StrokeMatthew Simmons, MD

Sept. 2013Matthew.simmons@usd.edu

TIA: Definition

• “A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction.”

• Note: Duration usually less than 60 minutes.

Stroke: New Definitions

• CNS infarction: Brain, spinal cord, or retinal cell death due to ischemia. Based on:– Pathological, imaging, or other objective evidence– Clinical evidence

• Symptoms greater than 24 hours (or until death)• Other etiologies excluded

• Ischemic stroke: Clinical neurologic dysfunction with evidence as above

• Silent CNS infarction: Evidence limited to imaging or neuropathological findings.

Stroke Definitions (cont.)

• Intracerebral hemorrhage• Stroke caused by intracerebral hemorrhage• Silent cerebral hemorrhage• Subarachnoid hemorrhage• Stroke caused by subarachnoid hemorrhage• Stroke caused by cerebral sinus thrombosis:

can be ischemic or hemorrhagic• Stroke not otherwise specified

Stroke: Outline

• 1. Prehospital care• 2. Emergency management• 3. Diagnostic approach• 4. Subacute care– Prevent complications– Rehabilitation– Secondary prevention

Stroke: Prehospital care

• Primary prevention• Public awareness/use 911• Emergency medical services (EMS)• Hospital stroke care:– Acute Stoke-Ready Hospital– Primary Stroke Center– Comprehensive Stroke Center– Telemedicine

Stroke: EMS Checklist

• ABC’s/ Establish time of symptom onset• Oxygen/ NPO/ Check Glucometer• Cardiac monitoring• IV access (if no delay in transport)• Rapid transport; alert receiving ED• Avoid dextrose solutions; use Normal Saline

Stroke: Emergency Management

• ABC’s and recheck H & P• Labs: CMP, CBC, PT/PTT, TROPONIN (toxicology,

Beta HCG, and HIV if indicated)• Imaging: CT (“gold standard”) or MRI• Cardiac Monitoring/EKG• Normothermia; avoid hyper/hypoglycemia• Cerebral ischemia pathway• Cerebral hemorrhage pathway• R/O Stroke Mimics.

Common Acute Stroke Mimics

• Postictal deficits (Todd paralysis)• Hypoglycemia• Complicated migraine• Mass lesions (i.e. tumor, subdural)• Conversion reaction (psychogenic)• Hypertensive encephalopathy• Others: Subarachnoid hemorrhage, peripheral

vestibulopathy, Bell’s Palsy, reactivation of old stroke.

Stroke mimic goals

• Identify stroke mimics with 97% accuracy.

• Means that less than 3% of patients who are diagnosed with acute stroke will have a stroke mimic that might be treated with thrombolytics.

Stroke Imaging: CT/MRI

• CT • MRI– Hemorrhage and Gradient Echo (GRE)– Diffusion-weighted images (DWI) and apparent

diffusion coefficient (ADC) Map– Note non ischemic causes of diffusion restriction: • Inflammation, infection, tumors, post seizure, etc.

• Vascular territories• Time related changes

CT scan: Cerebral Hemorrhage

Stroke:Cerebral Hemorrhage Pathway

• Additional diagnostics: toxicology?, angiography, LP (if needed for R/O SAH)

• Treatment– Supportive care (similar to ischemic stroke/TBI)– Anticoagulant reversal– BP Management per guidelines– Neurosurgery consultation

CT scan: Acute Ischemia

Stroke:Acute Cerebral ischemia pathway

• Systemic rtPA per protocol (save penumbra)– If no rtPA, then antiplatelet agent; NOT heparin

• Acute BP management per protocol– If rtPA: <185/110; post rtPA <180/105– If no rtPA: <220/130

• Endovascular thrombolytic or clot retrieval• Admit to appropriate stroke unit• Initiate diagnostic workup

Stroke:Cerebral ischemia diagnostics

• Major etiologies:– Atherothromboembolic disease

• Artery to artery embolus (most common)• Stenosis/occlusion with distal hypoperfusion

– Small vessel disease• Arteriosclerosis (fibrinoid necrosis)• Microatheromatous

– Cardioembolic (including “paradoxical embolus?”)– Hypotension (with or without stenosis)– Idiopathic/Cryptogenic (20-30%)– Misc.

Cryoptogenic Stroke: Current Issues

• Patent Foramen Ovale– Closure vs. medical treatment– Studies on going

• Atrial Fibrillation– Prolonged monitoring 20-50 days• 12-25% intermittent AFib

– “Wake up stroke”• 3X risk of new AFib

Stroke:Cerebral ischemia diagnostic tests

• MRI with diffusion• Extra labs: Lipids; others (i.e. “thrombo”)• Echocardiogram with agitated saline– Sometimes TEE

• Vascular imaging– Ultrasound (extracranial)– MRA (intracranial/extracranial)– CTA (intracranial/extracranial)

Dizziness, R face/L body numb; dysphagia

Right body numbness

Aphasia

Left hemiplegia and neglect

MRI with ADC Map: Acute Ischemia

Stroke Imaging: Vascular studies

• Carotid/vertebral ultrasound• Angiograms including cervical and intracranial

vessels:– CT angiograms (CTA)– MRI angiograms (MRA)– Conventional angiogram (endovascular)– Also venograms

• New options: CT or MR Perfusion

MR Angiogram: Normal Intracranial Study

MR Angiogram: Normal Cervical Study

MR Angiogram: Occluded Right Internal Carotid

• VTE prophylaxis by day 2• Stroke education provided• Rehabilitation needs assessed

Quality Metrics

In-patient Ischemic• Antithrombotic therapy initiated

by day 2• VTE prophylaxis by day 2• Anticoagulation at discharge for a

fib/flutter• TPA considered for patients

arriving within window• Lipid panel assessed and RX

statins for LDL>100• Discharged on antithrombotic• Stroke education provided• Rehabilitation needs assessed

In-patient Hemorrhagic

Stroke: Subacute care

• Major goals:– Reduce complications– Manage co morbidities– Maximize recovery/rehabilitation– Secondary prevention

Subacute Stroke care: reduce complications

• IMPORTANT: USE STROKE ORDER SET!• Follow evidence based guidelines:– Dysphagia screening– Cardiac monitoring– Avoid fever; avoid hyperglycemia (>140)– VTE prophylaxis– Stress ulcer prophylaxis– Rehab program/mobilization

• Cardiac• Cerebral edema, hemorrhage, hydrocephalus• Pulmonary/ Sleep apnea• Mental status change/delirium• Infections• Depression• Bowel/bladder

Subacute Stroke Care: Reduce Complications

Secondary Stroke Prevention

• Risk factor management• Anticoagulants• Antiplatelet agents• Surgery

Stroke:Risk factor management

• Lifestyle• Non-DM HTN: Diuretic; Diuretic &ACEI• DM with HTN: ACEI or Angiotension Rec

Blocker• Glucose control• Statins: LDL<100 or <70 (high risk patients)

Stroke: Anticoagulants

• Cardiac source of embolus• Some hyper thrombotic states?• Venous sinus thrombosis• Major arterial dissection• Few others?

Stroke: Antiplatelet agents

• For atherothomboembolic and small vessel disease

• Aspirin• Clopidogrel– Note nonresponders/drug-drug interactions (PPI)– Platelet function tests?

• Dipyridamole/aspirin• New agents?

Periprocedural management of antithrombotic medications

• For Dental procedures: Can continue ASA or Warfarin.

• ASA probably OK for invasive ocular anethesia, cataract surgery, derm procedures, US guided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery.

• Warfarin probably ok for most derm procedures.

Secondary Stroke Prevention: Surgery

• Carotid endarterectomy• Angioplasty/stenting• Cardiac surgery

Questions?

Dr. Matthew Simmonsmatthew.simmons@usd.edu

Kathy Hill, RN, MSNRapid City Regional Hospital Stroke Coordinatorkhill@regionalhealth.com 605-719-4374