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Stroke

Stroke. Matthew Simmons, MD Sept. 2013 Matthew.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.

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Stroke

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  1. Stroke Matthew Simmons, MD Sept. 2013 Matthew.simmons@usd.edu

  2. 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.

  3. 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 neuropathologicalfindings.

  4. 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

  5. Stroke: Outline • 1. Prehospital care • 2. Emergency management • 3. Diagnostic approach • 4. Subacute care • Prevent complications • Rehabilitation • Secondary prevention

  6. 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

  7. 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

  8. 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.

  9. 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.

  10. 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.

  11. 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

  12. CT scan: Cerebral Hemorrhage

  13. 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

  14. CT scan: Acute Ischemia

  15. 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

  16. 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.

  17. CryoptogenicStroke: 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

  18. 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)

  19. Dizziness, R face/L body numb; dysphagia

  20. Right body numbness

  21. Aphasia

  22. Left hemiplegia and neglect

  23. MRI with ADC Map: Acute Ischemia

  24. 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

  25. MR Angiogram: Normal Intracranial Study

  26. MR Angiogram: Normal Cervical Study

  27. MR Angiogram: Occluded Right Internal Carotid

  28. Quality Metrics In-patient Ischemic VTE prophylaxis by day 2 Stroke education provided Rehabilitation needs assessed In-patient Hemorrhagic • 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

  29. Stroke: Subacute care • Major goals: • Reduce complications • Manage co morbidities • Maximize recovery/rehabilitation • Secondary prevention

  30. 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

  31. Subacute Stroke Care: Reduce Complications • Cardiac • Cerebral edema, hemorrhage, hydrocephalus • Pulmonary/ Sleep apnea • Mental status change/delirium • Infections • Depression • Bowel/bladder

  32. Secondary Stroke Prevention • Risk factor management • Anticoagulants • Antiplatelet agents • Surgery

  33. 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)

  34. Stroke: Anticoagulants • Cardiac source of embolus • Some hyper thrombotic states? • Venous sinus thrombosis • Major arterial dissection • Few others?

  35. Stroke: Antiplatelet agents • For atherothomboembolic and small vessel disease • Aspirin • Clopidogrel • Note nonresponders/drug-drug interactions (PPI) • Platelet function tests? • Dipyridamole/aspirin • New agents?

  36. 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.

  37. Secondary Stroke Prevention: Surgery • Carotid endarterectomy • Angioplasty/stenting • Cardiac surgery

  38. Questions? Dr. Matthew Simmons matthew.simmons@usd.edu Kathy Hill, RN, MSN Rapid City Regional Hospital Stroke Coordinator khill@regionalhealth.com 605-719-4374

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