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Ischemic Posterior Circulation Stroke Christopher Lewandowski, M.D. Residency Program Director Department of Emergency Medicine Henry Ford Hospital, Detroit, MI Sunitha Santhakumar, M.D. Department of Emergency Medicine Henry Ford Hospital, Detroit, MI. Case Study. HPI:

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Case study

Ischemic Posterior Circulation Stroke Christopher Lewandowski, M.D.Residency Program Director Department of Emergency Medicine Henry Ford Hospital, Detroit, MI Sunitha Santhakumar, M.D.Department of Emergency Medicine Henry Ford Hospital, Detroit, MI


Case study
Case Study

  • HPI:

    The patient is 41 y.o. male, with a past history of alcohol abuse, hypertension who presents to the ED with a chief complaint of right -sided weakness, slurred speech, and loss of balance.

    The symptoms began 90 minutes prior to arrival.


Case study1
Case Study

  • PMHx:

    • Alcohol Abuse, quit for 3 years

    • Hypertension

    • Seizures, Generalized, none for past 7 years

  • Medications

    • Dyazide

  • Social Hx

    • Smoking- 2 pack per day

  • ROS: Mild dizzy spells for the past 2 weeks, each lasting 5-10 minutes


Case study2
Case Study

  • Physical Exam:

    • BP- 149/79, P-100, RR-18, T-36.9

    • A&Ox3 on presentation, later became stuporous

    • CN: dysarthria, pupils: R 3.5/ L 3.0 reactive

      • L facial droop, gaze palsy to the L

    • Motor: R arm and R leg weakness (3/5)

    • Sensory: Decreased to light touch and pinprick on R

    • Coordination: dysmetria on R (not out of proportion to weakness)

    • NIH Stroke Scale score = 14


What does this patient have
What does this patient have?

  • Differential Diagnosis

    • Stroke

    • Intracerebral Hemorrhage

    • Tumor

    • VBI

    • Migraine

    • Seizure


Epidemiology
Epidemiology

  • Stroke - leading cause of adult disability in the USA

  • 20% of strokes involve the vertebrobasilar arteries

    20% of global cerebral blood flow is vertebrobasilar

  • Vertebrobasilar ischemia ranges from intermittent vascular insufficiency (VBI) to total basilar artery occlusion (BAO)

  • 20% - 60% with unfavorable outcome

  • Overall mortality 4%, BAO - 90% mortality


Risk factors uncontrollable
Risk Factors: Uncontrollable

  • Age

    • Stroke risk doubles for every decade over 55

  • Gender, Males - 1.3 x

    • Males have a higher risk, but females live longer, therefore there are more female stroke survivors

  • Heredity

    • African Americans - 2x

    • Family History

  • Previous stroke or TIA - 10x

  • Diabetes - 3x (even if well controlled)


Risk factors controllable
Risk Factors: Controllable

  • Hypertension - 6x (consistently >140/90)

  • Atrial Fibrillation - 6x

  • Smoking - 2x

  • Hypercholesterolemia > 200

  • Heart Disease - 2x

  • Alcohol, (> 4oz/day)

  • Obesity

    • BMI > 30

    • 35 inch waist in women, 40 inches in men


Risk factors vertebrobasilar ischemia
Risk Factors Vertebrobasilar Ischemia

  • Risk factors for the Posterior circulation are the same as for the anterior circulation

  • Hypertension, diabetes mellitus, hyperlipidemia, and tobacco are especially important for the posterior circulation




Pathology

Atherosclerosis

In situ thrombosis

Often complete occlusion

90% mortality

Embolization (20%-50%)

Heart or proximal vessels

May cause VBI

Good prognosis

Subclavian steal syndrome

Symptoms brought on by arm exercise

Trauma

Especially in the young

Vertebral artery dissection

Lacunar (small vessel disease)

Pathology


Emergency department presentation
Emergency Department Presentation

  • Prodrome very common

    • 60 % of patients with Basilar artery thrombosis

    • Stuttering or progressive onset of symptoms

    • 2 weeks prior to ED presentation


Emergency department presentation1
Emergency Department Presentation

  • Prodromal Symptoms (in order of frequency)

    • Vertigo and Nausea (30%)

    • Headache, Neckache (20%)

    • Hemiparesis (10%)

    • Dysarthria, Diplopia (10%)

    • Hemianopia ( 6%)

      Ferbert, Stroke 1990


Emergency department presentation2
Emergency Department Presentation

  • Clinical Findings: Depends on the syndrome

    • Range: asymptomatic to comatose

  • The 5 Ds: Dizziness, Diplopia, Dysarthria, Dysphagia, Dystaxia

  • Hallmarks: Crossed findings

    • Cranial nerve deficits - Ipsilateral

    • Motor / Sensory deficits - Contralateral


Vertigo
Vertigo

  • Hallucination of movement of the patient or the environment, not associated with loss of consciousness

  • Visual, proprioceptive, and vestibular systems maintain position (Romberg test)

  • Semicircular canals connect to the vestibular nuclei in the brainstem via CN VIII

  • Vestibular nuclei connect to the cerebellum, MLF (eye movement) and the vestibulospinal tract


Nystagmus
Nystagmus

  • Nystagmus means “nodding” off (as in sleeping during this lecture, slow sleep phase with rapid correction)

  • Nystagmus is named for its fast component

  • Medial longitudinal fasciculus coordinates the ipsilateral medial rectus (CN III) and the contralateral lateral rectus (CN VI)

  • Inner ear provides symmetric resting discharge


Nystagmus1
Nystagmus

  • Loss of input from one side leaves the other side unopposed

  • Unopposed stimulation causes a slow drift toward the diseased side

  • Cerebral cortex corrects for slow drift with a very rapid return toward a more normal position

  • The brainstem can compensate for asymmetric peripheral inputs leading to latency, fatigue, and habituation


Vertebrobasilar ischemia syndromes
Vertebrobasilar Ischemia: Syndromes

  • VBI

    • Common term for TIAs of the vertebrobasilar system

    • Patients often asymptomatic in ED

    • Frequent episodes, especially as prodromal sx

    • Requires evaluation of etiology

    • Very rare to present as vertigo alone

    • Difficult to distinguish from other causes of dizziness


Was this patient s dizziness central or peripheral
Was this Patient’s Dizziness Central or Peripheral

Central Peripheral

Intensity Mild Severe

Tinnitis Rare Common

CN findings Frequent None

Nystagmus:

Visual fixation No inhibition Inhibits

Horizontorotary Rare Common

Latency None 3-40 sec

Fatigue None yes


Posterior circulation stroke syndromes
Posterior Circulation Stroke: Syndromes

  • VBI, brainstem TIAs:

    • Occur over days-weeks

    • Intermittent fluctuating brainstem sx

    • Dizziness plus cranial nerve symptoms

    • Rarely dizziness alone


Vertebrobasilar ischemia syndromes1
Vertebrobasilar Ischemia: Syndromes

  • Branch artery occlusions

    • Produce a specific stroke syndrome for each artery

    • Longer and circumfrential arteries

    • Small penetrating branches supplying midline structures and causing lacunar syndromes

    • Characterized by the 5Ds and crossed findings

    • The severity of the stroke depends on the collateral blood flow and the location of the occlusion



Vertebrobasilar ischemia syndromes2
Vertebrobasilar Ischemia: Syndromes

  • Basilar artery occlusion

    • 75% with prodromal symptoms

    • 63% with gradual and progressive onset

    • Can produce a locked-in syndrome

    • Awake, quadriplegia, bilateral facial and oropharyngeal palsy, preserved vertical gaze

    • May present comatose if reticular activating system is involved


Emergency department diagnosis
Emergency Department Diagnosis

  • History

    • Prodrome

    • Dizziness

  • Physical Exam,

    • Blood pressure in both arms

  • Diagnostic Studies

    • Blood tests,CXR, EKG

    • Imaging


Emergency department diagnosis1

Confirm the Diagnosis (Emergent)

CT Scan

MRI, MRA, DWI

TCD

Angiography (DSA)

Evaluation of Stroke Etiology (Inpatient)

MRA / Angiography

Echo / TEE

TCD

Carotid Doppler

Emergency Department Diagnosis


Emergency department evaluation
Emergency Department Evaluation

  • CT scan - head, noncontrast

    • Necessary to rule out intracerebral hemorrhage

      • Most sensitive test for ICH

    • Poor for posterior fossa visualization

      • Bone artifact

    • Can pick up Basilar artery thrombosis

      • Highly specific sign, very low sensitivity

  • CT Angiography (spiral CT)

    • Reliably assesses basilar artery patency, inconclusive in patients with advanced arterial calcification




Emergency department evaluation1
Emergency Department Evaluation

  • MRI - long scan times, unavailable, access to patient is poor

  • Standard MRI, not reliable for ICH in first hours

  • Major advantage is Posterior Fossa imaging

  • MR Angiography -reliable evaluation of arteries for VBI, BAO

  • DWI - Diffusion weighted imaging demonstrates infarcted tissue, this is not a contraindication to thrombolysis



Emergency department evaluation2
Emergency Department Evaluation

  • TCD

  • Assesses flow through Vertebrobasilar system

  • Limited in BAO

    • Patient anatomy, penetration to distal BA difficult

    • Brandt: TCD diagnostic in 7 of 19 patients with suspected BAO, 2 of 19 false negatives

  • Low sensitivity for BAO, not useful in ED


Emergency department evaluation3
Emergency Department Evaluation

  • Digital subtraction angiography

    • Gold Standard for diagnosis of BAO

    • Time consuming, expensive, invasive

    • Requires patient cooperation, anesthesia

    • Allows for intra-arterial intervention

      • Thrombolysis, angioplasty


Emergency department management
Emergency Department Management

  • Stabilization

    • Ensure oxygenation and ventilation

    • Optimize cerebral blood flow by managing the blood pressure and hydration carefully, as autoregulation lost, ischemic areas become perfusion dependant

    • Avoid glucose, avoid hypotension, treat fevers aggressively

    • Evaluate for anticoagulation or thrombolysis


Emergency department management1
Emergency Department Management

  • Conservative Treatment

    • Antiplatelet and Antithrombotic

  • Thrombolytic Treatment

    • Intravenous: within 3 hours symptom onset and the patient meets all treatment criteria

    • Intra-Arterial Therapy: infusion of thrombolytic agent into vessel or clot within 24 hours of onset of symptoms


Posterior circulation stroke treatment
Posterior Circulation Stroke: Treatment

  • Conservative Treatment

    • Antiplatelet and Anti thrombotic Therapy

    • Uncontrolled, Retrospective Studies , 1950s & 1960s

    • Compared to historical controls, patients treated with heparin had lower mortality (8-15% vs. 40-60%)

    • Stopped progression of VBI to infarction

  • TOAST Trial

    • No evidence to support heparinization in acute stroke


Posterior circulation stroke treatment1
Posterior Circulation Stroke: Treatment

  • Intravenous Thrombolysis

    • NINDS rt-PA Acute Stroke Trial

    • t-PA approved within 3 hours of symptom onset

    • Few posterior circulation strokes


Posterior circulation stroke treatment2
Posterior Circulation Stroke: Treatment

  • Intra-arterial Thrombolysis

    • No randomized controlled trials completed

    • Multiple small series and reports

  • Results (Over 200 patients treated)

    • Mortality 20-60% , assoc. with lack of recanalization

    • Favorable outcomes in 25%-60%

    • ICH rate low, 0-15%


Posterior circulation stroke future treatment
Posterior Circulation Stroke Future Treatment

  • Intra-arterial Thrombolysis

    • Superselective approach, micro-catheters

  • Angioplasty

  • Angio-jet


What is the prognosis for this patient
What is the prognosis for this patient ?

  • All Posterior Circulation Strokes

    • New England Medical Center Posterior Circulation Stroke Registry:

      • Mortality = 4%

      • Minor or no Disability = 79%

  • Locked In Syndrome (Basilar artery occlusion)

    • Mortality > 90%

  • How do you know if a patient will progress to locked-in syndrome ? Observation


Case study outcome
Case Study: Outcome

  • The patient mental status deteriorated, repeat NIH-SS score was 22

  • He received intravenous thrombolysis

  • He had significant early improvement but without complete resolution of symptoms

  • On day 4, the NIH - SS score was 10

  • MRA : L sup. cerebellar art. and R&L Ant-Inf cerebellar arteries were non-visualized,

  • Cardiac evaluation was negative

  • He was discharged on Coumadin to Rehab


Case study mri dwi 12 hours 4 days
Case Study: MRI - DWI<12 Hours 4 Days


Summary
Summary

  • Posterior Circulation Strokes are characterized by the 5D’s and crossed findings

  • Maintain a high index of suspicion for prodromal symptoms - vertigo with CN sx

  • The locked-in syndrome consists of quadriplegia, bilateral facial and oropharyngeal palsy; but preservation of cortical function and vertical gaze


Summary1
Summary

  • The prognosis for vertebrobasilar ischemia is generally good, except for locked-in syndrome (basilar artery occlusion)

  • Treatment consists of conservative therapy (aspirin and heparin) or IV thrombolysis (<3 hrs) or IA thrombolysis (up to 24 hours)


Question 1
Question 1

All of the following are posterior circulation syndromes except:

  • Ipsilateral CN III palsy with contralateral

    hemiplegia

    B) Ipsolateral facial palsy with contralateral

    hemiplegia

    C) Hemiaplegia and hemisensory loss of the face arm and leg on one side of the body

    D) Ipsilateral ataxia and Horner”s with contralateral

    loss of pain and temperature sensation


Question 2
Question 2

Locked-in Syndrome consists of:

A) Coma with quadriplegia

B) Bilateral upper extremity weakness greater than lower extremity weakness

C) Quadriplegia, bilateral facial and oropharyngeal palsy but preservation of cortical function and vertical gaze

D) cranial nerve findings contralateral to motor and sensory findings


Question 3
Question 3

Vertigo of central origin is:

A)Generally severe and sudden in onset

B) Is a very common isolated prodromal symptom of VBI

C) Is often associated with tinnitus

D) Fatigues easily

E)Is generally associated with cranial nerve findings


Question 4
Question 4

Proven therapy for posterior circulation stroke includes:

A) Heparin

B) Low molecular weight heparin

C) IV thrombolysis

D) Intra-arterial regional thrombolysis

E) Intra-arterial local thrombolysis


Question 5
Question 5

Overall mortality for posterior circulation strokes is:

A) < 5%

B) 20%

C) 40%

D) 70%

E) > 90%


Question 6
Question 6

Mortality for Locked-in Syndrome is:

A) < 5%

B) 20%

C) 40%

D) 70%

E) > 90%