Download - Stroke Overview - EM Orientation
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David Marcus, MD @EMIMDoc - EMIMDoc.org
Assistant Program Director – LIJ EM/IM
Co-Director of Student Education - LIJ
Stroke and the Neurologic Exam
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Doctor – What’s Wrong With Me?!?!?!
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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.
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Intro to Stroke: epidemiology, definitions, pathophysCategories
Risk FactorsEvaluation of Suspected Stroke
Management
Goals
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Epidemiology
700,000
20%
#3
#1
1/3 < 65
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Epidemiology
Black > White > Hispanic
Men > Women
YoungerMore frequent
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“Sudden loss of circulation to an area of the brain, resulting in a corresponding loss of neurologic function.”
Definition
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Cerebrovascular Accident (CVA) Stroke syndrome
Brain Attack
AKA
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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
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Ischemic: Hemorrhagic/ICH
Categories
Ischemic: Hemorrhagic
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Hemorrhagic Conversion
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Vascular occlusion >>> Ischemia >>> cell hypoxia and depletion of ATP>>>
Cell membrane failure >>> Cytotoxic Edema
4-6 hours: breakdown of BBB >>> Vasogenic edema
Pathophys - Ischemic
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Pathophys - Hemorrhagic
Direct damage due to hematoma
Increasing mass effect and ICP
Inflammatory changes
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Anatomy - Circle of Willis
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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)
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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
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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
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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.
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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
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History and Physical Exam
Labs?
Imaging?
Clinical Evaluation
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The History
In addition to all the usual, focus on:
• Onset: When was patient last seen normal?
• Fluctuating symptoms
• Previous episodes
• Medications, anticoagulation?
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The Physical
General Physical Exam
Focused Neurologic Exam
Scoring Systems
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Components: • General appearance, posture, GCS• Speech/MMSE• Motor• Sensory• Reflexes• Coordination, Gait, Rhomberg
Neurologic Exam
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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
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• 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
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Scoring Systems
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HiNTS
Scoring Systems
Differentiating between central and peripheral vertigo
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• 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
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Pathophys - Ischemic
Ischemic core and penumbraPrimary circulation vs collateralsCore - cells die within MINUTESPenumbra - cells die within HOURS
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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.
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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
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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
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• 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
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Review This
1.Your Neuro Exam Skills2.The HiNTS Exam3.tPA indications/contraindications4.CVA mimickers