stroke: selected diagnosis & management issues, & bgsmc's stroke center
DESCRIPTION
Stroke: Selected Diagnosis & Management Issues, & BGSMC's Stroke Center. Douglas Franz MD Assistant Director, Banner Good Samaritan Stroke Center. July 2011. 1-1.5 Kg 100 Billion Neurons. 32,000 neurons die per second during a stroke. Stroke 2006;37;263. Ischemic Penumbra. - PowerPoint PPT PresentationTRANSCRIPT
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Douglas Franz MD
Assistant Director, Banner Good Samaritan Stroke Center
July 2011
Stroke: Selected Diagnosis & Management Issues, & BGSMC's
Stroke Center
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•1-1.5 Kg•100 Billion Neurons
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32,000 neurons die per second during a stroke
Stroke 2006;37;263
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Ischemic Penumbra
Core InfarctPenumbraBenign Oligemia
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Cerebral Autoregulation
CNS Spectr 2007;12(1):35
•Autoregulation maintains constant perfusion for Mean Arterial Pressures between ~60-140 mm Hg
•Physiologic dysfunction with MAP ≲ 60 mm Hg•Ischemia with CBF ≲ 20 ml/min/100 g
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Cerebral Perfusion Pressure
• CPP=MAP-ICP (or MAP-JVP if JVP>ICP)
• Normal: ICP ~7-15 mmHg, and MAP 50-150 mmHg
• Normal CPP ~70-90 mmHg– Perhaps as low as 50 mmHg in adults– Children require at least 60 mmHg
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TINS 1999;22(9):391
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Epidemiology of Stroke• Stroke WAS the third leading cause of death, behind
cardiovascular diseases and cancer• 150,000 deaths each year (US)• Approximately 780,000 strokes occur each year in the
USA and 450,000 strokes each year in Europe• 600,000 first strokes (US)• 180,000 recurrent strokes (US)• Leading cause of disability in US• 350,000 survivors each year (US)• 7.6% of ischemic strokes and 37.5% of hemorrhagic
strokes result in death within 30 days• Risk factors overlap significantly with cardiovascular
disease• Our best treatment is preventionAmerican Heart Association. 2003, 2008 Heart and Stroke Statistical Update.
ESH-ESC Guidelines Committee. J Hypertens 2003; 21 (6): 1011–1053.
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Definitions• Stroke is the acute onset of a
focal neurologic deficit resulting from decreased perfusion to the brain, causing permanent tissue damage
• Strokes are usually the result of vascular disease
• The symptoms of a stroke depend on the part of the brain involved
• 85% are ischemic• 15% are hemorrhagic
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Stroke Subtypes
Albers et al. Chest 2004; 126 (3 Suppl): 438S–512S.
15%
17%
21%17%
26%
4%
•Hemorrhagic Stroke•Atherosclerotic Cerebrovascular Disease•Small Vessel Disease (“lacunes”)•Cardiogenic Embolism
•Cryptogenic•Other
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Ischemic Stroke
encephalomalacialacune
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Ischemic Stroke
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Hemorrhagic Stroke: Parenchymal Intracerebral Hemorrhage
(ICH)
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Hemorrhagic Stroke
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Other ICH locations:
A.Cortex (amyloidosis)
B.Basal GangliaC.ThalamusD.PonsE.Cerebellum
NEJM 2001;344(19):1450
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Stroke Risk Factors
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Stroke Risk Factors
• Older age• Male gender• Non-white genetic
background• Family history• Prior stroke or TIA
Non-modifiable risk factors Modifiable risk factors (PAR)
Previous TIA or stroke is the most importantrisk factor for stroke.
Hypertension is the most prevalent.
Hankey GJ. Cerebrovasc Dis 2003; 16 (Suppl 1): 14–19.Wolf PA. Adv Neurol 2003; 92: 165–172.
Sacco et al. Stroke 1997; 28 (7): 1507–1517.
• Hypertension (20-40%)• Diabetes mellitus (5-
27%)• Atrial fibrillation (1.5-
23.5%)• Carotid artery disease (2-
7%)• Dyslipidemia (10-15%)• Cardiac disease (1.1-
5.8%)• Cigarette smoking (12-
18%)• Obesity (12-20%)• Others…
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Less Well Understood Risks
• Insulin resistance
• Sleep disordered breathing
• Na intake > 2300 mg/d
• Metabolic syndrome
• Alcohol abuse
• Hyperhomocysteinemia
• Drug abuse
• Hypercoagulable states
• OCP use
• Inflammatory processes– CMV, C. pneumoniae, periodontal disease, etc
• Migraine
• Lp(a) status
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TIA: Transient Ischemic Attack
• Old Definition: stroke symptoms lasting less than 24 hours
• New Definition: “a brief episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction”
• TIA prevalence 7-40% in stroke patients, most in 30 days preceding first stroke, 41% lasting < 1 hour
• In another study: 17% TIAs on day of stroke, 9% previous day, 43% in previous week
Stroke 2009;40:2276
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Cumulative Stroke Risk after TIA or Minor Stroke
Coull et al., BMJ 2004;328:326
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Acute Stroke Risk After TIA• meta-analysis of 18 cohorts, 10126 TIAs
• 5.2% strokes in 7 days, 3.2% in 2 days• i.e., 1 in 20 patients will have a stroke soon after
their TIA
• TIA Management "Patchy"
• ½ of strokes after TIA occur in 24 hours
Lancet Neurol. 2007 Dec;6(12):1063
SettingPatients with
subsequent stroke (%)
95% CI
Non-urgent treatment 11 8.6 - 13.5
Urgent treatment 0.9 0.0-1.9 Neurology 2009;72:1941
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New TIA Guidelines• Neuroimaging, preferably MRI with DWI within 24 hours
• Noninvasive cervicocephalic imaging
• Consider noninvasive cranial vessel imaging if management would be affected
• ECG ASAP after TIA
• TTE reasonable if no other causes, TEE if indicated
• CBC, CMP, PT/PTT, fasting lipids
• Hospitalize if <72 hours from event, and ABCD2 ≥ 3, or if work-up can’t be completed in 2 days
Stroke 2009;40:2276
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Hypertension Risk and Prevalence
• JNC VII, 2003:• In patients > 50 years/age, SBP>140mmHg is a more important risk factor for
cardiovascular disease than DBP• Beginning with 115/75mmHg, CV disease risk doubles with each increment of
20/10mmHg• Individuals who are normotensive at age 55 have a 90% lifetime risk of
developing HTN• Odds ratio of developing HTN 4 at 50 years old
• NHANES, 1999-2002:
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Hypertension Overall
•Lowering BP by 10/5 mmHg lowers CHD by ¼ and stroke by ⅓ regardless of starting BP, vascular risks, and how it was done
• Meta-analysis of 147 trials, 958,000 patients aged 60-69, over 42 years: ~40% reduction in stroke
• In patients with DBP > 90 mmHg, over 60% RRR with combination therapy
BMJ 2009;338:b1665
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Lipids: SPARCL• 4731 patients with stroke/TIA 1-6 mo
before entry• LDL 100-190 mg/dl• atorvastatin 80mg vs placebo
– LDL: 73 vs 129 mg/dl– 5-year stroke risk 0.84 (0.71-0.99)– 5-year decrease in major cardiovascular
events:• ARR 2.2% (0.2-4.2), RRR 16%
– RRR ischemic stroke 22%– Increase in hemorrhagic stroke (2.3% vs. 1.4%)
• ARR 3.5%, RRR 20%
NEJM 2006; 355: 549
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Lipids: SPARCL Net Benefit
Even
ts/5
Year
s (%
)
n=2,366 n=2,365
11.2%
2.3%
8.9%
13.1%
1.4%
11.7%
Prevent 22 events/1,000 treated/5 years
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Carotid Stenosis Risk• Accounts for 15-20% of ischemic
strokes
• Carotid endarterectomy (CEA) surgery if symptomatic:• 70-99% stenosis: NNT 8 (2
years)• 50-69% stenosis: NNT 20
• Surgery if asymptomatic:• 60-99% stenosis: NNT 53 (3
years)
• In US ½ - ⅔ of carotid surgeries are still on asymptomatic patients
• <5% of asymptomatic patients will benefit from surgery, with 4-5% surgical risk
JAMA 1995;273:1421
NEJM 1991;325:445Lancet 2003;361:107
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Patent Foramen Ovale• Detected incidentally in ~20% of
individuals
• Over-represented (>50%) in young people (<55) with cryptogenic stroke• PFO alone confers no statistical risk
(A)• PFO with septal aneurysm might (C)
Neurology 2004;62:1042
• Consensus: antiplatelet therapy if associated with cryptogenic stroke, antocoagulation for DVTs (U,A)
• CLOSURE trial
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Acute Stroke
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Specific Treatment Targets
• Blood Pressure:• SBP <185 after lytics• SBP < 160 in hemorrhage• SBP < 220 in general ischemia• Be aware of autoregulation, sudden changes
• Euvolemia
• Normoglycemia
• Normothermia
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Stroke Mimics• Seizures, especially partial/focal ones
• Hyper/hypoglycemia
• Toxic/metabolic encephalopathy
• Decompensation of old deficits
• “Generalized” weakness
• Hemorrhage
• Tumors
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IV tPA
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SITS-MOST• 6,483 stroke patients in 285 European centers,
50% with little experience with tPA• Monitoring of safety profile of tPA in routine use
Lancet 2007;369:275
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tPA Meta-Analysis
Lancet 2004; 363:768
•Pooled analysis of NINDS, ECASS, ATLANTIS trials
•OR 1.4 (1.05-1.85) for favorable outcomes with OTT 181-270 mins
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ECASS-III
NEJM 2008;359(13):1317
• 821 pts; 403 placebo, 418 tPA (standard protocol) @ 3-4.5 hours
• Primary outcome: dichotomized mRS: 0-1 vs. 2-6
• Secondary outcomes: combined global scores
• Median administration time 3 hrs 59 mins
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ECASS-III: Outcomes
NEJM 2008;359(13):1317
• Favorable 52.4% (tPA) vs. 45.2% (placebo)• OR 1.34 (95% CI: 1.02-1.76, p=0.04)
• Secondary outcomes: OR 1.28 (1.0-1.65, p<0.05)
• ICH higher with tPA: 27.0% vs. 17.6%, p=0.001• symptomatic 2.4% vs. 0.2%, p=0.001
• Mortality 7.7% vs. 8.4% (p=0.68)
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SITS-ISTR
Lancet Online; 9/15/08
3: Moderate disability; requiring some
help, but able to walk without
assistance
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Intra-Arterial TherapiesIndications: <6 hours, Significant disability,
Gross thrombus in large vessels (M1/M2, PCA, basilar, ACA)
Risks: 10-15% with complication/sICH
Options: thrombolysis, thrombectomy
Evidence: PROACT II, pending trials IMS III, MR RESCUE
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MERCI Retrieval System™
Stroke 2004;35:A294
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The Penumbra System™
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Benefit of Revascularization
Saver / UCLA Stroke Center (MERCI)
90-day modified Rankin
53% 16% 31%
6% 32% 62%
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Harm in Revascularization
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Stroke Codes• Criteria:
• any patient you think clinically is having a stroke• time of onset/last-well < 6 hours ago• “meaningful” deficits
• Call 1-6666, ask for a “stroke alert”• On the floor, a SA is initiated by the MD or RRT, not the
nurses
• 6B/neuro-ICU nurse responds to guide process, gather data
• Decision on disposition made in ~45 mins and discussed (we may call you sooner)
• Calling office for doc-to-doc guarantees delays; if SA criteria are met, activate it
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Acute Stroke Labs
• CBC
• BMP
• PT/INR/PTT
• lipid panel/HgBA1c (no so acute)
• Exotics: ESR/CRP, Hypercoagulable panels, vasculitis panels
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Imaging Acute Stroke• Non-contrast CT head
• MR brain – obtained sub-acutely
• Vascular Imaging• CT angiogram head/neck• MRA neck/brain • Carotid U/S
• Acute Stroke <6 hours• CT angiogram/perfusion head and neck
• Telemetry
• TTE with bubbles, TEE in selected cases
• Cerebral Angiogram selected cases
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Artery
VeinTissue
Perfusion Imaging
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Cerebral Blood Volume (CBV)
• mL/100gm
• total volume of blood in a given unit volume of brain; including the blood in the tissues and the large capacitance vessels (arteries, capillaries and veins)
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Cerebral Blood Flow (CBF)
• mL/100gm/min
• volume of blood moving through a given unit volume of brain per unit time
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Mean Transit Time (MTT)
• seconds
• average time it takes for blood to travel from the arterial inlet, through the capillary bed, to the venous outlet
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Blood Pressure Management
•>60% have at least transient SBP > 160
•Not clear if adjusting BP changes outcomes
•Not clear if home meds should be continued
•Consensus is permissive BP to 220/120 before lowering in ischemic stroke• IV boluses, labetalol, hydralazine• Nicardipine
•More aggressive lowering in ICH, generally to SBP <160 mmHg
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Baseline BP and Outcomes in IST
Stroke 2002;33:1315
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Medications
• Anti-platelets : ASA, Aggrenox, Plavix• Start <48 hours (unless tPA• ANY agent appropriate• ASA 325 mg initially/300 mg PR• ASA 81 mg long term
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Platelet Inhibition
MJA 2003;178(11):568
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Anti-thrombotics• DVT prophylaxis
• Lovenox 40 mg SQ Daily > SQ Heparin• Use SCD unless contraindicated
• Heparin Drips• Benefit not established, Risk known• Selected cases only: dissections, Cardiac
thrombus, Dural Venous thrombosis with stroke
• Coumadin• AFIB INR 2.5 (2-3)• LVEF < 35% -experimental • Rare indications: Hypercoagulable state,
dissection
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Anti-Hypertensives• ACUTE GOAL < 200/100 mmHg Ischemia
• POST-tPA GOAL <185/110 mmHg
• ACUTE GOAL <160 mmHg ICH
• Restart outpatient meds prior to discharge
• Long term goal • <140/90 mmHg• <130/80 mmHg with DM, CKD
• Which agent?• Any but consider diuretic or diuretic/ACE-I
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Statins• LDL goal <100mg/dL Uncomplicated
patients
• LDL goal <70mg/dL • In diabetics, identified atherosclerosis,
comorbidities
• Recommend atorvastatin first
• Be sure to continue outpatient statin
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Hyperglycemia
• Treat with insulin sliding scale if BG > 140 mg/dL
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JC Stroke Core Quality Measures
1. All patients given tPA when indicated2. Swallowing eval on all patients done or considered
• NPO means NPO
3. DVT prophylaxis within 48 hours4. Anti-thrombotic drugs within 48 hours5. Lipid profile on all stroke patients6. Anticoagulation for all a-fib patients considered7. Patients discharged on anti-thrombotic drugs8. Patients assessed for rehab needs9. Stroke education for patients and caregivers10. Smoking cessation
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BGSMC Stroke Center
• “Acute” stroke: symptoms < 6 hours• In ED – “Stroke Alert”• On floor, in-house – Rapid Response Team• Elsewhere – CALL 911!
• Subacute or unclear stroke: routine neurology consult
• Clinic: 239-6515
• Stroke Program Office: 239-4531
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Stroke Program Office: 239-4531
Thanks to Jeremy Payne