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Stroke Matthew Simmons, MD Sept. 2013

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1 Stroke Matthew Simmons, MD Sept

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 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 Kathy Hill, RN, MSN Rapid City Regional Hospital Stroke Coordinator

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