stroke overview - em orientation

David Marcus, MD @EMIMDoc - EMIMDoc.org

Assistant Program Director – LIJ EM/IM

Co-Director of Student Education - LIJ

Stroke and the Neurologic Exam

Doctor – What’s Wrong With Me?!?!?!

Doctor – What’s Wrong With Me?!?!?!

A 78 year old woman is brought in by her daughter after waking up this morning unable to get out of bed. She is alert, appears tired, follows commands slowly and cannot move the left side of her body.

Your patient, a 66 year old man with diabetes and HTN presents with 1 full day of severe dizziness. He says the room is spinning and he cannot walk unassisted.

The 48 year old woman you are examining in room in intake is complaining of a sudden onset of severe headache about 1 hour ago. This is the worst headache of her life. It is associated with drooping of her left eyelid and facial asymmetry. She has a history of HTN, occasional headaches and asthma.

Intro to Stroke: epidemiology, definitions, pathophysCategories

Risk FactorsEvaluation of Suspected Stroke

Management

Goals

Epidemiology

700,000

20%

#3

#1

1/3 < 65

Epidemiology

Black > White > Hispanic

Men > Women

YoungerMore frequent

“Sudden loss of circulation to an area of the brain, resulting in a corresponding loss of neurologic function.”

Definition

Cerebrovascular Accident (CVA) Stroke syndrome

Brain Attack

AKA

TIA

“…a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.” (AHA)

10% - CVA in 90 days 48 hrs

Ischemic: Hemorrhagic/ICH

Categories

Ischemic: Hemorrhagic

Hemorrhagic Conversion

Vascular occlusion >>> Ischemia >>> cell hypoxia and depletion of ATP>>>

Cell membrane failure >>> Cytotoxic Edema

4-6 hours: breakdown of BBB >>> Vasogenic edema

Pathophys - Ischemic

Pathophys - Hemorrhagic

Direct damage due to hematoma

Increasing mass effect and ICP

Inflammatory changes

Anatomy - Circle of Willis

Anterior Cerebral ArteryMedial frontal and parietal lobe, caudate head, globus pallidus, anterior limb of internal capsule

Middle Cerebral ArteryLateral frontal and parietal lobes lateral and anterior temporal lobe, globus pallidus and putamen, internal capsule

Anterior Choroidal ArteryOptic tracts, medial temporal lobe, ventrolateral thalamus, corona radiata, posterior limb of the internal capsule

Anterior Circulation (Carotid)

Posterior Circulation(AKA Vertebro-basilar)

Posterior Cerebral ArteryOccipital lobes, medial and posterior temporal and parietal lobes, brainstem, posterior thalamus and midbrain

Posterior Inferior Cerebellar Artery : Inferior vermis; posterior and inferior cerebellar hemispheres

Anterior Inferior Cerebellar Artery: Anterolateral cerebellum

Superior Cerebellar Artery: Superior vermis; superior cerebellum

AgeRaceSexEthnicityHistory of migraine headachesSickle cell diseaseFibromuscular dysplasiaHeredityHypertension (the most important modifiable factor)Diabetes mellitusCardiac disease HypercholesterolemiaTransient ischemic attacks (TIAs)Carotid stenosisHyperhomocystinemiaLifestyle issues - Excessive alcohol intake, tobacco use, illicit drug use, obesity, physical inactivityOral contraceptive use

Risk Factors

Remember Us?

A 78 year old woman is brought in by her daughter after waking up this morning unable to get out of bed. She is alert, appears tired, follows commands slowly and cannot move the left side of her body.

Your patient, a 66 year old man with diabetes and HTN presents with 1 full day of severe dizziness. He says the room is spinning and he cannot walk unassisted.

The 48 year old woman you are examining in room in intake is complaining of a sudden onset of severe headache about 1 hour ago. This is the worst headache of her life. It is associated with drooping of her left eyelid and facial asymmetry. She has a history of HTN, occasional headaches and asthma.

DDX

Seizure (17%)

Systemic infection (17%)

Brain tumor (15%)

Toxic-metabolic (hyponatremia, hypoglycemia…)(13%)

Positional vertigo (6%)

Bell’s palsy and other mono/poly neuropathies

History and Physical Exam

Labs?

Imaging?

Clinical Evaluation

The History

In addition to all the usual, focus on:

• Onset: When was patient last seen normal?

• Fluctuating symptoms

• Previous episodes

• Medications, anticoagulation?

The Physical

General Physical Exam

Focused Neurologic Exam

Scoring Systems

Components: • General appearance, posture, GCS• Speech/MMSE• Motor• Sensory• Reflexes• Coordination, Gait, Rhomberg

Neurologic Exam

Well organized exam and good instructions - http://cloud.med.nyu.edu/modules/pub/neurosurgery/

Good videos, especially of abnormals - http://library.med.utah.edu/neurologicexam/html/home_exam.html

Neuro Exam - Aides

• Assess level of responsiveness (AVPU/GCS)• Focus on signs of persistent lateralizing asymmetry• Reflex abnormalities may localize to brainstem• Prognosis of decorticate better than decerebrate

• May assess the following, even in unresponsive:• Corneal reflex (CNV)• Doll’s eye (Brainstem, EOM)• Calorics (EOM)• Pupillary response• Introducing objects into field of view• Facial grimacing (CNVII)• Gag reflex (CN IX, X)

The Altered Patient

Scoring Systems

HiNTS

Scoring Systems

Differentiating between central and peripheral vertigo

• ACLS(ABCDE, IV x 2, O2, Monitor, Vitals c F.S.)• Consider thrombolytics or endovascular

intervention if appropriate• ASA, Plavix, Statin, Control BP• Serial Neuro checks????

Management

Pathophys - Ischemic

Ischemic core and penumbraPrimary circulation vs collateralsCore - cells die within MINUTESPenumbra - cells die within HOURS

IV-tPA - Indications

• Time of symptom onset < 4.5 hours

• Measurable neurologic deficit.

• 4 < NIH stroke scale (maximum score 42) < 22.

• High-risk patients often have early CT scan changes showing a large area of edema or mass effect.

IV-tPA - Contraindications

Absolute contraindications

• History or evidence of intracranial hemorrhage• Clinical presentation suggestive of subarachnoid hemorrhage• Known arteriovenous malformation• Systolic blood pressure (SBP) >185 mm Hg or diastolic blood

pressure (DBP) >110 mm Hg despite repeated measurements and treatment

• Seizure with postictal residual neurologic impairment• Platelet count < 100,000/mm3• Prothrombin time (PT) >15 or INR >1.7• Active internal bleeding or acute trauma (fracture)• Head trauma or stroke in the previous 3 months• Arterial puncture at a noncompressible site within 1 week

IV-tPA - Dosing

1. 0.9 mg/kg (maximum of 90 mg) infused over 60 minutes

2. 10% of the total dose administered as an initial IV bolus over 1 minute

• 5% of ischemic strokes undergo hemorrhagic conversion

• In the US, 20% of individuals die within one year after a first-time stroke

• In stroke survivors from the Framingham Heart Study:• 31% needed help caring for themselves• 20% needed help when walking• 71% had impaired vocational capacity

Prognosis

Review This

1.Your Neuro Exam Skills2.The HiNTS Exam3.tPA indications/contraindications4.CVA mimickers