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Stroke. Matthew Simmons, MD Sept. 2013 [email protected]. 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. - PowerPoint PPT Presentation
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StrokeMatthew Simmons, MD
Sept. [email protected]
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 [email protected]
Kathy Hill, RN, MSNRapid City Regional Hospital Stroke [email protected] 605-719-4374