Managing CVA in ED Learning Objectives Is it a stroke? Diagnosis ...

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Relative 90 day risk of CVA • One risk 3% • Two risks 7% >1700 patients • Three risks 11% • Four risks 15% • Five risks 34% Relative 90 day Risk of Adverse Event • >25% have an adverse event 12.7% recurrent TIA 10% CVA 2.6% cardiac event 2.6% deaths Johnson, C. et al; Short term prognosis after emergency department diagnosisof TIA; JAMA 2000 Vol 284 No. 22 Johnson, C. et al; Short term prognosis after emergency department diagnosisof TIA; JAMA 2000 Vol 284 No. 22 TIA work-up • Carotid evaluation (MRI/MRA, CTA, U/S) • ECHO bubble study (r/o PDA) • Lab work • EKG, telemetry to r/o paroxysmal A.fib. Reducing CVA risk with TIA patients • ASA and other anti-platelet meds • HTN management • Diabetes management • Endarterectomy or stenting for carotid disease • Anticoagulation with atrial Fib. • Statins Clinical approach to TIA CVA Patient • Appropriate discussion/disclosure of risk • Timely work-up to rule out treatable causes • ASA or other antiplatelet meds • Clinical home to address risk factor management Acute Symptoms < 5 hrs. Or “stuttering” No Bleed Imaging Subacute >5hrs No Bleed Persistent Neuro Deficit Bleed 6
Aggressive Interventional Options • Systemic rTPA • Neuro cath with targeted lytics • Neuro cath with lytics/embolectomy Systemic rTPA • Still controversial after all these years! • Generally accepted caveats: -no mortality impact (save some, lose some) -improves neuro outcome in 12 patients/100 treat. -MUST do it right to receive benefit! (overdosing is most common error) -NIHSS >22; severe strokes = no benefit -Cost/benefit is positive Systemic rTPA Neuro-interventional approaches • Earlier in course is better • Expeditious process and decisionmaking will change outcomes (minutes matter) • Community institutions can do this well • Appropriate disclosure of risk/benefit -12 improved outcomes/100 treated -1 in 15 have severe bleed • Targeted approach – fewer complications • Can cause delays in treatment • Limited resources • Limited efficacy data Single Center Experience With IA Intervention in 177 Consecutive Patients With Angiographically Confirmed Large Vessel Ischemic Stroke from 2003–2007 Michael T. Madison M.D., James K. Goddard, III. M.D., Jeffrey P. Lassig M.D., Mark E. Myers M.D. Background • IA thrombolytics and mechanical intervention have been shown to recanalize acute ischemic strokes at high rates (PROACT II = 66%; Multi MERCI = 68%) • Less data has been presented on use of these interventions in community based settings • Goal: to see if results from our group of 4 Neuro- Interventionalists covering acute stroke at 5 hospitals in the Minneapolis/St. Paul area were consistent with outcomes presented in other trials St. Paul Radiology, St. Paul, MN 7
Page 1 and 2: Managing CVA in ED Dave Moen, MD Me
Page 3 and 4: What about timing • If therapy av
Page 5: Clinical Caveats • ASA within 24
Page 9 and 10: Clinical Outcomes Clinical Outcomes

Managing CVA in ED Learning Objectives Is it a stroke? Diagnosis ...

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