revision		Revision as of 19:33, 20 September 2022
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	* [[Stroke (CVA)\|Stroke RMT Guide]]		* [[Stroke (CVA)\|Stroke RMT Guide]]
	* [http://www.sorcan.ca/iscore/ iScore]		* [http://www.sorcan.ca/iscore/ iScore]
	* Siket Matt, Marcolini Evadne, Ganti Latha. [https://www.emrap.org/corependium/chapter/recEAr4nPXQE4eOBH/Transient-Ischemic-Attack-and-Acute-Ischemic-Stroke Transient Ischemic Attack and Acute Ischemic Stroke.] In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recEAr4nPXQE4eOBH/Transient-Ischemic-Attack-and-Acute-Ischemic-Stroke.		* Siket Matt, Marcolini Evadne, Ganti Latha. [https://www.emrap.org/corependium/chapter/recEAr4nPXQE4eOBH/Transient-Ischemic-Attack-and-Acute-Ischemic-Stroke Transient Ischemic Attack and Acute Ischemic Stroke.] In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recEAr4nPXQE4eOBH/Transient-Ischemic-Attack-and-Acute-Ischemic-Stroke.
			* Emberson J et al.; Stroke Thrombolysis Trialists' Collaborative Group. [https://www.sciencedirect.com/science/article/pii/S0140673614605845?via%3Dihub Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials.] Lancet. 2014 Nov 29;384(9958):1929-35. doi: 10.1016/S0140-6736(14)60584-5. Epub 2014 Aug 5. PMID: 25106063; PMCID: PMC4441266.
	* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)		* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)

JenniferH: /* Resources/References */

2022-09-20T19:30:45Z

Resources/References

← Older revision		Revision as of 19:30, 20 September 2022
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	* [[Stroke (CVA)\|Stroke RMT Guide]]		* [[Stroke (CVA)\|Stroke RMT Guide]]
	* [http://www.sorcan.ca/iscore/ iScore]		* [http://www.sorcan.ca/iscore/ iScore]
			* Siket Matt, Marcolini Evadne, Ganti Latha. [https://www.emrap.org/corependium/chapter/recEAr4nPXQE4eOBH/Transient-Ischemic-Attack-and-Acute-Ischemic-Stroke Transient Ischemic Attack and Acute Ischemic Stroke.] In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recEAr4nPXQE4eOBH/Transient-Ischemic-Attack-and-Acute-Ischemic-Stroke.
	* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)		* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)

JenniferH: /* Resources/References */

2022-09-20T19:27:33Z

Resources/References

← Older revision		Revision as of 19:27, 20 September 2022
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	* [[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]		* [[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]
	* [[Stroke (CVA)\|Stroke RMT Guide]]		* [[Stroke (CVA)\|Stroke RMT Guide]]
			* [http://www.sorcan.ca/iscore/ iScore]
	* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)		* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)

JenniferH at 19:25, 20 September 2022

2022-09-20T19:25:53Z

← Older revision		Revision as of 19:25, 20 September 2022
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	~~Direct transfer of an~~ acute CVA ~~patient~~ from ~~the~~ ER to ANMC ~~should always be considered as these patients have~~ better ~~chance at rehab as the rehab-queue for Alaska Regional starts at ANMC inpatient~~.		Generally speaking, all acute CVA patients should be transferred from ER to ANMC for full stroke workup and better access to consistent PT/OT/SLP.

	~~That being said~~, ~~non-hemorrhagic~~, ~~non-brain stem and stable stroke patients can~~ be monitored ~~inpatient~~ for 1-2 days to ~~assure there is no clinical~~ worsening~~. On a cardiac-respiratory monitor emboli-producing arrhythmias can be screened while Physical Therapy can help assess~~ for ~~rehabilitation potential~~ and ~~ability to swallow can be grossly assessed~~.		Patients who decline transfer, particularly those without hemorrhage who have returned to neurologic baseline, could be monitored for 1-2 days at YKHC to monitor for worsening, screen for arrhythmia on telemetry, and work with our physical therapy colleagues. These patients should then be referred to ANMC neurology for MRI, echo, and carotid imaging (if not done in Bethel).

	~~Neurology and/or IM at ANMC~~ should be ~~consulted and the patient transferred there if rehabilitation is a possibility. YKHC inpatients can only go~~ to ~~rehab via~~ ANMC ~~inpatient. Otherwise, YKHC patients are discharged home with an ANMC IM follow-up appointment~~ for an MRI, ~~echocardiogram~~ and carotid ~~duplex~~ (if ~~latter~~ not done in Bethel).

	*We do give lytics for acute stroke if appropriate and no contraindications. Neurology at ANMC must be consulted if you are considering lytics.
	*All acute strokes and TIAs are medevac’d to ANMC for further workup. This is true even if they have recovered from a neuro standpoint.

	===Resources/References===		===Resources/References===

JenniferH: /* Resources/References */

2020-11-20T08:39:45Z

Resources/References

← Older revision		Revision as of 08:39, 20 November 2020
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	* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)		* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)

	[[:category:YKHC Guidelines]]
			[[:category:YKHC Guidelines\|YKHC Clinical Guidelines]]
	<br/>[[Practicing Medicine in Bush Alaska—Some ABCs\|Common/Unique Medical Diagnoses]]		<br/>[[Practicing Medicine in Bush Alaska—Some ABCs\|Common/Unique Medical Diagnoses]]

JenniferH: /* Resources/References */

2020-10-22T00:00:15Z

Resources/References

← Older revision		Revision as of 00:00, 22 October 2020
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	* [[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]		* [[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]
	* [[Stroke (CVA)\|Stroke RMT Guide]]		* [[Stroke (CVA)\|Stroke RMT Guide]]
			* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)

	[[:category:YKHC Guidelines]]		[[:category:YKHC Guidelines]]
	<br/>[[Practicing Medicine in Bush Alaska—Some ABCs\|Common/Unique Medical Diagnoses]]		<br/>[[Practicing Medicine in Bush Alaska—Some ABCs\|Common/Unique Medical Diagnoses]]

JenniferH at 04:51, 25 September 2020

2020-09-25T04:51:17Z

← Older revision		Revision as of 04:51, 25 September 2020
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	*All acute strokes and TIAs are medevac’d to ANMC for further workup. This is true even if they have recovered from a neuro standpoint.		*All acute strokes and TIAs are medevac’d to ANMC for further workup. This is true even if they have recovered from a neuro standpoint.

	[[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]		===Resources/References===
			* [[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]
	[[Stroke (CVA)\|Stroke RMT Guide]]		* [[Stroke (CVA)\|Stroke RMT Guide]]

	[[:category:YKHC Guidelines]]		[[:category:YKHC Guidelines]]
	<br/>[[Practicing Medicine in Bush Alaska—Some ABCs\|Common/Unique Medical Diagnoses]]		<br/>[[Practicing Medicine in Bush Alaska—Some ABCs\|Common/Unique Medical Diagnoses]]

JenniferH at 03:54, 25 September 2020

2020-09-25T03:54:46Z

← Older revision		Revision as of 03:54, 25 September 2020
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	[[:category:YKHC Guidelines]]		[[:category:YKHC Guidelines]]
			<br/>[[Practicing Medicine in Bush Alaska—Some ABCs\|Common/Unique Medical Diagnoses]]

← Older revision		Revision as of 19:27, 20 September 2022
Line 6:		Line 6:
	* [[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]		* [[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]
	* [[Stroke (CVA)\|Stroke RMT Guide]]		* [[Stroke (CVA)\|Stroke RMT Guide]]
			* [http://www.sorcan.ca/iscore/ iScore]
	* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)		* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)

← Older revision		Revision as of 00:00, 22 October 2020
Line 11:		Line 11:
	* [[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]		* [[media:Stroke.pdf\|Acute Ischemic Stroke YKHC Clinical Guideline]]
	* [[Stroke (CVA)\|Stroke RMT Guide]]		* [[Stroke (CVA)\|Stroke RMT Guide]]
			* [[media:Alaska Stroke Systems of Care 7.29.17.pdf\|Alaska Stroke Systems of Care]] (PowerPoint Presentation)

	[[:category:YKHC Guidelines]]		[[:category:YKHC Guidelines]]
	<br/>[[Practicing Medicine in Bush Alaska—Some ABCs\|Common/Unique Medical Diagnoses]]		<br/>[[Practicing Medicine in Bush Alaska—Some ABCs\|Common/Unique Medical Diagnoses]]