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 neuropathological findings.

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. 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

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. 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

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

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