Stroke: An Introduction

1. Stroke:An Introduction Maarten Lansberg, MD, PhD Neil Schwartz, MD, PhD Stanford Stroke Center

2. Outline • Background • Stroke Diagnosis • Stroke Treatment • Stroke Prevention

3. What is a Stroke? (Brain Attack) Disruption of blood flow to part of the brain caused by: • Occlusion of a blood vessel (ischemic stroke) OR • Rupture of a blood vessel (hemorrhagic stroke)

4. Types of Stroke Mohr JP, Caplan LR, Melski JW, et al. Neurology 1978;28:754-62

5. Anatomy

7. MR Angiogram

8. What happens with cutoff of blood supply? Oxygen deprivation to nerve cells in the affected area of the brain --> Nerve cells injured and die --> The part of the body controlled by those nerve cells cannot function.

9. What Causes Ischemic Stroke? Thrombotic Embolic Thrombus Embolus

10. Ischemic Stroke

12. What happens with rupture of a blood vessel? Oxygen deprivation to nerve cells in the affected area of the brain and local destruction of nerve cells--> Nerve cells injured and die --> The part of the body controlled by those nerve cells cannot function.

13. Intracerebral Hemorrhage

16. Head CT: Ischemic or Hemorrhagic Stroke?

17. Head CT: Ischemic or Hemorrhagic Stroke?

18. Stroke Impact • 750,000 strokes per year • Third leading cause of death (1st: heart disease, 2nd: all cancers) • Over 160,000 deaths per year • Over 4 million stroke survivors 1. Williams GR, Jiang JG, Matchar DB, et al. Stroke 1999; 30:2523-28. 2. Hoyert DL, Kochanek KD, Murphy SL. National Vital Statistics Report 1999; 47:19.

19. Stroke Impact (2) • Leading cause of adult disability • Of those who survive, 90% have deficit • Half of all patients hospitalized for acute neurological disease. • Stroke costs the U.S. $30 to $40 billion per year.

20. The Stroke Belt Perry HM, Roccella EJ. Hypertension 1998;6:1206-15.

21. 2. Stroke Diagnosis

22. Symptoms of Stroke • Sudden numbness or weakness of face, arm or leg, especially on one side of the body • Sudden confusion, trouble speaking or understanding • Sudden trouble seeing from one or both eyes • Sudden unsteadiness, dizziness, loss of balance or coordination • Sudden severe headache with no known cause

23. Other Stroke Symptoms • Also common following stroke • Depression • Other emotional problems • Memory problems

24. Common Stroke Patterns • Left (Dominant) Hemisphere: • Aphasia • Right hemiparesis • Right hemisensory loss • Right visual field defect • Left gaze preference • Dysarthria • Difficulty reading, writing, or calculating

25. Common Stroke Patterns (2) • Right (Nondominant) Hemisphere: • Left hemiparesis • Left hemisensory loss • Left neglect • Left visual field defect • Right gaze preference • Dysarthria

26. Common Stroke Patterns (3) • Brainstem/Cerebellum/Posterior Circulation • Motor or sensory loss in all 4 limbs • Crossed signs (face vs. body) • Limb or gait ataxia • Dysarthria • Dysconjugate gaze • Nystagmus • Amnesia • Cortical blindness

27. Common Stroke Patterns (4) • Small Vessel (Lacunar) Strokes (Subcortical or Brain Stem) • Pure Motor • Weakness of face, arm, leg • Pure Sensory • Decreased sensation of face, arm, leg

28. Differential Diagnosis • Stroke (ischemic; hemorrhagic) • Intracranial mass • Tumor • Subdural hematoma • Seizure with persistent neurological signs • Migraine with persistent neurological signs • Metabolic • Hyper/Hypoglycemia • Infectious • Meningitis / Encephalitis / Cerebral abscess • Systemic

29. 3. Stroke Treatment

30. Time is Brain

31. EMS/ED evaluation of acute stroke • Assure adequate airway • Monitor vital signs • Conduct general assessment • Evidence of trauma to head or neck • Cardiovascular abnormalities

32. EMS/ED evaluation of acute stroke (cont.) • Conduct neurological examination • Level of consciousness (Glasgow Coma Scale) • Presence of seizure activity • NIH Stroke Scale

33. ED evaluation of acute stroke: diagnostic tests • Non-contrast Head CT • EKG • Blood Glucose • CBC, platelets, PTT, PT/INR • Serum electrolytes

34. t-PA therapy

35. Candidate for IV tPA? Stroke onset < 3 hours (When was the patient last seen at baseline ?) Benefit: 12 % increased chance of good recovery Risk: bleeding (up to 6%) tPA therapy for acute stroke

36. tPA exclusion criteria • Symptoms mild or rapidly resolving • SBP > 180 or DBP > 110 • Blood on head CT • History of ICH • CNS tumor or vascular malformation • Bacterial endocarditis • Known bleeding disorder • PTT > 40; PT > 15 (INR > 1.7) • Stroke within 3 months • Significant trauma in last 3 months • GI/GU/Resp hemorrhage within 21 days • Major surgery within 14 days / minor surgery within 10 days • Peritoneal dialysis or hemodialysis • Seizure at onset of stroke • Glucose <50 or >400 • Pregnant

37. IV t-Pa outside the three hour window IA t-PA IA mechanical thrombolysis/thrombectomy Neuroprotective agents Other therapies for acute stroke

38. Stroke Management If not a candidate for acute intervention, then focus on: • Prevention of recurrent stroke • Diagnostic evaluation for stroke etiology • Risk factor assessment • Rehabilitation (PT/OT/SLP) • Prevention of Complications • DVT, aspiration PNA, decubitus ulcers, falls

39. Diagnostic stroke evaluation • Purpose: Identify location, size, and cause of stroke • Tests may include: • Follow-up head CT • Brain MRI/MRA • Carotid ultrasound • Cardiac echo (transthoracic or transesophageal) • Cerebral angiogram or CT angiogram • Lipid panel • Hemoglobin A1c • Hypercoagulable tests: antiphospholipid antibodies, Protein C & S, Antithrombin III, Factor V Leiden mutation, Prothrombin 20210A mutation…

40. 4. Stroke Prevention

41. Stroke survivor’s greatest risk is another stroke 16 Stroke Heart Attack 14% 14 13% 13% 12 10% 10 Percent of patients with events 8 7% 6 4 3% 3% 2% 2 CATS TASS CAPRIE* ESPS 2 * Stroke patient subgroup only (n = 6,431) Albers, G.W. Neurology. 2000;14;54(5):1022-8.

42. Transient Ischemic Attack (TIA) • Stroke symptoms resolve in less than 24 hours (most resolve in < 1 hour) • Warning sign for stroke and heart attack • One third go on to have a stroke within 5 years • Stroke risk can be reduced • Opportunity to prevent full stroke

43. Stroke risk factors Non - Modifiable • Age • Gender (men) • Heredity: family history of stroke, hypercoagulable states • Race/ethnicity (e.g. African Americans) Sacco RL, Benjamin EJ, Broderick JP, et al. Stroke: 1997;28:1507-17.

44. Stroke risk factors Modifiable Medical Conditions • Hypertension • Heart disease • Atrial fibrillation • High Cholesterol • Diabetes • Carotid stenosis • Prior stroke or TIA • Behaviors • Cigarette smoking • Alcohol abuse • Physical inactivity Sacco RL. et al. Stroke. 1997;28:1507-1517 Pancioli AM et al. JAMA. 1998;279:1288-1292

45. How many strokes can be prevented?* Adapted from Gorelick PB. Arch Neurol 1995;52:347-55 *Based on an estimated 731,000 strokes annually

46. HypertensionJNC VII Guidelines

47. < 140/90 < 140/90 Cardiovascular Events Cardiovascular Events (%) < 130/85 < 130/85 < 120/80 < 120/80 Vasan RS et al N Engl J Med 345; 1291-7, 2001 Lower blood pressure = Lower Risk

48. PROGRESS Trial Blood pressure reduction following stroke 20 28% relative risk reduction 14% 15 Stroke Rate (%) 10% 10 Placebo Active 5 0 1 2 3 4 Follow-up time (years) Progress, Lancet. 2001;358:1033-41

49. Condition Hyperlipidemia or atherosclerotic disease (LDL >100 mg/dL) Recommendation Diet: decrease fat and cholesterol Exercise Add pharmacologic therapy: statin agents Risk factor modificationsfor blood lipidsNational Cholesterol Education Program (NCEP) Guidelines Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 1993;269:3015-23.

50. Risk factor modifications for DMADA Recommendations to Reduce Microvascular Complications • Average pre-prandial glucose <120 mg/dL • Average bedtime glucose 100 to 140 mg/dL • HbA1c <7% 1. Lukovitis TG, Mazzone T, Gorelick PB. Neuroepidemiology 1999;18:1-14. 2. Diabetes Care 1998;21 (Suppl 1):1-200