Stroke Management: Opportunities and Developments

Lindsey Ryan, MSN, RN, CCRN-K, ACNS-BC

Stroke Management

The Centers for Disease Control and Prevention (CDC) reports approximately 795,000 strokes occur in the United States annually. Of these, 87% are diagnosed as ischemic. In 2017, an estimated 140,000 Americans died from stroke, making stroke the fifth leading cause of death in the United States (CDC, 2017). Globally, in 2013 there were 6.5 million stroke deaths, making stroke the second-leading cause of death behind ischemic heart disease (Benjamin et al., 2017).

From 2001 to 2011, the relative rate of strokes fell by 35.1% and the actual number of stroke deaths declined 21.2%. These vast improvements in outcomes are associated with improved cardiovascular risk factor interventions (Mozaffarian et al., 2015).

Acute ischemic strokes have devastating effects for both the individual and the healthcare system. Total direct medical stroke-related costs are projected to triple by 2030, from $71.6 billion in 2012 to $184.1 billion (Benjamin et al., 2017).

In 1998, the FAST mnemonic was developed in the UK to help detect and enhance responsiveness to the needs of a person having a stroke. More recently, studies show that 14% of ischemic stroke patients experienced symptoms that were not captured in the FAST mnemonic (Arror, Singh, Goldstein, 2017). While awaiting validation from prospective studies, the BE FAST mnemonic has added “Balance” and “Eyes”. With the two additional symptoms added, the proportion of stroke patients not identified with the revised BE FAST mnemonic was reduced to 2.6%.

Balance – Is there a sudden loss of balance or coordination?

Eyes – Is there sudden blurred or double vision or sudden, persistent vision trouble?

Face – Ask the person to smile. Is one or both sides of the face drooping?

Arms – Ask the person to raise both arms. Does one side drift downward? Is there weakness or numbness on one side?

Speech – Does the person have slurred or garbled speech? Can he/she repeat simple phrases?

Time – Call 911 for immediate medical attention if you notice one or more of these signs. Also, take note of when symptoms began.

Community Stroke Education
Studies have shown that early stroke recognition is associated with decreased morbidity and mortality. Public awareness of stroke symptoms varies throughout the country (Rademacher et al., 2018). In one survey, 93% of respondents identified sudden numbness on one side as a stroke symptom. However, only 38% were aware of all major symptoms and recognized the need to call 9-1-1 (CDC, 2018). In an attempt to increase public education, creative efforts have been undertaken. The Hip Hop Stroke program, designed by Olajide Williams, M.D., M.S., has been shown to dramatically increase stroke recognition, both acutely and long term, among the public. Click here to view the Hip Hop Stroke music video (American Heart Association, 2018): https://www.youtube.com/watch?v=lTykAih-USY&feature=youtu.be

What’s New…
Two, relatively new, treatment options for ischemic stroke patients are showing great promise. In a recent meta-analysis, nine trials were identified where 2,711 patients treated with intra-arterial Activase®. Analysis showed a significant improvement in patient outcomes (Lakhan, Walther, Morganstein, & Nguyen, 2017). Secondly, results from a randomized controlled trial show that endovascular treatment (ET) to remove a thrombus in the brain is effective in some patients even when performed within 6 to 24 hours after a stroke (Powers et al., 2018).

The first hour after arriving to the ED and treatment with Activase® is referred to as The Golden Hour. Since the initiation of The Golden Hour initiative, many organizations have achieved the goal of treating more than 50% of patients with an acute ischemic stroke within 60 minutes. The 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke have now included a secondary aim to treat >50% of patients with an acute ischemic stroke within 45 minutes (Powers et al., 2018).

A recent study presented at the 4th European Stroke Organization Conference this past May, showed that combining clopidogrel and aspirin following a small stroke decreases the risk of a new stroke, heart attack or other ischemic event within 90 days. These findings will likely have an impact on future Stroke Guidelines set forth by the American Stroke Association.

Next Steps
Research is ongoing, as doctors and scientists try to mitigate stroke risk factors and improve outcomes for stroke survivors. While strokes are complex and require the efforts and skills of interdisciplinary team members, nurses play a pivotal role in the prevention, identification, and treatment of strokes. To learn more, check out the resources below:
  •   American Stroke Association: http://www.strokeassociation.org/STROKEORG/#
  •   Brain Attack Coalition: https://www.brainattackcoalition.org/
  •   Centers for Disease Control and Prevention: https://www.cdc.gov/stroke/index.htm
  •   National Institute of Neurological Disorders and Stroke: https://www.ninds.nih.gov/Disorders/All-Disorders/Stroke-Information-Page

American Heart Association. (2018, March 22). Hip hop music teaches children, parents to recognize stroke and act quickly. Stroke Journal Report. Retrieved from: http://newsroom.heart.org/news/hip-hop-music-teaches-children-parents-to-recognize-stroke-and-act-quickly

Aroor, S., Singh, R., & Goldstein, L. B. (2017). BE-FAST (Balance, eyes, face, arm, speech, time): reducing the proportion of strokes missed using the fast mnemonic. Stroke, 48(2), 479-481.

Benjamin, E. J., Blaha, M. J., Chiuve, S. E., Cushman, M., Das, S. R., Deo, R., ... & Jiménez, M. C. (2017). Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation, 135(10), e146-e603.

Centers for Disease Control and Prevention. (2017, September, 6). Stroke Facts. Retrieved from: https://www.cdc.gov/stroke/facts.htm

Lakhan, S. E., Walther, M. M., Morganstein, D. R., & Nguyen, T. (2017). Intra-arterial treatment for acute ischemic stroke: a meta-analysis. International Archives of Medicine, 10.

Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., ... & Turner, M. B. (2015). Executive summary: Heart disease and stroke statistics-2015 update a report from the American Heart Association. Circulation, 131(4), 434-441.

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., ... & Jauch, E. C. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49(3), e46-e110.

Rademacher, E. W., Khoury, J. C., Kissela, B. M., Woo, D., Flaherty, M., Khatri, P., ... & Kleindorfer, D. O. (2018). Abstract WP176: Temporal Trends in Public Awareness of Stroke: Knowledge is Key.

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