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Stroke Proceedings: Koroshetz


Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

Acute Stroke Management: Hospital Stroke Expertise

Walter J. Koroshetz, M.D. 
Massachusetts General Hospital, Boston

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Goals for Special Expertise in the Care of the Stroke Patient

The need for expertise in the care of the acute stroke patient is governed by three, well-established goals:

1. To minimize the extent of brain injury.

2. To medically support the stroke patient and encourage optimal chance for functional recovery.

3. To prevent further brain injury secondary to the initial accident or repeated vascular accidents.

The above goals are unlikely to change though the tools available to achieve them are constantly being refined. The wide array of management problems posed by treating patients with acute neurovascular emergencies drives the requirements for medical expertise. The development of new tools that improve patient outcome after stroke necessitates new expertise to ensure patient access to optimal care. The following discussion is centered primarily on skills and knowledge needed by hospital medical professionals involved in the emergency management of the acute ischemic and hemorrhagic stroke patient.

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Advanced Stroke Expertise in Current Practice: Goals for Emergency Management of the Stroke Patient

Certain guidelines for emergency care, based on clinical experience and knowledge of pathophysiology, have been accepted in many institutions as the standard. These guidelines have led to the development of varying levels of coordinated care between emergency physicians, neurologists, neurosurgeons, general practice physicians, and radiologists. Only a few guidelines have been studied in randomized clinical trials and some, though not all (1-3), are labeled controversial.

Generally accepted standards for management are frequent in treating patients with stroke, especially hemorrhagic stroke, which requires prompt diagnosis and neurosurgical intervention to preserve life and brain function. Because it is not possible to reliably distinguish among different stroke types in the field, and because intracranial hemorrhage is a complication of many treatments, comprehensive stroke centers require access to the expertise needed to manage all forms of stroke.

Currently, centers without the expertise to manage some of these intracranial emergencies develop referral patterns with other institutions that have special resources. All stroke care programs require staff with the expertise to recognize the different stroke types and to manage their acute presentations.

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Present and Future Needs for Expertise in Stroke Care

Given the tragic personal loss and financial cost of long-term care of the stroke patient, changes in medical expertise will be dictated by new therapies that improve the patient's functional outcome. Stroke research has clearly established that a variety of strategies decrease infarct size in animal stroke models (4).

A number of agents are currently in clinical trials; one of these agents, t-PA, has recently been approved by the FDA for the treatment of stroke. This approval was based on results from clinical trials performed by organized stroke teams. Results in community practice may differ. This is especially of concern for agents whose benefit relies on strict conditions of use and sophisticated stroke experience. Duplication of the expertise required by the clinical trial stroke teams at the community level is the most defensible position in planning to incorporate a new stroke therapy.

The major current challenge is to meet the increased need for acute stroke expertise and to make stroke expertise as available as possible in sparsely populated settings. Communications technology should make it possible to share resources over geographic areas. Telecommunications to transmit high-quality brain images to expert stroke physicians and video conferencing to bring neurological expertise into the emergency department (ED) and inpatient units should allow the development of acute stroke teams with members in widely separate locations. Larger health care corporations may test the benefit of using telecommunications to centralize their acute stroke care decisions. A relatively small team of specialists may communicate with a large network of emergency facilities.

Identifying Appropriate Patients for the Administration of t-PA in Clinical Practice

One major difference between the evolution of treatment of ischemic brain attack and the evolution of treatment of ischemic myocardial attack is the lack of a reliable diagnostic test for stroke in the emergency setting. Intravenous thrombolysis in myocardial infarction is predicated on combining an appropriate clinical evaluation with a positive diagnostic test--ST segment elevation on the electrocardiogram. Intravenous thrombolysis in stroke is predicated on appropriate clinical evaluation and a negative test--the absence of abnormality on the CT scan. At present, the clinical neurological evaluation is the sole procedure upon which to make decisions about the use of a fairly toxic drug. Sensitive and specific diagnostic tests to identify cerebral ischemia or an occluded cerebral artery in the acute setting are currently under investigation (5).

Excluding Inappropriate Patients for the Administration of t-PA in Clinical Practice

The risk of intracranial hemorrhage with the use of intravenous t-PA places a premium on not treating patients unlikely to benefit. Even in established centers, up to 19% of patients are incorrectly diagnosed as suffering from acute stroke (6). In the NINDS t-PA Stroke Study (7), t-PA was administered by teams of neurologists and emergency physicians with expertise in stroke and in CT interpretation. One of many differences between the successful NINDS study and the failed European Cooperative Acute Stroke Study (ECASS) of t-PA (8) was the high rate of intracranial hemorrhage and mortality in patients entered into the ECASS study who did not meet specified entry criteria.

Expertise is needed to exclude patients in whom t-PA treatment is dangerous or not appropriate including:

  • Patients with CT signs of hemorrhagic stroke: subarachnoid hemorrhage, intracerebral hemorrhage, subdural or epidural hemorrhage.
  • Patients without stroke who may present with a history suggestive of stroke-like onset of focal neurological deficit.
  • Patients with rapidly resolving neurological deficits.
  • Patients in whom the time of onset is difficult to establish (especially difficult in patients with stepwise progression of deficits in which the last of multiple events brought them to the hospital).
  • Patients in whom the CT scan shows infarction.

Estimating Risk and Benefit

Stroke expertise is also necessary to discuss the risks and benefits with the individual patients. In community practice the decision to treat with t-PA is determined by: (a) the individual's risk of t-PA-induced hemorrhage and death; (b)

t-PA's expected effect on the individual's potential for neurological recovery; and (c) the individual's (surrogate's) wishes to accept (a) in an attempt to attain (b). This discussion must occur but can be difficult and requires considerable stroke knowledge. The patient and family are usually most influenced by the physician's prediction of the expected long-term outcome without intervention. Some knowledge of the patterns of stroke recovery is necessary to present the risks and benefits of t-PA in the ED.

Management of Treated Patients

The NINDS t-PA Stroke Study and the American Heart Association recommendations for t-PA include strict monitoring and regulation of blood pressure below defined upper limits with antihypertensive agents (2). They mandate hourly assessment of neurological status for 24 hours after treatment. They include protocols for emergency management of hemorrhage in t-PA-treated patients, specific guidelines for the control of hypertension, and recommendations for management of bleeding complications. The American Heart Association recommends admission of treated patients to a skilled care facility (intensive care or acute stroke unit). This underlines the need for inpatient stroke care expertise on the part of nurses and physicians in facilities using t-PA for acute stroke patients in the ED.

Treatment of Intracranial Hemorrhage

The risk of hemorrhage after t-PA necessitates careful monitoring of treated patients to prevent, as well as to detect and respond to, intracranial hemorrhage should it occur. Patients with intracranial hemorrhage require specific medical, neuroradiological, and neurosurgical response. Expertise to deliver such a response must be available for patients treated with t-PA as it is for other patients with intracranial hemorrhage. The American Heart Association recommends that thrombolytic therapy not be used unless facilities that can handle bleeding complications are readily available.

Expertise in the treatment of patients with intracranial hemorrhage currently includes:

(a) Neurosurgical response to evacuate hematoma when appropriate.

(b) Intensive care management of changing neurological function to:

(i) guide timing of (a);

(ii) administer cryoprecipitate and platelets; and

(iii) manage raised intracranial pressure.

(c) Neuroimaging expertise to emergently detect intracranial hemorrhage and mass effect.

Management of the Acute Stroke Patient After t-PA Treatment

Expertise in the management of the stroke patient in the days following t-PA use is crucial to allow the patient to recover to his or her full potential. Diagnostic and therapeutic decisions will have an impact on the patient's risk of recurrent stroke. These issues are not dealt with here.

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The Stroke Team, t-PA, and the Future of Acute Stroke Care

The above discussion centers on the medical decisions that a hospital staff faces in attempting to provide optimal care for the stroke patient. Noncontroversial requirements exist for: (a) emergency clinical evaluation of the stroke patient by knowledgeable staff; (b) accurate, emergency evaluation of the CT scan; (c) knowledgeable discussion with the patient and family of available acute treatments, risks, and benefits; and (d) availability of stroke-trained nurses and physicians to ensure safe inpatient management. At present there are too few stroke physicians (primarily specialized neurologists numbering only a few hundred) who engage in all phases of acute and inpatient management. A stroke team of dedicated professionals with a variety of training backgrounds is needed to meet the requirements set by the 500,000 strokes that occur annually in the United States.

The introduction of t-PA as an FDA-approved treatment for certain stroke patients within 3 hours of symptom onset calls for improved organizational efforts to manage these patients. It does not necessitate anything unique, but it does mandate that the same level of organization and expertise currently applied to myocardial infarction, head trauma, and intracranial hemorrhage be available to patients with ischemic stroke. Perhaps the greatest challenge is to provide consistent, 24-hour-a-day stroke care. The current level of stroke expertise can not meet the need for universally available acute stroke treatment. Professional stroke education programs are needed to recruit emergency physicians, neurologists, radiologists, emergency nurses, intensive care physicians and nurses, and primary care physicians to form stroke teams. Hospitals must form networks to ensure that patients with all types of neurovascular emergencies have access to needed expertise, especially stroke and neurosurgical expertise.

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The Future

Major improvement in tissue preservation requires timely reperfusion. Future stroke care will strive to reduce the risks and improve the benefits inherent in thrombolysis. Hyperacute administration of cytoprotective agents will likely show benefit and require the level of coordinated effort demanded by t-PA. Agents that limit reperfusion injury may improve the risk/benefit ratio of thrombolysis. These new agents and combinations of multiple therapies will improve patient outcome but complicate medical decision-making. An expansion of stroke expertise will be necessary to ensure access to optimal stroke treatments and to evaluate and optimize their performance in community use. Expanded medical expertise and coordinated systems of stroke care will also enhance the development of new and better strategies to diagnose and treat stroke. The rapid institution of stroke teams will advance the present level of medical expertise and lead more quickly to better stroke care for the nation.

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References

1. Adams HP, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994;25:1901-1914.

2. Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy in acute stroke: A supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1996;94:1167-1174.

3. Mayberg MR, Batjer HH, Dacey R, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1994;90:2592-2605.

4. Koroshetz WJ, and Moskowitz MA. Emerging treatments for stroke in humans. Trends Pharmacol Sci 1996;17:227-233.

5. Sorenson AG, Buonanno FS, Gonzalez RG, et al.Hyperacute stroke: Evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Radiology 1996;199:391-401.

6. Libman RB, Wirkowski E, Alvir J, et al. Conditions that mimic stroke in the emergency department. Arch Neurol 1995;52:1119-1122.

7. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-1587.

8. Hache W, Kaste M, Fieschi C, et al (for the ECASS Study Group). Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke: The European Cooperative Acute Stroke Study (ECASS). JAMA 1995;274:1017-1025.

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Table 1. Stroke Teams in Standard Care of Patient Groups in Whom Specific Emergency Intervention Has Shown Benefit

Patient group

Emergency expertise

Neuroimaging expertise

Neurosurgical expertise

Inpatient unit expertise.

Intracranial hemorrhage:

subarachnoid

intracerebral

subdural

epidural

lobar

Emergency staff trained to recognize signs of stroke and rapidly stabilize hematologic and cardiopulmonary status.

Emergency transport services to transfer patients when necessary to sites with needed expertise.

Emergency CT scan to identify or rule out hemorrhage or mass effect. Emergency availability of cerebral angiography to identify aneurysm, AVM, or venous sinus thrombosis. Neurointerventional team for endovascular occlusion of inoperable vascular lesions; intra-arterial papaverine or angioplasty for vasospasm after SAH. Emergency neurosurgical response to evacuate hematoma, clip berry aneurysm. Trained intensive care staff (nurses and physicians) to manage hemodynamic parameters and intracranial pressure, treat vasospasm, and monitor neurologic status in the pre- and post-operative period. Stroke neurology staff to manage venous thrombosis and aid neurosurgeon in the management of others.
Cerebellar infarction Recognition of signs of cerebellar infarct; often requires stroke neurology staff.
Define vascular lesion using angiography, CT or MR angiogram or transcranial doppler. Emergency imaging to detect secondary hydrocephalus or brainstem compression. Emergency neurosurgical response to decompress posterior fossa or place ventriculostomy. Trained staff to recognize signs of hydrocephalus or brainstem compression. Stroke neurology staff to manage patients with likely underlying vertebrobasilar artery stenosis or occlusion, and to monitor anticoagulation.
Basilar occlusion Recognition of signs of basilar disease. Often requires input from stroke neurology staff. Define vascular lesion as above; neurointerventional team for intra-arterial thrombolysis. Emergency neurosurgical response to evacuate potential posterior fossa hemorrhage. Stroke neurology and trained staff to monitor cardiopulmonary condition, anticoagulation, and neurologic signs. Intensive care unit for management after thrombolysis.

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Table 2. Task-Specific Guidelines for Medical Expertise in the Treatment of Acute Stroke With t-PA

 

Goals

Training

Location

Professionals to train for these roles

Pre-treatment expertise

Clinical Evaluation a. Identify appropriate stroke patients

b. Exclude patients from t-PA treatment who do not have ischemic stroke or have little chance of benefit

a. Experience in recognizing and dating symptoms and signs of acute stroke types; knowledge of management of acute stroke types

b. Experience in diagnosis of conditions that mimic ischemic stroke

c. Knowledgeable in use of t-PA

Available in the ER; special personnel on site, in phone contact with emergency staff, in phone contact with family, in video contact, on call to ER a. EMT

b. Triage nurse

c. ER nurse

d. ER physician

e. Neurologist

f. Primary care physician

Radiologic Evaluation a. Identify intracranial hemorrhage.

b. Identify signs of early stroke, or recent stroke.

Experience in recognizing subtle SAH, subdural and epidural hematoma, AVM, tumor, cavernous angioma Available to ER; personnel on site or quality appropriate images downloaded for interpretation a. Neuroradiologist

b. Neurologist

c. General radiologist

d. ER physician

Informed Consent a. Discuss likely long-term disability from stroke

b. Discuss risks of hemorrhage and death from stroke and from t-PA use

c. Discuss potential for individual to benefit from t-PA.

Knowledge of outcome after stroke, risks/benefits of t-PA Personnel on site or in phone contact with patient and family a. Neurologist

b. ER physician

c. Primary care physician

Immediate post-treatment expertise

Medical Management a. Monitor neurologic function for signs of hemorrhage, brain edema, progressive stroke

b. Monitor and control blood pressure

c. Identify and treat hemorrhagic complications

d. Manage raised intracranial pressure in case of hemorrhage or malignant ischemic edema.

a. Nursing and physician experience in critical care of neurology/neuro-surgery patients a. Intensive care unit or specialized stroke unit

b. Unit on site or at site to which patient can be rapidly transferred

a. Neuroscience nurses

b. Intensive care nurses

c. Intensivists

d. Neurologists with training in stroke/ intensive care

Surgical Management a. Evacuate and manage intracranial hemorrhage

b. Perform carotid endarterectomy when appropriate

Experience in managing patients with subdural, epidural, and intra-cranial hemorrhage On call to site, or on call to site to which patient can be rapidly transferred Neurosurgeon
Radiologic Management a. Emergency ability to recognize intracranial hemorrhage and

mass effect due to cerebral edema

Experience in brain CT evaluation

(changes are usually dramatic)

On site or images downloaded for interpretation and physician in phone contact a. Radiologist

b. Neurologist

c. Primary care physician

Quality Assurance a. Collect data on patient outcome and complications

b. Improve time to treat appropriate patients

c. Identify patients treated inappropriately and change practice accordingly

d. Refine practice and incorporate resources needed to provide safe effective stroke care in the community

e. Incorporate new treatments into the acute stroke armamentarium

Experience in data collection and quality assurance On site or part of larger database Stroke team leader and support personnel

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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

Last updated May 17, 2011