Stroke Prevention and Treatment - Rush University Medical Center

Stroke Prevention and 

Treatment 

Shyam Prabhakaran, MD, MS 

Rush University Medical Center 

2/11/12 

©2003 RUSH University Medical Center

Public Awareness 


Public health impact of stroke 

• 1 stroke every 40 seconds in the US 

– 780,000 new strokes per year 

– 150,000 transient ischemic attacks per year 

• 1 of 6 Americans will be affected in a lifetime 

• 4 th leading cause of death 

– Every 3 minutes someone dies of a stroke 

– 175,000 per year: 25% mortality 

• Leading cause of major disability 

• About 4.8 million stroke survivors 

• Economic burden: $64 billion/year in the US 


Knowledge about stroke 

• General public awareness is poor (Pancioli AM 1998) 

– 43% could not identify 1 warning sign 

– 32% could not identify 1 risk factor 

• Up to 40% of stroke patients cannot identify 

symptoms, signs, or risk factors for stroke (Kothari R 

1997) 

• Knowledge is worse among elderly, and 

especially among women and minorities (Ferris A 

2005) 

• Awareness of time-dependent treatments such 

as clot-busting agents (tPA) is also less than 

optimal 


• Knowledge is POWER 

Fixing the problems 

– Public and medical education 

– Recognize stroke symptoms and risk factors 

• TIME IS BRAIN 

– Realize that there are approved and effective 

treatments 

• Clot busters (TPA) 

• Surgeries 

• Medications 


= 

EACH MINUTE THAT THE BRAIN DOESN’T RECEIVE 

BLOOD FLOW, 1.9 MILLION NEURONS DIE 

COMPARED TO NORMAL AGING, THE BRAIN AGES 36 

YEARS AFTER AN ISCHEMIC STROKE 

Saver J. Stroke 2006. Jan;37(1):263-6. 


What is a stroke? 


Types of stroke 

• Ischemic stroke – persistent blockage of 

blood vessel 

• Transient ischemic attack – temporary 

blockage of blood vessel 

• Hemorrhagic stroke – rupture of blood 

vessel 


• Stroke as in “struck down” 

What’s in a name? 

– Emphasizes the suddenness but suggests 

that it is something out of our control 

• Other technical (confusing) terms 

– Cerebrovascular accident (CVA), cerebral 

infarction, cerebral thrombosis 

• From a public health perspective, “brain 

attack” may be more preferable 

– Similar to “heart attack” 



Brain Attack: Warning Signs 


Common symptoms 

• Paralysis (usually one-sided) 

• Language or speech 

disturbance 

• Blindness in one or both eyes 

• Numbness (usually one-sided) 

• Double vision 

• Vertigo 

• Imbalance 

• Loss of consciousness 


Unilateral Paralysis 

• Weakness, clumsiness, or heaviness. 

Involves hand, arm, face, or leg, alone or in 

combination, most commonly the hand and 

face 

• Droop on one side of the face may occur 

(facial palsy) 

• The involved body parts are opposite the side 

of the diseased artery 


Visual Disturbance 

• Blurred or indistinct vision in one side of 

the field of vision in both eyes 

• Involved visual field is opposite the side 

of the diseased artery 


Double vision 

• Perception of 

two images 

instead of one 

due to 

misalignment of 

the eyes 


Vertigo 

• An illusion of 

movement 

caused by a 

dysfunction of 

equilibrium 

centers of the 

nervous system 


Brain Attack: Risk Factors 


• Age 

Things you CAN’T change 

– Risk doubles each decade after 55 

• Gender 

– Men have 50% higher risk as women 

• Race-Ethnicity 

– African-American, Hispanic, and Asians 

have 2x risk as Caucasians 

• Genetics / Heredity 

– First-degree relatives at higher risk 


• High blood pressure (hypertension) 

• Tobacco use (smoking) 

• High cholesterol and obesity 

• Carotid artery narrowing 

• Prior transient ischemic attack 

• Irregular heart rhythm (atrial fibrillation) 

• High sugar (diabetes) 

• Other heart diseases 

Things you CAN change 


High blood pressure 

• Most important risk factor for stroke, 

both ischemic and hemorrhagic 

• Normal blood pressure is < 120/80 

mmHg 

• Risk rises steadily with higher blood 

pressures above this level 

• Treatment with blood-pressure lowering 

pills reduces risk of stroke by 40% 

• Treatment should also include weight 

loss, salt restriction, and exercise 



• One in four Americans 

still smoke 

• Increasing among 

young women 

• Smoking doubles risk 

of stroke 

• Smoking cessation 

can reduce stroke risk 

to normal within 2 – 5 

years 

Smoking 


• 6 of 10 Americans are 

overweight or obese 

• 1 in 4 have high 

cholesterol 

• Cholesterol lowering 

therapy with “statins” 

reduces risk of stroke 

by 30% in primary and 

secondary prevention 

• Weight loss, exercise, 

and balanced diet 

must be part of every 

healthy lifestyle 

High cholesterol 


• 5-10% of general population have 

narrowing of carotid arteries 

• Significant narrowing (> 60%) can 

increase risk of stroke 2-fold 

• Early identification and aggressive 

risk factor control is warranted 

• Opening of narrowed arteries in 

addition to medical therapies can 

reduce risk of stroke in selected 

patients 

Narrowing of arteries 

– Most beneficial if after prior stroke or TIA 


Carotid artery stenting 


Gorelick, PB. Arch Neurol. 1995; 52: 347-355. 

Primary Prevention 

Up to 80% of all 

strokes are 

preventable!! 


Transient ischemic attack (TIA) 

• 15-20% of stroke patients have a TIA prior 

to the stroke, usually within a week 

TIA is an 

– TIA is a “warning sign” of an impending stroke 

– Analogous emergency to a minor tremor and before a major 

earthquake 

an opportunity 

• Symptoms and risk factors for TIA and 

stroke are identical to intervene except that to TIA is 

short-lived prevent (usually minutes stroke 

to 1 hour) 

• 5% of TIA patients have strokes within 48 

hours of the TIA and 11% within 3 months 


Guidelines 

• Acute hospitalization is recommended for: 

Timeframe Patients should go to 

Within 48 hours of 1 st TIA 

Multiple recurrent TIAs 

(crescendo) within past 7 days 

Within 7 days of 1 st TIA if: 

>1 hour duration 

ABCD 2 score > 3 

High-risk co-morbidity 

Carotid stenosis 

Atrial fibrillation 

©2003 RUSH University Medical Center 

Emergency 

department 

Emergency 

department 

Emergency 

department 

Johnston SC, Ann Neurol 2006

ED 

Acute Stroke Team 

Head CT 

ECG 

Basic labs 

Admit Stroke Service 

MRI/A or CTA or Doppler 

Cardiac echo and monitor 

Specific labs 

TIA Express Service 

Suspected TIA 

Within 48 hrs 

Crescendo 

High risk 

Yes No 


Stroke Clinic 

Behavioral modification 

Smoking cessation 

Weight loss 

Stroke education 

Medical management 

Antithrombotic therapy 

Blood pressure control 

Lipid lowering therapy 

Glycemic control

Patient after 

stroke or TIA 

Cardioembolic 

stroke 

Oral anticoagulants: 

1. Warfarin 

2. Dabigatran 

3. Rivaroxaban 

RELY, NEJM 2009; ACTIVE NEJM 2009; ARISTOTLE 

NEJM 2010; ROCKET-AF NEJM 2010 

Cardioembolic stroke - AFib 

Warfarin reduces risk of 

stroke by 68% 

Aspirin reduces risk of stroke 

by 21% 

Contraindication 

to warfarin? 

YES 

NO 


Initiate 

Oral 

anticoagulant 

Initiate 

1. aspirin or 

2. clopidogrel/aspirin

Cardioembolic stroke - AFib 

• Patients with ischemic stroke or TIA with persistent or 

paroxysmal (intermittent) AF 

– Recommended: 

• Anticoagulation with adjusted-dose warfarin 

(target INR 2.5, range 2.0 to 3.0) 

(Class I, LOE A) 

• Patients unable to take oral anticoagulants 

– Recommended: Aspirin 325 mg per day 

(Class I LOE A) 

– Clopidogrel plus aspirin is slightly better than aspirin 

alone (RRR 11%) in those who are not eligible for 

warfarin (ACTIVE NEJM 2009; 360:2066-2078) 

• Direct thrombin and Factor Xa inhibitors (dibigatran, 

rivaroxaban) has lower embolic stroke risks than 

warfarin with similar hazards and less concern 

regarding monitoring and dose adjustment 


Impact on # Strokes/Year 

0 

-10000 

-20000 

-30000 

-40000 

-50000 

-60000 

BP 

lowering 

After 

ACEI/ 

stroke/TIA, 

Smoking 

Indapamide Statin Antiplatelet Cessation 

-36,960 

-35,840 

per year (80% of 

-44,600 

Hankey; Lancet 1999;354:1457-63. 

Secondary Prevention 

over 200,000 

recurrent strokes 

can be prevented 

total) 

-56,700 


Anticoag. 

for 

Atr. Fibrl. 

-23,520 -23,800

Brain Attack: Treatment 


Acute Treatments 

Time window Treatment Study 

0-4.5 hours IV rt-PA 0.9 mg/kg NINDS 

ECASS III 

0-6 hours IA pro-UK (rt-PA) PROACT 

MELT 

0-8 hours mechanical extraction MERCI 

PENUMBRA 


% Favorable 

50 

40 

30 

20 

10 

0 

Clot Busters 

Global Test OR=1.7 (1.2-2.6) p=0.008 

60-70% more 

50 

likely to 38 have 

39 

31 

26 

20 

favorable 

outcome if 

treated with tPA 

NIHSS Barthel Modified 

Rankin 

44 


32 

Glasgow 

Outcome 

Odds Ratio 1.7 1.6 1.7 1.6 

95% CI 1.0-2.8 1.1-2.5 1.1-2.6 1.1-2.5 

p value 0.033 0.026 0.019 0.025 

t - PA 

Placebo

Clot Retrievers 






Time to arrival: < 3 hours 68 (23%) 

> 3 hours 224 (77%) 

% 

Sacco RL, et al. 

30 

25 

20 

15 

10 

5 

0 

Average time 7.2 hours 

Time is BRAIN 

0 3 6 9 12 15 18 21 24+ 

TTA among those awake at onset (hrs) 


Brain Attack: Organized 

Systems of Care 


Care at Primary Stroke Centers 

• Certified primary stroke centers (PSC) 

– Written protocols and pathways 

– Stroke team 24/7 for prompt response 

– Stroke unit 

– Data collection and quality improvement 

• Treatment at a PSC reduces mortality, 

complications, increases chance of 

treatments with standards of care such as: 

– Aspirin 

– Tissue plasminogen activator (clot-buster) 

– Specialized stroke unit admission 

– Medications and surgeries for prevention 


Triage to PSCs 

• AHA guidelines recommend preferential 

triage to stroke centers 

– “For patients with suspected acute stroke, 

EMS should bypass hospitals that do not 

have resources to treat stroke and go to the 

closest facility capable of treating acute 

stroke” 

• Routinely done in many other cities, 

regions, and states 

– New York City, Houston, Phoenix, Bay Area 

– Florida, Massachusetts, New York 


Chicago 

• 2.8 million reside in Chicago city limits 

– 3 rd largest in US 

• 33 Chicago hospitals 

• About 8500-9000 strokes/TIA in Chicago per 

year 

• Arrival mode 

– 35-45% EMS 

– 35% private/walk-in 

– 15% transfers 

– 5-10% other 

• Prior to 3/1/11 

– patients taken to closest hospital 


IL 

IL 

LAKE 

LAKE 

COOK 

COOK 

Epidemiology in Chicago 

Lake Michigan 

Lake Michigan 

LAKE 

©2003 RUSH LAKE LAKE LAKESource: 

University IHA IN 

IN INMedical 

CompData 

Center 

Stroke 

PORTER 

PORTER 

Found Locations 

State Borders 

5-digit ZIP Boundaries 

Patients 

Territories - Chicago Stroke By Er, Icd 9, Fa 

0 1 to – 10 

10 11 to – 30 30 

30 31 to – 60 60 

Lake Michigan 60 61 to – 120 120 

120 121 to – 180 180 

180 181 to – 240 340 

Counties 

Lakes, Major Riv ers 

Big Riv ers or Streams 

Big Lakes or Ponds 

Medium Lakes or Ponds 

Reserv oirs 

Bay s, Gulf s 

Parks, Forests 

National Parks and Forests 

State Parks and Forests 

Landmark Boundaries 

Military Installations 

States

Illinois Law: HB2244 

• Signed by Governor Quinn in August 

2009 

– Allows Illinois Department of Public 

Health (IDPH) to designate hospitals 

as stroke centers and directs EMS 

personnel to transport possible acute 

stroke patients to stroke centers 

• Chicago began diversion to PSCs on 

3/1/11 


Estimated Impact 

• Impact of preferential triage for this 

area 

– 9000 patients x (35% use EMS) x (50% < 

6-hr) x 1.15 (15% false positive) ~ 1812 

patients estimated annually (20% of all 

strokes) 

– 5 under 6-hr patients triaged per day 

• Every 50 patients treated at a PSC 1 

life is saved (Xian, JAMA 2011) 

• Increase tPA rate to 5% 190 more 

patients get treated 61 improved 

outcome

IL 

IL 

LAKE 

LAKE 

2 

3 

7 

14 

4 

6 

COOK 

COOK 

1 

11 

20 

12 

8 22 

5 

9 

16 

10 

18 15 

21 

19 

Chicago PSC Map 

13 

17 

Lake Michigan 

1. Advocate Christ 

2. Advocate Lutheran General 

3. Loyola 

4. MacNeal 

5. Northwestern Memorial 

6. Our Lady of Resurrection 

7. Resurrection 

8. St. Mary/Elizabeth 

9. Rush University 

10. University of Illinois Chicago 

11. St. Francis 

12. St. Joseph 

13. University Lake Michigan of Chicago 

14. West Suburban 

15. Mercy 

16. Stroger 

17. Lake Trinity 

Michigan 

18. Mount Sinai 

19. Little Company of Mary 

20. Swedish Covenant 

21. Holy Cross 

22. Illinois Masonic 

Within 

Chicago 

Outside IN 

IN 

Chicago 

LAKE LAKE IN 

Non- 

GWTG 

PSC 

PORTER 

PORTER 

GWTG 

Non- 

PSC 

After 

3/10

Actual Impact 

• March-June 2010 vs. March-June 2011 

– At 11 centers in Chicago, 768 vs. 780 

strokes 

– EMS activation used in 31.5 38.5% 

– EMS pre-notification: 54.5 74.3% 

– Onset-to-arrival times: 200 120 

minutes 

– TPA treatment: 4.2 7.5% 

– Eligible patients treated: 40.2 

58.8%

• Know your risk factors and 

ask your doctor if you’re on 

the right medications to 

lower risk 

• Know stroke warning signs 

• Call 911 immediately if you 

or someone you love may be 

having a stroke 

• Ask about clot-busting and 

other treatments 

• REMEMBER TIME LOST IS 

BRAIN LOST! 

What can you do? 

FACE 

ARMS 

SPEECH 

TIME 

Act F.A.S.T. 

Ask the person to smile. 

Does one side of the face droop? 

Ask the person to raise both arms. 

Does one arm drift downward? 

Ask the person to repeat a simple sentence. 

Are the words slurred? Can he/she repeat 

the sentence correctly? 

If the person shows any of these symptoms, 

time is important. 

Call 911 or get to the hospital fast. Brain 

cells are dying. 


Thank you for your attention!!!

Stroke Prevention and Treatment - Rush University Medical Center

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