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7/27/2019 Stroke Diagnosis, Evaluation, And Treatment of
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2 broad categories of stroke:
Ischemia
Inadequate blood supply (oxygen & nutrients) to an areaof the brain
Hemorrhage-
Leakage of blood into the closed cranial cavity
Direct damage to tissue by compression/edema
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Incidence
~700K per year (~200K are recurrent)
80-90% are ischemic Male:Female ratio 1.25:1
Ratio reverses after age 80
Higher rates in Blacks, Hispanics, & NativeAmericans
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Heart disease
AFib, Valvular Dz, MI, endocarditis
Hypertension
Smoking Diabetes/Metabolic Syndrome Dyslipidemia Pregnancy Drug Abuse/Meds Bleeding Disorders/Anticoagulant Use
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Thrombosis In situ arterial obstruction
Arteriosclerosis, dissection, FMD
Superimposed thrombosis
Embolism Arterial obstruction from debris from another
source Systemic Hypoperfusion
Circulatory collapse
Multiorgan involvement
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Large Vessel Disease
Common & InternalCarotids
Circle of Willis & proximalbranches
Small Vessel Disease
Penetrating arteries
Lacunar Stroke
Stuttering course
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Cardiac Atrial fibrillation
Heart valves, atrial thrombus, recent MI, dilatedCM, endocarditis, recent CABG Aortic Arterial (e.g. carotids)
Other/Unknown DVT- Paradoxical embolus
Abrupt onset, rapid improvement
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Shock
Cardiogenic, septic, hypovolemic
Sx are more diffuse/nonfocal Border-zone regions
Cortical blindness
Stupor Proximal Weakness
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IntracerebralHemorrhage (ICH) Bleeding within the brain
tissue Forms a hematoma
Growth stopped bytamponade or leaking intothe ventricles or CSF
Headache, vomiting,delirium
Progressive sx
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HTN Trauma Bleeding Disorder
Inherited Acquired, i.e. meds
Amyloid
Drug use
Cocaine
Amphetamines
AVMs Bleeding into tumor Vasculitis
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SubarachnoidHemorrhage (SAH)
Bleeding into CSF on outer
aspect of brain Quick rise in ICP
Sudden onset headache in97%
Aneurysm & AVMs aremost common cause
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Seizure with ToddsParalysis
Syncope
Migraine Head Trauma Brain tumor
Metabolic Causes
Hypoglycemia
Hyponatremia
Intoxication Uremia/ARF
Hepatic Encephalopathy
Conversion Disorder
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Vital signs
Temperature, Pulse, Blood Pressure
Pulses Carotid Bruit Cardiac Exam Funduscopic exam Skin exam Signs of trauma
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Neurologic Exam
Level of consciousness/GCS
Language/Speech Cranial nerves
Vertigo, diplopia, ataxia
Visual deficits Weakness/Paralysis
Reflexes/ Babinski
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Patients are awarded points based on eye opening, best verbal response,and best motor response. The patient's GCS score can range from 3/15 to15/15
Eye opening score: 4, eyes open; 3, eyes open to speech; 2, eyes open inresponse to pain; 1, no eye opening
Best verbal response score: 5, alert and oriented; 4, confused; 3,responds with inappropriate words; 2, makes incomprehensible sounds;1, no verbal response
Best motor response score: 6, obeys commands; 5, localizes pain; 4,responds to pain with normal flexion/withdrawal; 3, responds to pain
with abnormal flexion; 2, extends in response to pain; 1, no response topain
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CBC with platelets Electrolytes, Bun, Cr Glucose
LFTs PT/PTT O2 Sat ECG Chest XRay
ESR Blood Cultures ANA
Tox screen Alcohol level Blood type & cross Urine/Serum HCG Hypercoaguability Profile
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CT Scan
R/O Bleed
Sensitivity much better after 24 hrs forischemic stroke
Early signs (
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MRI
T1/T2 images, DWI
Provides immediate
evaluation of ischemia Not available for
emergency use in manysettings
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Carotid U/S for stenosis If ASVD, but no stenosis
Risk Factor Modification If stenosis, consider
Carotid Endarterectomy
?Carotid Stenting Vertigo & Syncope are not considered
symptomatic
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100% occlusion
No treatment
70-99% occlusion
If good 5-yr survival & risks
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Sudden onset of neurologic dysfunction thatlasts less than 24 hrs, brought on bypresumed transient ischemia to a portion ofthe brain
May be better to describe as sx
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Transient Sx Associated with Infarction No established diagnostic criteria
In one case series, 15% of TSI pts had arecurrent stroke in-hospital vs. 0% in TIAgroup.
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Could consider home if able to expediteurgent outpatient work-up
AHA does not make a recommendation re:hospitalization One study suggested cost-effective if 24-hr
stroke risk is >5%
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NASCET trial suggested 90-day stroke risk of 20% with non-retinal TIAs (higher than for true stroke)
2000 JAMA study
5% risk w/in 2 days 11% risk w/in 90 days
Higher risk with age >60, DM, sx >10 min, weakness, speechimpairment
2004 Neurology study: 21% risk of stroke/MI/death within 1
year of TIA
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Age >60 = 1 pt Blood Pressure >140/90 = 1 Clinical Features
Unilateral weakness = 2 Isolated speech deficit = 1
Other = 0
Duration
>60 minutes = 2
10-59 minutes = 1
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Risk factor modification Antithrombotic therapy
Anticoagulant therapy
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Hypertension
Goal 80 may not benefit as much & aggressive BP
lowering may increase mortality
Diuretic +/- ACEI as 1st line
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Smoking
Stop it
Diabetes
Goal A1c
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Dyslipidemia
Evidence not as strong as may think, but still a
good idea, especially given other vascular disease SPARCL Study
Atorvastatin 80 mg/day in pts 1-6 months from CVA/TIA
Mean LDL reduction 56
Endpoint was stroke: 16% RRR, but only 2.2% ARR (NNT~50)
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Dyslipidemia, continued
For average-risk patient, goal LDL
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Lifestyle Modification
Weight loss
Exercise Dietary changes
Reduce alcohol intake, especially heavydrinkers
?Homocysteine
Consider B12, B6, Folate (MVI doses OK)
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Aspirin
20-25% reduction in stroke (& MI or other vascular
death) Standard doses of 81-325 mg as good as higher
doses
81 mg dose just as good and less risk of bleeding
ASA-non-responders?
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Clopidogrel (Plavix)
8% RRR vs. ASA for stroke/MI/Vasc death
5.3% vs. 5.8%: NNT ~200 All for only $100+/month
?2nd-line therapy or ASA-allergic patients
No increased bleeding vs. ASA, but combo should
be avoided
No neutropenia (like ticlopidine)
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Dipyridamole
Alone 50-100 mg TID
Aggrenox (200mg ER-DP & 25mg ASA) BID 2 studies have shown ~3% ARR (NNT 33) over ASA
alone for stroke prevention
Some guidelines are suggesting this a 1st line
therapy over ASA alone for stroke prevention
Cost >$100/month
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Warfarin has only been proven effective inprimary prevention of stroke in the setting ofatrial fibrillation
AF is responsible for 1/6th of all strokes inpatients older than 60
Risk reduction
Warfarin about 3 times as effective as ASA Absolute annual risk reduction of ~3%
Low Risk patients may consider ASA rx
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Highest Risk: Prior Stroke or TIA High Risk: Any of the following
Prior thromboembolism Female >75 yo
SBP >160
Heart failure
Moderate Risk: None of above, but HTN Low Risk: None of the above, no HTN
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Thrombolysis Blood Pressure Management
Antithrombotic Therapy Management of Medical Complications
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Time-sensitive
Studies show that thrombolytics must be given
within 3 hours of symptom onset
Effective
NINDS- Complete or near-complete recovery at 3
months post-event (38% vs. 21%, NNT=6)
No difference in mortality
Harmful
At least 6% risk of ICH
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Alteplase (tPA) 0.9 mg/kg dose up to 90 mg
10% as IV bolus, then 60 min infusion Multiple exclusion criteria Obtain informed consent (if possible)
"There is a treatment for your stroke called alteplase that must be given within three hours
after the stroke started. It is a 'clot-buster' drug that can lead to a complete or near-completereversal of a stroke in about one of every three patients treated. However, it has a major risk,since it can cause severe bleeding in the brain in about one of every 15 patients. If bleedingoccurs in the brain, it can be fatal. When used to treat large numbers of stroke patients, onaverage the potential benefits of this treatment outweigh the risks; however, in anyindividual patient it is a very personal decision."
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Stroke/head trauma
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Guidelines for In-Hospital Evaluation Physician Evaluation: 10 minutes
Stroke Team Contact: 15 minutes
Imaging: 25 minutes
Interpretation: 45 minutes
Thrombolysis Started: 60 minutes
?Coagulopathy- Dont wait for labs unless onCoumadin, Heparin, or Dialysis
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Early Treatment
Less severe symptoms
Younger Age Lack of systolic HTN Normoglycemia
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Blood flow in dilated, post-obstructive bloodvessels is BP-dependent
Aggressive BP lowering canincrease
mortality In one study, a fall in SBP >20 in first 24 hrs
was the most likely factor associated with
neurologic deterioration This does NOT apply to hemorrhagic stroke
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Do not treat BP unless >220/120, unless Given thrombolytics (goal
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ASA
IST- ASA 300 mg within 48 hrs
Reduced 14 day recurrent stroke (NNT=100)
Reduced nonfatal stroke & death (NNT=100)
CAST- ASA 160 mg within 48 hrs
Reduced mortality at 4 weeks (NNT=166)
Slight increased risk of hemorrhagic stroke
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Heparin (LMWH) No clear benefit over ASA alone
Reduced recurrent ischemic strokes by 9/1000 patients,
but increased hemorrhagic strokes by same number
?Effective in some subsets
Stroke-in-evolution or Progressive Stroke
Many patients show neurologic deterioration in 1st
24hrs
No studies effectively define this population or prove abenefit
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Acute Coronary Syndromes/Heart Failure Infections
Aspiration pneumonia UTI
Venous thromboembolism Consider DVT prophylaxis for all patients
SCDs for pts with bleeds Heparin or Lovenox SQ for others
Malnutrition/Dehydration (consider Adv Directives) Decubitus ulcers Contractures
CONSIDER EARLY MOBILIZATION IN ALL PATIENTS!
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Accounts for ~8% of all strokes Presenting sx
Headache (~50%) Seizures (7-9%)
Delirium/Altered LOC
Focal neuro sx (depends on area of brain)
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Mortality 35-50%
Half of deaths in 1st 24 hours
Prognosis Size & location of hemorrhage
Age
Glasgow Coma Score
Comorbid conditions
Prior antiplatelet/anticoagulant therapy
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Neurosurgery Constant monitoring
Bedrest Pain control Reverse coagulopathies
Vitamin K, Fresh Frozen Plasma, Platelets
ICP control
Mannitol, Induced Coma, Hyperventilation
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Blood pressure management Surgery
Indicated for cerebellar bleeds >3 cm Supratentorial bleeds more controversial
Depends on size, location, LOC, comorbidities
Recombinant activated factor VII
(rFVIIa) therapy Small studies show promise, but concern for pro-
thrombotic effects
http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/169728337/27/2019 Stroke Diagnosis, Evaluation, And Treatment of
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High mortality rate, ~50%
10% pre-hospital
25% within 24 hrs 45% within 30 days
Prognostic Factors
Level of consciousness
Age
Amount of blood on CT
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Diagnosis
Head CT
(+) in 92% of cases w/in 24 hrs
Most sensitive in first 12 hrs
Lumbar Puncture
Not necessary for diagnosis but consider if clinical
suspicion & negative head CT Elevated pressure & RBCs
Xanthochromia: pink/yellow tint due to RBC breakdown
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Neurosurgical ICU Constant monitoring Bedrest Pain control Reverse coagulopathies DVT Prophylaxis (SCDs)
Blood Pressure Management Management of Aneurysms/AVMs