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Stroke

Stroke. David Friedgood, DO. Stroke - definition. A sudden loss of brain function caused by blockage or rupture of a blood vessel to the brain Associated Neurologic deficit loss of muscular control loss of sensation or consciousness dizziness Speech disturbance / aphasia

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Stroke

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  1. Stroke David Friedgood, DO

  2. Stroke - definition • A sudden loss of brain function caused by blockage or rupture of a blood vessel to the brain • Associated Neurologic deficit • loss of muscular control • loss of sensation or consciousness • dizziness • Speech disturbance / aphasia • Visual disturbance / diploplia, hemiaopsia

  3. Definitions • Stroke is a medical emergency • Prompt recognition, evaluation, and treatment can minimize brain damage • Stroke can be treated and prevented • Risk factor management • Synonym = Brain Attack • Avoid ‘CVA’

  4. Transient Ischemic Attack (TIA) • A TIA is a stroke • Symptoms usually resolve in minutes • Symptoms may persist up to 24 hours • Symptoms of Neurologic deficit similar to completed stroke • 2° temporary decrease in local cerebral blood flow • May be associated with MRI evidence of acute ischemia

  5. Statistics • Stroke is 4th leading cause of death • 129,180 (CDC 2010, rate – 1.5% decrease from 2009) • ~ 795,000 strokes in USA (1 every 40 sec.) • 87% ischemic • 10% intracranial hemorrhage • 3% subarachnoid hemorrhage • 7,000,000 Americans ≥ 20 have had a stroke • Greater incidence in ♂, but more ♀ with strokes

  6. Annual rate 1st Stroke Cinn. / N. Kentucky Stroke Study - 1999

  7. Prevalence of Stroke 2005 – 2008 data Circ. 2012

  8. Annual age adjusted Stroke incidence Kleindorfer, et al – 1993, 1999, 2005

  9. Types of Stroke • Ischemic • Embolic • Thrombotic • Secondly hemorrhagic • Intracranial Hemorrhage • Subarachnoid Hemorrhage

  10. Embolic Stroke • Most often presents with sudden onset, maximum Neurologic deficit • Embolic source: • Cardiac / Paroxysmal • Aorta, carotid, vertebral arteries • Associated with: • Cardiac arrhythmia – atrial fibrillation • Myocardial infarction • Patent Foramen Ovale

  11. Thrombotic Stroke • Often presents with evolving / fluctuating Neurologic deficit • History TIA’s • Typical patient: • Chronic vascular disease (vasculopath) • Multiple stroke risk factors

  12. Secondarily Hemorrhagic Stroke • Typically a re-perfusion phenomenon after cerebral ischemia • ~ 5% of ischemic infarctions • Increased incidence with: • t-PA (~ 6%) • anticoagulation • anti-platelet therapy (small risk) • Often results in deterioration of neurologic status

  13. Intracranial Hemorrhage • Primary ICH • 2° hypertensive cerebral-vascular disease • 2° cerebral amyloid angiopathy • Vascular anomaly • AV malformation • Cavernous angioma • Venous angioma • Capillary telangiectasia • Trauma

  14. 82 yo hypertensive ♀ presents with obtundation and R hemiplegia.

  15. Subarachnoid Hemorrhage • Intracranial aneurysms (~ 80 %) • 80% about circle of Willis • 10% at post. inf. cerebellar a. origin • Consider mycotic aneurysm if in distal middle cerebral artery • May have history of sentinel leaks / headaches • Post-traumatic • Rarely 2° other vascular anomalies / coagulopathies

  16. 34 yo ♀ presents with 2nd ‘thunderclap’ headache. She was lethargic without significant neuro deficit.

  17. Bleeding Management • Warfarin reversal • Vitamin K 10 mg IV • FFP (fresh frozen plasma) 2 – 6 units IV • rFactor VIIa 15-90 µg/kg • PCC (prothrombin complex concentrate) • Factors II, VII, IX, X • Heparin reversal • Protamine SO4 10-50 mg IV • Thrombocytopenia • Platelet infusion IV

  18. Common Stroke Mimics • Conversion disorder • No cranial nerve deficits • Atypical symptoms in a non-vascular distribution • Hypertensive encephalopathy • HA, delirium, ↑ BP (PRES syndrome) • Hypoglycemia • Complicated migraine • History similar events, HA, prodrome / aura • Seizures • With post-ictal symptoms

  19. Stroke Risk Factors • Prior stroke • Age > 55 • HTN – 30 – 40 % • DM - 14 – 50 % • Tobacco use – 50 % @ 1 yr. • Dyslipidemia - ~ 25% • Obesity • Estrogen use • Alcoholism • Substance abuse • Cocaine, Methamphetamine • Race - > African-American • Coagulopathy – SS disease • Anti-phospholipid syn. • ↑ homocysteine • Chronic inflamation / Vasculitis – Temporal arteritis • Family history / Congenital • MELAS syndrome

  20. Cardiac Risk Factors for Stroke • Arrhythmia • Atrial fibrillation • Myocardial infarction • Valvular disease • Sub-acute bacterial endocarditis • Prosthetic heart valve • Mitral / Aortic disease (increased with Rheumatic valve dis.) • Patent foramen ovale • Cardiac surgery

  21. Complications of Stroke • Paralysis • Sensory loss / Perceptual deficit (Apraxia, Agnosia) • Visual loss / Diploplia • Speech disturbance / Aphasia • Dysphagia / Nutritional deficiency • Memory / Behavioral disturbance • Pain – (Central pain syndrome / allodynia) • Seizures

  22. Stroke Management • Recognition and pre-hospital • Emergency Room evaluation and Rx • Hospital Care • Rehabilitation • Post-hospital care • Stroke prophylaxis

  23. Stroke Chain of Survival • Detection • Dispatch • Delivery • Door • Data • Decision • Drug - Recognition of stroke sign / symptoms - Call 911, priority EMS dispatch - Prompt transport / hospital notification - Immediate ED triage - Prompt ED evaluation, lab, CT brain - Diagnosis / decision i.e. appropriate Rx - Administration of appropriate drugs / other therapies Circulation 2007:115:e478-534

  24. Stroke Evaluation • History and Physical – time of Stroke onset • Attention to ABC’s • Urgent Lab: • CBC, CMP, ESR / CRP, PT, PTT, B-HCG, drug Screen, CK / troponin, pulse oximetry / ABG’s • Lab: • Lipid profile, TSH, coagulopathy screen, etc. • Brain scan • CT / CT angiogram • MRI / MR angiogram

  25. Stroke Evaluation (cont.) • Urgent: • EKG, Chest X-ray • Echocardiogram • Trans-thoracic, Trans-esophageal • Carotid / Vertebral US • Optional: • MR venogram - Lumbar puncture • TA biopsy, brain biopsy - Catheter angiogram • EEG • Etc.

  26. Emergency Stroke Treatment • Emergency transport to ER with capabilities for Stroke management • Address ABC’s, open IV, O2 • Serum Glucose management • BP management • Avoid hypotension / Rx hypertension cautiously • except SAH • Do not lower BP < 220/120 (185/110 for t-PA) • Labetalol 10 mg IV (nitropaste, nicardipine) • ? ASA • Stroke Scale (NIH stroke scale) • 0 - 42

  27. ED-Based Care – Time Goals • Door to physician ≤10 minutes • Door to stroke team ≤15 minutes • Door to CT initiation ≤25 minutes • Door to CT interpretation ≤45 minutes • Door to drug (≥80% compliance) ≤60 minutes • Door to stroke unit admission ≤3 hours

  28. Recombinant Tissue Plasminogen Activator (t-PA) • Indicated for acute non-hemorrhagic Stroke • Up to 3 hrs. after stroke onset • Extend to 4.5 hrs in selected patients ≤ 80 yo • Benefit in ~ ⅓ patients • 2° hemorrhage rate ~ 6 % • Dose: • 0.9 mg / kg IV (90 mg max.) • 10% bolus, remainder over 1 hour

  29. t-PA • FDA approved 1996 • The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581–1587 • 624 stroke patients • ↑ odds favorable outcome - OR 1.9 • Less global disability, neurologic deficits, and increased ADL’s (34% vs 20%) • 3 mo to see statistical significance. Persisted at 1 year • No change in mortality at 3 mo., or 1 yr.

  30. t-PA • Significant improvement in outcome when treatment initiated < 90 min. • Relative safety with treatment up to 4.5 hrs • Studies excluded: > 80 yo, large strokes, any anticoagulant use, and diabetics with prior stroke • Morbidity and mortality significantly increase with treatment > 4.5 hrs • FDA maintains 3 hour window

  31. T-PA Side Effects • Bleeding • Myocardial rupture • Treatment within few days of an acute MI • Angioedema • 1-5% • Possibly increased risk with ACE inh • Rx: antihistamines, steroids Anaphylaxis • Anaphylaxis - rare

  32. Contraindications to t-PA • Minor stroke / rapidly clearing symptoms • Major neuro deficits / significant CT edema • Stroke / head trauma within 3 mo. • GI / GU hemorrhage within 21 days • Major surgery within 14 days • History intracranial hemorrhage • Acute trauma / active bleeding • Plts < 100,000 • Uncontrolled BP > 185/110

  33. Contraindications to t-PA (cont.) • Symptoms suggesting SAH • Anticoagulation with INR > 1.7 • Use of direct thrombin inh., or Xa inhibitors • Blood glucose < 50 or > 400 mg/dl • Acute seizure • Arterial puncture @ non-compressible site < 7 days • Recent LP • Intracranial neoplasm, AVM, aneurysm • Pregnancy

  34. Intra-arterial Thrombolysis • Option up to 6 hours post Stroke onset (or later) • For patients with major stroke and documented arterial thrombus • May follow IV t-PA

  35. 64 year old diabetic, hypertensive woman presented to ER following a seizure at dinner. No prior seizures. Had L hemiplegia and confusion on admission. Stroke Alert called. 2nd seizure in CT.

  36. Endovascular Therapy • Carotid angioplasty / stenting • May be an alternative to surgery in selected pts • Best for patients with previous endarterectomy / neck radiation therapy • Vertebral a. angioplasty / stenting • Reserved for medical failures • Arterial clot retrieval devices (Merci) • Reported ‘good’ outcome at 90 days – 33% • Intracranial hemorrhage rate – 38%

  37. Merci Clot Retrieval

  38. Case Presentation • 56 yo diabetic, hypertensive ♀ presents with right hemiplegia and expressive aphasia. • History untreated paroxysmal atrial fibrillation • Found by family laying on her bed in night clothes. Disheveled, incontinent of urine.

  39. CT Scans Day 1 24 hours

  40. MRI Scan several hours after admission DWI images Flair T2 weighted

  41. Case Management • Not a t-PA candidate • Started on ASA 81 mg, later switched to Heparin and Coumadin (INR 2.0 – 3.0) • Simvastatin 20mg started in hospital • Speech, Occupational and Physical therapy started in hospital • Discharged to Rehabilitation Unit • Now living at home with family. Moderate Aphasia and mild R hemiplegia persists

  42. Best treatment for Ischemic Stroke • Prevention: • Risk factor management • Exercise / weight loss • Avoid tobacco • Moderate alcohol intake • Treating hypertension and diabetes mellitus early is more effective than any medical or surgical therapy for stroke prophylaxis.

  43. Palliative Care • Consider for patient’s with devastating / irreversible brain injury • Consider prognosis of pre-existing conditions • Cancer, Dementia • Consider advanced directives, family / guardian concerns • Provide comfort care and Hospice support

  44. Reference • Guidelines for the Early Management of Patients With Acute Ischemic Stroke - A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association Edward C. Jauch, MD, MS, FAHA, Chair; Jeffrey L. Saver, MD, FAHA, Vice Chair; Harold P. Adams, Jr, MD, FAHA; Askiel Bruno, MD, MS; J.J. (Buddy) Connors, MD; Bart M. Demaerschalk, MD, MSc; Pooja Khatri, MD, MSc, FAHA; Paul W. McMullan, Jr, MD, FAHA; Adnan I. Qureshi, MD, FAHA; Kenneth Rosenfield, MD, FAHA; Phillip A. Scott, MD, FAHA; Debbie R. Summers, RN, MSN, FAHA; David Z. Wang, DO, FAHA; Max Wintermark, MD; Howard Yonas, MD; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology Stroke. 2013;44:1-78

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