1. Cerebrovascular Disease
Wednesday AM lecture series
Mitch Deshazer 1

2. Focus on the basics Stroke: ischemic, hemorrhagic
Subarachnoid hemorrhage 2

3. Stroke guidelines in 1 slide
Clinical diagnosis
Yell “Please page a Brain Attack to room X”
Resume coffee drinking while watching the fun. 3

4. What the Brain Attack team does, as per 2008 guidelines
Clinical diagnosis
NIH stroke scale
CT/MRI to confirm dx and determine type of stroke (level 1A recc), CT just as good as MRI 4

5. Then things diverge a bit
Ischemic stroke:
Supportive care: airway/breathing, fever control*, BP control if SBP over 180 for tPA, 220 otherwise*; (safe to restart outpt HTN meds in 24 hrs; CHHIPS study), euglycemia.
Go quick quick to tPA. 5

6. 6

7. IA tPA? What about with mechanical lysis added on?7

8. Time to treatment: >6 but <24 hours8

9. Stuff that doesn’t work
Heparin/ASA*
Hemodilution
Vasodialators
Induced hypertension if pt hypotensive
Combinations of thrombolytics↓
“neuroprotective” agents—see next slide 9

10. Neuroprotective drugs?10

11. Complications 11

12. 12

13. No data on prophylactic anticonvulsants
In ischemic stroke 13

14. The bleedy kind 14

15. To Do list- intracerebral bleed
Image head
Check for and correct coagulopathy (prothrombin complex concentrates or FFP, but NOT fVII)
Take blood pressure down to SBP 140s*
Fix hypoglycemia, not sure what to do with hyperglycemia; fix fever#, DVT SQ heparin ok after day 1-4 if no bleeding
I guess we should call neurosurgery 15

16. The other level 1A recommendation (clinical seizures only)
Prophylaxis changes the frequency, but no evidence that seizures change outcomes 16

17. 17

18. All data about ICH, etc from TBI literature18

19. Within TBI literature, ICP monitors define 3 patient populations
1) Normal ICP
2) Abnormal ICP that responds to treatment; type of treatment appears unimportant
3) Abnormal ICP that doesn’t respond to treatment 19

20. Data for ICP monitor in hemorrhagic stroke20

21. What about the ventricles?* 21

22. What about surgery? 22

23. Prognosis
The ICH score is determined by adding the score from each component as follows:
Glasgow Coma Scale (GCS) score 3 to 4 (= 2 points); GCS 5 to 12 (= 1 point) and GCS 13 to 15 (= 0 points)
ICH volume ≥30 cm3 (= 1 point), ICH volume <30 cm3 (= 0 points)
Intraventricular extension of hemorrhage present (= 1 point); absent (= 0 points)
Infratentorial origin yes (= 1 point); no (= 0 points)
Age ≥80 (= 1 point); <80 (= 0 points)
Thirty-day mortality rates increased steadily with ICH score; mortality rates for ICH scores of 1, 2, 3, 4, and 5 were 13, 26, 72, 97, and 100 percent, respectively. No patient with an ICH score of 0 died, and none had a score of 6 in the cohort 23

24. Subarachnoid Hemorrhage24

25. Clinical Presentation
“Worst headache of my life”--80%
Sentinel bleed—10%
AMS, vomiting, seizures, stiff neck, focal deficits
Diagnosis: CT scan, if negative LP
If positive, then either CTA, MRA, or angiography to spot the lesion 25

26. Hunt & Hess grading scale
Asymptomatic, mild headache, slight nuchal rigidity--1
Moderate to severe headache, nuchal rigidity , no neurologic deficit other than cranial nerve pals--2
Drowsiness / confusion, mild focal neurologic deficit--3
Stupor, moderate-severe hemiparesis--4
Coma, decerebrate posturing--5 26

30. Vasospasm

31. General Concepts in management
Establish baseline TCD to watch for vasospasm
DVT with SCD until after coil/clip, then SQ hep
Get rid of all blood thinners
Nimodipine, baby.
HyperNa done frequently but without data
Fluctuations in BP thought to cause rebleed, so keep it even. Absolute value unclear.
Fix hypoxia, hypo- or hyperglycemia, pH 31

32. Stuff that doesn’t work
Antfibrinolytic therapy—stops bleeding but causes more ischemic strokes
Hypothermia
Hemodilution, Hypertension, hypervolemia (triple H therapy)

33. Stuff that might work
Infusion of urokinase into CSF to prevent vasospasm
Statins to prevent vasospasm
Magnesium sulfate to prevent vasospasm
Unclear how to prevent rebleed