2013 seventh annual nky tbi 3/22/13 conferencebridgesnky.org/public/bavishi 2013 nky tbi conf ppt...

2013 Seventh Annual NKY TBIConference

3/22/13

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UC Neuroscience Institute UC Neuroscience Institute

Sheital Bavishi, DOAssistant Professor University of Cincinnati

Department of Physical Medicine and RehabilitationDirector Brain Injury Program

University of Cincinnati

UC Neuroscience Institute

• Affects more than 700,000 people in the USannually

• Third leading cause of death

• One of the most common causes of long-term disability, certainly one of the mostserious and life-changing


Ischemic, 85%

ICH, 10%

SAH, 5%


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• Stroke: focal neurologic deficit caused bycerebrovascular event lasting at least 24 hours;usually of sudden onset– ischemia: 80% (thrombosis, embolism,

hypotension)– hemorrhage: 20% (subarachnoid,

intracerebral)• TIA (transient ischemic attack): same as above,

caused by transient ischemia and resolvingcompletely within 24 hours


• Non-modifiable:• Age, Race, Gender, Family history

• Modifiable/Treatable:– Hypertension --obesity– Diabetes --alcohol/drug consumption– TIA’s/previous strokes --oral contraceptives– Cardiac disease (?PFO) --migraine headaches– Atrial fibrillation --cigarette smoking– Hypercholesterolemia --autoimmune/inflammatory disease– Hypercoagulable states --homocysteine


• Carotid arteries– Internal: brain– External: face

“anteriorcirculation”

• Vertebral arteries“posteriorcirculation”


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• Catheterangiography

• CT angiography• MR angiography

Contrast dye injected in bloodstream makes vessels show up



Aneurysm AVM

Artery stenosis Tumor

Stroke

blockage


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• Limiting cellular injury• Reperfusion

• Preventing Systemic Complications• Preventing Neurologic Complications

• Rehabilitation


• Maintain cerebral perfusion– auto-regulation/adequate blood pressure (BP)

• Maintain cerebral oxygenation --(allow increasedoxygen extraction as compensatory mechanism foraltered perfusion)

• Maintain normothermia -- (increased temp =increased oxygen metabolism/demand)

• Maintain euglycemia -- (hyperglycemia exacerbatesischemic damage)


• Acute stroke– Clot dissolve (tPA)– Clot retrieval

• Aneurysm– Coil– Glue

• Artery stenosis– Angioplasty & stent

• AVMs and tumors– Glue (embolization)

Onyx glue


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Clot retrieval• Device grabs and

pulls clot out• Suction catheter

aspirates clot

Clot-buster (tPA)• Drug dissolves clot• Give within 4.5 hours


• A clot-busting drugcalled t-PA (tissueplasminogenactivator) givenwithin 3 hoursafter stroke onset

• New data suggesttime window outto 4 ½ hours


• BOTTOM LINE: Appropriate patientswithout contraindications should betreated at 0-3 hours, as per the NINDSstudy protocol.

• TIME IS BRAIN: the soonertreatment is started, the greaterthe odds ratio of favorableoutcome


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blockage t-PA restoresblood flow



Inflate balloon andinject for 2 minutes,let Onyx solidify for3 minutesthen re-perfuse


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• Bypass reroutes an artery from outsideof skull into a brain artery to protectblood supply to brain before clipping theaneurysm bypass



Medications– Blood thinner– Cholesterol reduction– Blood pressure

control Endarterectomy

– Surgery removesplaque

Angioplasty &stenting– Balloon compresses

plaque and stentholds artery open


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• Angioplasty & stenting– Restores vessel

diameter– Reduces clot risk




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Dilated arteries and veins with nocapillary bed


• Goal is to reducesize of nidus and toocclude arterialfeeders difficult toaccess surgically

• Surgical dissectionand control of fragiledeep feedingarteries significantlyimproved

• Embolization alonewill not cure


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• Prevent medical and neurologicalcomplications

• Risk factor modification– Especially treatments for hypertension, diabetes,

high cholesterol and smoking cessation• Appropriate medical or surgical therapy

– must know mechanism of stroke– Echo to look for cardiac source– Imaging to look for carotid source– Otherwise, staged anti-platelet therapy


• Aspiration (feeding tube, intubation)• DVT (subQ Heparin)• Infection (leading cause of late

death)• Skin Breakdown


• Increased intracranial pressure– hemorrhagic transformation– cytotoxic edema

• Edema maximal at 36-72 hours, usuallymanifests as decline in level ofconsciousness

• Herniation is leading cause of death inacute setting

(fatal arrhythmia is second)


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• Seizures– Approximately 4% of patients– recur in 20-80% cases– treat with anticonvulsants

• Depression– As high as 75% incidence after stroke– TREAT IT!!– New study suggests that early SSRI might

improve outcome even if depression not yetpresent


• Benefit is well established• Mechanism by which this facilitates

recovery is unclear• Begin Occupational Therapy, Physical

Therapy, Speech Therapy immediately

• Recovery maximal in first weeks, months;can continue

--DON’T GIVE UP!--Recovery is the next great frontier for stroke and

brain injury


• Spasticity Management• Neurogenic bowel and bladder• Constraint-Induced therapy• Body-weight supported treadmill

training• Splints and bracing• Pain Syndromes• Psychosocial Considerations


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• Acute hospital therapies• Acute Inpatient rehabilitation• Short-term skilled rehabilitation• Transitional Rehabilitation programs• Day Rehabilitation programs• Outpatient therapy• Home Health therapy


The Stroke Recovery Center at Drake is amulti-disciplinary evaluation andtreatment program for those individualswith physical and cognitive deficits froma previous CVA, designed to maximizeindependence and function.


• Stroke Recovery Center:– refers now to the full spectrum of services--

from acute rehab on• START

– Stroke Team Assessment and RecoveryTreatment (START) Program

– The START program is the outpatientmultidisciplinary team evaluation


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The therapeutic plan may bedeveloped around:

• out patient rehabilitation services,• research programs, or• a combination of both


The Stroke Recovery Center wasonly one of five programs of thistype identified in the UnitedStates

(as of July 2008)


To provide collaborative care thatimproves the function and qualityof life of people with strokes whilescientifically advancing the field ofstroke recovery.


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To be the premier destination forthe most innovative, aggressiveand comprehensive treatment forpeople with stroke.


Dr. Brett Kissela

ProfessorCo-Director, Neurology

Residency ProgramVice-Chair of Education

and Clinical ServicesDepartment of

NeurologyUniversity of Cincinnati

Dr. Mark Goddard

Associate ProfessorChairman, Department of

Physical Medicine andRehabilitation

University of CincinnatiRehabilitation Medical

Director – Drake Center


Questions?

2013 seventh annual nky tbi 3/22/13 conferencebridgesnky.org/public/bavishi 2013 nky tbi conf ppt...

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