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2022 Update to Canadian Acute Stroke �Best Practices Recommendations�

Rhonda Whiteman, R.N., MN, CNN (C)

Clinical Nurse Specialist - Central South Regional Stroke Network

September 14, 2023

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Impact of Stroke in Canada

108,707

strokes/year

Someone has a stroke

every 5 minutes

20% chance of

second stroke

within 2 years

Risk of stroke

doubles every year

over the

age of 65 years

Having a stroke more than doubles the risk of developing dementia

Leading cause of

adult disability

Third leading cause of death

More than 878.000 Canadians

are living with stroke

Strokes are increasing younger adults aged

20 – 59 years

1 in 3 Canadians will develop stroke, dementia or both

The impact of stroke in Canada can be devastating. Statistics from 2017 reveal that there are approximately 108,707 strokes occurring in Canada per year.
It is also known that there are approximately 878,000 Canadians living with stroke.
Someone is having a stroke about every 5 minutes in Canada.
The leading cause of adult disability
Stroke is the 3^rd leading cause of death in Canada, half of all people in Canada living with stroke need help with daily activities such as eating, bathing, dressing, going to the washroom and getting around.
Stroke doubles every year over the age of 65 years. Over the last few years, stroke among younger adults in increasing – ages 20 – 59. Stroke can happen at any age to anyone. Research is expecting stroke will double in this younger age group.
Almost half of Canadians have been touch by stroke, either experiencing it themselves or having a close family member or friend who has had a stroke.
Having a stroke more than doubles someone’s risk of developing dementia.
And, for every clinically evident stroke, there are as many as 9 covert strokes that result in cognitive impairment.
Research has shown that persons who have had a stroke have a 20 % chance of having a second stroke within the next 2 years.
This raises the concern and need for aggressive secondary prevention management.

• Stroke can happen at any age.

• One in 6,300 babies is born with stroke; this is one each week.

• In Canada there are more than 10,000 children (0 – 18 years) living with stroke.

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2022 Canadian Stroke Acute Best Practice Recommendations (CSBPR) Update

Two Phases of Care for all stroke subtypes:

Prehospital and Emergency Department Acute Stroke Care:

“Hyperacute” Time Sensitive Window – �First 24 hours

Acute Stroke Care:

Discharge from acute care or first 30 days

https://www.strokebestpractices.ca/recommendations/acute-stroke-management

Canadian Acute Stroke Best Practice Recommendations Module covers the:

Prehospital and Emergency Department Acute Stroke Care

Covers the key interventions needed for the assessment, diagnosis, stabilization and treatment in the first hours after stroke onset
Includes all the prehospital and initial emergency care for TIA, Ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage and acute cerebral venous thrombosis
Rapid Triaging of patients based on time of stroke onset, stroke acuity and brain imaging
Treatment including acute intravenous thrombolysis or acute endovascular interventions for ischemic stroke, emergency neurosurgical procedures and TIA diagnosis and risk stratification evaluations
Goal to diagnosis stroke type and implement plan of care
Time period is time sensitive – minutes matter
“Hyperacute” Time Sensitive Window refers to care offered in the first 24 hours after acute stroke or TIA

Acute Stroke Care:

Key interventions involved in the assessment, treatment or management and early recovery in the first days to weeks after stroke onset
Initial diagnostic procedures to identify nature and mechanism of stroke, interdisciplinary care to prevent complications and promote early persons with stroke and their family to assess and plan for transition to next level of care
Time frame – when discharged from acute or 30 days after hospital admission

Focus on highlighting the Canadian Stroke Best Practice Recommendations in following areas:

Stroke Awareness, Recognition and Response
Triage and Initial Diagnostic Evaluation of TIA and Non Disabling Stroke Recommendations
Emergency Medical Services Management of Acute Stroke
Emergency Department Evaluation and Management of Patients with TIA and Acute Stroke Recommendations
Acute Ischemic Stroke Treatment:

- Thrombolysis

- Endovascular Therapy

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CSBPR Section 1 - Stroke Awareness, �Recognition & Response

Organized systems of care established to enable rapid emergency stroke management

✔

Education that stroke is a medical emergency that can affect persons of any age - Newborns, Children and Adults

✔

Awareness campaigns and Recognition of signs of stroke (FAST) and immediate Response by calling 911

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Ontario was the first province in Canada to organize stroke care in the province.
In 2000, the Ontario Stroke System was developed. The OSS is a system of regional networks that were developed for stroke care delivery across Ontario and rapid access to emergency stroke management was a key element to this reorganization.

The province was divided into 11 regional stroke networks with a regional stroke centre with regional stroke centres and district stroke centres to organize and coordinate stroke services across the continuum within the region and in each district.

Part of this Provincial system was working with Base Hospital Medical Directors, Provincial Medical Advisory Committee and the Emergency Health Services Branch of the Ministry to create the Provincial Paramedic Prompt Card, Acute Stroke Protocol. The Provincial Prompt Card has been updated as stroke best practices have changed with introduction of stroke mechanical thrombectomy and to address the changing treatment windows for the LAMS.

The Central South Regional Stroke Networks has worked with the Base Hospital Program or CPER and Paramedic Services to have an organized system of stroke care and has had Central South Regional Stroke Network Stroke Memorandum of Understanding for Acute Stroke Bypass and Redirection since 2006.

Education of the public and health care providers is essential that Stroke can happen at any age to anyone. Recent statistics show that:

• One in 6,300 babies is born with stroke; this is one each week.

• In Canada there are more than 10,000 children (0 – 18 years) living with stroke.

Over the last few years, stroke among younger adults in increasing – ages 20 – 59. Stroke can happen at any age to anyone. Research is expecting stroke will double in this younger age group

Surveys indicate that the knowledge of signs and symptoms of stroke remains very low – 65.2% of people can identify 4 of 6 signs of stroke – 11.4% could not identify a single symptom
Public awareness campaigns focusing on FAST Warning Signs looking at multimedia approaches has shown increase awareness of signs and symptoms of stroke and to call 911
The Central South Regional Stroke Network with our partners do Public Awareness Campaigns in June for Stroke Month and October for World Stroke Day - October 29, 2023
Women had better knowledge of stroke symptoms, risk factors and learn more from public awareness campaigns

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CSBPR Section 2 – Triage and Initial Diagnostic Evaluation of TIA/Non Disabling Stroke

Highest Risk for Recurrent Stroke

Pts within 48 hours of symptom onset

Transient motor, speech or persistent symptoms

Immediately sent to ED with capacity for stroke care

After 48 hours

Need comprehensive evaluation and brain imaging ASAP

Stroke Prevention Clinics provide rapid access to stroke experts, investigations, risk factor management

Vertebrobasilar Ischemia

Diplopia, dysarthria, dysphagia, vertigo, ataxia may occur for greater than 48 hours

Can be mistaken as stroke mimics and need urgent evaluation and brain imaging

TIA or minor strokes are unstable conditions that can be at high risk of recurrent stroke. Risk of recurrent stroke is reported to be 4.7% within 90 days with the risk being front loaded – 3.8% of recurrent strokes occur within 2 days of initial symptom onset. 7 Day risk of stroke following TIA can be as high as 36% in patients with multiple risk factors. Timely initiation of secondary prevention medical therapy and carotid revascularization have been shown to reduce the risk of major stroke after initial TIA or non disabling stroke.

Individuals experiencing signs or symptoms of acute stroke require rapid assessment, diagnosis, and determination of risk for a recurrent stroke. Patients diagnosed with TIA or minor ischemic stroke who are not candidates for acute stroke treatment should be prioritized for secondary prevention of stroke assessment and management.

Patients who present with onset of symptoms within 4.5 hours, regardless of whether the symptoms have resolved or not, should be sent for emergent assessment.

Patients with onset of symptoms within 4.5 to 48 hours, regardless of whether the symptoms have resolved or not, should be referred for urgent assessment.

Patients presenting to an outpatient setting should undergo evaluation by HCP with stroke expertise to determine stroke recurrence risk

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CSBPR Section 3 – Emergency Medical Management of Acute Stroke

Prehospital Phase

Emergency Department Phase

Interhospital Transfer Time

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CSBPR Section 3 – Emergency Medical Management of Acute Stroke

Handover in Emergency Department

Rapid TOA and patients within window have highest priority in ED Triage

TOA in ED to facilitate Acute Stroke Treatment Decision Making:

Onset or Last Known Well
Presenting symptoms
Current status
Baseline Functional Status and independence level
Current medications (especially anticoagulants) and time take
Advanced care plans
Additional health concerns

Transport of Suspected Stroke Patients

Direct Transport Protocols should be in place to facilitate transfer of stroke patients eligible for acute stroke therapy to acute stroke hospitals
Triage as CTAS Level 2 or Level 1 if compromised ABC’s
Pre-Notification to ED including LKW, S&S, LAMS score, ETA to hospital
Patient outside of acute stroke treatment window transported to closest hospital
System of rapid transport should be available to facilitate the movement of pts from one ED to another for time sensitive stroke treatment (Walk In Protocols, Transport for EVT, etc.)

Paramedic On Scene Treatment

PreHospital Stroke Screening Tool
Screening for Large Vessel Occlusion (LVO) stroke on scene
Limit treatments on scene to immediately needed
History from witness
On-scene time less than 20 minutes
Capillary glucose
Instruct family to be accessible to hospital either in person or via phone

Access to Emergency Medical Services

911

Central Ambulance Communication Centres

Dispatch communication to paramedics

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CSBPR - Mobile Stroke Units �(Stroke Ambulances)

CSBPR is could not make a recommendations about mobile stroke units as published data in Canadian context and health system organization is lacking.

High quality studies in other countries suggest use of mobile stroke units is associated with reduced time to thrombolysis, increased proportion of patients requiring thrombolysis and better functional outcomes at 90 days.

Mobile Stroke Units are Ambulances that have a CT Scanner installed on board that can do a CT and CT angiogram and either have a nurse and/or neurologist on board or link by videoconference (similar to Telestroke) to a neurologist at a stroke centre.

The patients undergoes the CT/CTA in the ambulance, links to neurologist who reviews the imaging and decisions are make regarding thrombolysis and it can be given in the ambulance prior to arrival to the hospital and also decisions about eligibility for EVT.

They have been implemented in rural and remote areas in Alberta and in the US in Large Urban Cities. The stroke ambulance can meet a regular ambulance and do the imaging, make treatment decisions and transport to either EVT centre or local Thrombolysis hospital or if neither to closest hospital.

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CSBPR Section 4 – Emergency Department Evaluation and Management of TIA/Acute Stroke�Initial ED Evaluation of suspected stroke patients

Immediately assessed and undergo diagnostic investigations to determine eligibility for Hyperacute Stroke Treatments

Rapid Neurological Examination and assessment of vitals signs, heart rhythm and presence of seizures

Acute stroke bloodwork and Brain Imaging

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CSBPR 4.2 Neurovascular Imaging�Within 6 Hours

Non Contrast CT Head

First Line diagnostic tool for patients with suspected neurological conditions
Looking for areas of infarction or bleeding in the brain
Identify eligibility for stroke thrombolysis

Multiphase CT Angiogram

Identify Large Vessel Ischemic Stroke who are eligible for EVT
Head and Neck
Used to evaluate collateral circulation in brain
Requires Contrast – Large Bore IV

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All patients with suspected acute stroke should undergo brain and vascular imaging;

Vascular Imaging – aortic arch to vertex of the brain

All patients with suspected stroke who arrive at hospital within 6 hours who are eligible for Hyperacute Stroke Treatments should undergo Immediate NCCT and CTA of head and neck.

CT Head Non Contrast : because it does not require a consent .

Early identification of ischemic changes with patients that have a large vessel occlusion in their anterior circulation

CSBPR identify a validated tools such as ASPECTS used to rapidly identify patients eligible for EVT 10 point grading scale

Used to assess for eligibility of EVT and tPA

Score > 6 for tPA and/or EVT

www.aspectsinstroke.com

Used to evaluating collateral circulation in the brain

Time resolved imaging from the base of the brain to the vertex in 3 phases and compare arteries from the affected side to the unaffected side

Requires contrast

Collaterals are measured on multiphase CTA by comparing backfilling arteries beyond the blocked artery to similar arteries in the opposite unaffected hemisphere

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CSBPR 4.2 Neurovascular Imaging�6 - 24 Hours

Stroke patients within 6 to 24 hours including stroke on awakening or with unknown onset time who are potentially eligible for EVT should undergo CT Head, CTA and CT Perfusion

CTP assess cerebral blood flow to identify areas of reduced cerebral blood flow in acute ischemic stroke

Provides clear, easy to interpret maps �which quantifies cerebral blood flow and volumes to identify patient eligible for EVT

Requires CT Contrast – Large Bore IV

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CSBPR Section 5 – Acute Ischemic �Stroke Treatment

All stroke patients with disabling ischemic stroke symptoms within 6 hours should be screened without delay by a physician with stroke expertise for eligibility for intravenous thrombolysis or interventional treatment with EVT.

All patients with disabling stroke symptoms between 6 to 24 hours should be rapidly screened to determine eligibility for advanced imaging and acute stroke treatments.

Use of intravenous thrombolysis and/or EVT in patients who are not functionally independent may be considered weighing risks and benefits for the patient.

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CSBPR 5.2 Intravenous Thrombolysis Administration

All eligible patients with disabling ischemic stroke, who can receive intravenous thrombolysis with alteplase or tenecteplase within 4.5 hours of stroke symptom onset/last known well should be offered it.

All eligible patients should receive intravenous thrombolysis as soon as possible , with a median Door-to-Needle time of 30 minutes or less, and a Door-to-Needle time of 60 minutes or less in at least 90% of treated patients.”

Tenecteplase may be considered an alternate to alteplase within 4.5 hours of acute stroke onset.

Single bolus dose of 0.25 mg/kg up to a maximum of 25 mg

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AcT Trial (Alteplase compared to Tenecteplase)

AcT Trial found the Tenecteplase was non-inferior to Alteplase in terms of functional outcomes and risk of complications:

37% had functional improvement at 90 days
Symptomatic ICH rates were same – 3.4%
Systematic Hemorrhage were rare – 1%
Angioedema was rare – 1%

Why switch to TNK?

Easy to administer as a one time bolus

TPA is a Bolus over 1 minute followed by infusion over 1 hour

No need for an infusion pump
Simplified dosing – less likelihood of dosing errors

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CSBPR 5.4 Endovascular Therapy for Acute Ischemic Stroke

5.4.1 Anterior Circulation:

For large artery occlusions in anterior circulation, EVT should be considered based on patient pre-morbid function, clinical deficit and imaging findings. Patients who can be treated within 6 hours of symptom onset should be receive EVT

Selected patients with Large artery occlusion and who are eligible based on premorbid status and advanced neuroimaging, should be treated with EVT within 24 hours of last known well

5.4.2 Posterior Circulation:

For large artery occlusions in the posterior circulation (basilar artery occlusion) EVT should be considered based on patient pre-morbid function, clinical deficit and imaging findings.

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Benefits of Endovascular Therapy

Benefits of EVT – 24% have a positive outcome

NNT = 4 (to live independently)

Risk of ICH = 3%

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Questions

Rhonda Whiteman

mcnicolr@hhsc.ca