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STROKE, TIA, AND OTHER CENTRAL FOCAL CONDITIONS Dee Mortensen PGY2 November 10, 2005 Tintinalli Ch. 228.

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Presentation on theme: "STROKE, TIA, AND OTHER CENTRAL FOCAL CONDITIONS Dee Mortensen PGY2 November 10, 2005 Tintinalli Ch. 228."— Presentation transcript:

1 STROKE, TIA, AND OTHER CENTRAL FOCAL CONDITIONS Dee Mortensen PGY2 November 10, 2005 Tintinalli Ch. 228

2 Background Third leading cause of death in US Third leading cause of death in US Leading cause of adult disability Leading cause of adult disability 700,000 patients/year 700,000 patients/year 1/3 of patients younger than 65 1/3 of patients younger than 65

3 Definition of Stroke Any disease process that disrupts blood flow to a focal region of the brain. Any disease process that disrupts blood flow to a focal region of the brain.

4 Stroke Types 80% ischemic 80% ischemic Thrombosis Thrombosis Embolism Embolism Hypoperfusion Hypoperfusion 20% hemorrhagic 20% hemorrhagic Intracerebral Intracerebral Subarachnoid Subarachnoid

5 Ischemic Strokes Thrombosis-most common cause Thrombosis-most common cause Etiology Etiology Atherosclerotic disease-most common Atherosclerotic disease-most common Vasculitis Vasculitis Dissection Dissection Polycythemia Polycythemia Hypercoagulable states Hypercoagulable states Infectious Diseases-HIV, TB, syphilis Infectious Diseases-HIV, TB, syphilis

6 Ischemic Strokes 1/5 th due to Embolism 1/5 th due to Embolism Etiology Etiology Cardiac Cardiac Valvular Vegetations Valvular Vegetations Mural thrombi- caused by A-fib, MI, or dysrhythmias Mural thrombi- caused by A-fib, MI, or dysrhythmias Paradoxical emboli-from ASD, VSD Paradoxical emboli-from ASD, VSD Cardiac tumors-myxoma Cardiac tumors-myxoma Fat emboli Fat emboli Particulate emboli – IV drug injections Particulate emboli – IV drug injections Septic Emboli Septic Emboli

7 Ischemic Strokes Hypoperfusion- less common mechanism Hypoperfusion- less common mechanism Typically caused by cardiac failure Typically caused by cardiac failure More diffuse injury pattern vs thrombosis or embolism More diffuse injury pattern vs thrombosis or embolism Usually occur in watershed regions of brain Usually occur in watershed regions of brain

8 Hemorrhagic Strokes Intracerebral hemorrhage (ICH) Intracerebral hemorrhage (ICH) - approx. 10% of all strokes Risk Factors Risk Factors HTN HTN Increasing Age Increasing Age Race: Asians and Blacks Race: Asians and Blacks Amyloidosis- esp. in the elderly Amyloidosis- esp. in the elderly AVMs or tumors AVMs or tumors Anticoagulants/Thrombolitic use Anticoagulants/Thrombolitic use History of previous stroke History of previous stroke Tobacco, ETOH, and cocaine use Tobacco, ETOH, and cocaine use

9 Subarachnoid hemorrhage (SAH) Subarachnoid hemorrhage (SAH) Result from rupture of berry aneurysm or rupture of AVMs Result from rupture of berry aneurysm or rupture of AVMs Hemorrhagic Stroke

10 Cerebral Anatomy Vascular circulation: Anterior and Posterior Vascular circulation: Anterior and Posterior Anterior circulation Anterior circulation Origin: carotid system Origin: carotid system supplies 80% brain- optic nerve, retina, frontoparietal and anterotemporal lobes of brain supplies 80% brain- optic nerve, retina, frontoparietal and anterotemporal lobes of brain

11 Anterior Circulation Anatomy Common carotid artery Common carotid artery Divides into Internal and External carotids at angle of mandible Divides into Internal and External carotids at angle of mandible Internal carotid artery – terminates at anterior and middle cerebral artery at the circle of Willis Internal carotid artery – terminates at anterior and middle cerebral artery at the circle of Willis Ophthalmic artery – 1 st branch off internal carotid Ophthalmic artery – 1 st branch off internal carotid -supplies optic nerve and retina

12 Posterior circulation: supplies 20% of brain Posterior circulation: supplies 20% of brain Derived from vertebral arteries Derived from vertebral arteries Posterior circulation supplies brainstem, cerebellum, thalamus, auditory centers and visual cortex Posterior circulation supplies brainstem, cerebellum, thalamus, auditory centers and visual cortex Posterior Circulation Anatomy

13 Neurons are very sensitive to cerebral blood flow and die within minutes of complete cessation Neurons are very sensitive to cerebral blood flow and die within minutes of complete cessation Extent of injury depends on vessel involved and presence or absence of collateral blood flow Extent of injury depends on vessel involved and presence or absence of collateral blood flow Penumbra Penumbra Reversibly injured neurons surrounding the primary injury with collateral circulation, which can be preserved with proper timely intervention Reversibly injured neurons surrounding the primary injury with collateral circulation, which can be preserved with proper timely intervention Ischemic Pathophysiology

14 Hemorrhagic Pathophysiology In ICH and SAH, intracranial pressure rises following vascular rupture with resulting global hypoperfusion In ICH and SAH, intracranial pressure rises following vascular rupture with resulting global hypoperfusion Marked reduction in perfusion occurs near the hematoma as a result of local compression Marked reduction in perfusion occurs near the hematoma as a result of local compression

15 Clinical Features Stroke presentation often subtle and varied Stroke presentation often subtle and varied Key aspects in determining the underlying cause and location of the lesion include: Key aspects in determining the underlying cause and location of the lesion include: History History Physical Exam Physical Exam Neurologic Exam Neurologic Exam

16 History History of: History of: HTN HTN CAD CAD DM DM Previous TIA in same vascular distribution Previous TIA in same vascular distribution Symptomatic deficits that wax and wan Symptomatic deficits that wax and wan Gradual onset Gradual onset Suggests: atherosclerotic disease and thrombosis Suggests: atherosclerotic disease and thrombosis

17 History History of History of A-Fib A-Fib Valvular replacement Valvular replacement Recent MI Recent MI Multiple TIAs involving different vascular distributions Multiple TIAs involving different vascular distributions Sudden onset of symptoms Sudden onset of symptoms Suggests: Embolism Suggests: Embolism

18 History of : History of : Recent neck injury-MVA, Sports injury Recent neck injury-MVA, Sports injury Chiropractic manipulation Chiropractic manipulation Suggests: Carotid dissection Suggests: Carotid dissection History

19 History of: History of: Straining or coughing immediately preceding symptoms Straining or coughing immediately preceding symptoms Suggests: ruptured aneurysm Suggests: ruptured aneurysm History

20 History History of: History of: Sudden onset of symptoms Sudden onset of symptoms Headache (minority of patients with ischemic stroke) Headache (minority of patients with ischemic stroke) Suggests: Hemorrhagic stroke Suggests: Hemorrhagic stroke

21 Physical Exam Not inclusive, but some pointers: Not inclusive, but some pointers: Signs of emboli- Janeway lesions, Osler nodes Signs of emboli- Janeway lesions, Osler nodes Bleeding dyscrasia- ecchymosis, petechiae Bleeding dyscrasia- ecchymosis, petechiae Papilledema- mass lesion, HTN crisis, cerebral vein thrombosis Papilledema- mass lesion, HTN crisis, cerebral vein thrombosis Carotid bruit or murmurs- vascular or cardiac etiol. Carotid bruit or murmurs- vascular or cardiac etiol.

22 Neurologic Exam (see Ch 226) National Institutes of Health (NIH) Stroke Scale- correlates to infarct volume National Institutes of Health (NIH) Stroke Scale- correlates to infarct volume Six major areas: Six major areas: 1. LOC 2. Visual Assessment 3. Motor Function 4. Cerebellar Function 5. Sensation and Neglect 6. Cranial Nerves

23 Stroke Syndromes Classic physical exam findings that assist in localizing the lesion. Classic physical exam findings that assist in localizing the lesion.

24 Transient Ischemic Attack (TIA) Transient Ischemic Attack (TIA) Neurologic deficit that resolves within 24 hours Neurologic deficit that resolves within 24 hours Most TIAs resolve < 30 minutes Most TIAs resolve < 30 minutes Approx. 10% of patients will have a stroke in 90 days Approx. 10% of patients will have a stroke in 90 days Half of these in just 2 days Half of these in just 2 days Ischemic Stroke Syndrome

25 Anterior Cerebral Artery Infarction Anterior Cerebral Artery Infarction Contralateral weakness/numbness greater in leg than arm Contralateral weakness/numbness greater in leg than arm Dyspraxia Dyspraxia Speech perseveration Speech perseveration Slow responses Slow responses Ischemic Stroke Syndromes Ischemic Stroke Syndromes

26 Middle cerebral artery occlusion Middle cerebral artery occlusion Dominant Hemisphere (usually the left) Dominant Hemisphere (usually the left) Contralateral weakness/numbness in arm and face greater than leg Contralateral weakness/numbness in arm and face greater than leg Contralateral hemianopsia Contralateral hemianopsia Gaze preference toward side of infarct Gaze preference toward side of infarct Aphasia (Wernicke’s -receptive, Broca’s -expressive or may have both) Aphasia (Wernicke’s -receptive, Broca’s -expressive or may have both) Dysarthria Dysarthria Ischemic Stroke Syndromes Ischemic Stroke Syndromes

27 Ischemic Stroke Syndromes Middle cerebral artery occlusion Middle cerebral artery occlusion Nondominant hemisphere Nondominant hemisphere Contralateral weakness/numbness in arm and face greater than in the leg Contralateral weakness/numbness in arm and face greater than in the leg Constructional Apraxia Constructional Apraxia Dysarthria Dysarthria Inattention, neglect, or extinction Inattention, neglect, or extinction

28 Posterior Cerebral Artery Infarct Posterior Cerebral Artery Infarct Often unrecognized by patient- minimal motor involvement Often unrecognized by patient- minimal motor involvement Light-touch/pinprick may be significantly reduced Light-touch/pinprick may be significantly reduced Visual cortex abnormalities also minimal Visual cortex abnormalities also minimal Ischemic Stroke Syndromes Ischemic Stroke Syndromes

29 Vertebrobasilar Syndrome Vertebrobasilar Syndrome Posterior circulation supplies brainstem, cerebellum, and visual cortex Posterior circulation supplies brainstem, cerebellum, and visual cortex Dizziness, vertigo, diplopia, dysphagia, ataxia, cranial nerve palsies, and b/l limb weakness, singly or in combination Dizziness, vertigo, diplopia, dysphagia, ataxia, cranial nerve palsies, and b/l limb weakness, singly or in combination HALLMARK: Crossed neurological deficits: ipsilateral CN deficits with contralateral motor weakness HALLMARK: Crossed neurological deficits: ipsilateral CN deficits with contralateral motor weakness Ischemic Stroke Syndromes Ischemic Stroke Syndromes

30 Ischemic Stroke Syndromes Lateral Medullary (Wallenburg) Syndrome Lateral Medullary (Wallenburg) Syndrome Specific post. Circulation infarct involving vertebrobasilar and/or post inferior cerebellar Art. Specific post. Circulation infarct involving vertebrobasilar and/or post inferior cerebellar Art. Signs: Signs: Ipsilateral loss of facial pain and temperature with contralateral loss of these senses over the body Ipsilateral loss of facial pain and temperature with contralateral loss of these senses over the body Gait and limb ataxia Gait and limb ataxia Partial ipsilateral loss of CN V, IX, X, and XI Partial ipsilateral loss of CN V, IX, X, and XI Ipsilateral Horner Syndrome may be present Ipsilateral Horner Syndrome may be present

31 Ischemic Stroke Syndromes Basilar Artery Occlusion Basilar Artery Occlusion Severe quadriplegia Severe quadriplegia Coma Coma Locked-in syndrome-complete muscle paralysis except for upward gaze Locked-in syndrome-complete muscle paralysis except for upward gaze

32 Ischemic Stroke Syndromes Cerebellar Infarction-subset of post. circ. infarcts Cerebellar Infarction-subset of post. circ. infarcts Symptoms: “drop attack” with sudden inability to walk or stand, often a/w vertigo, HA, nausea/vomiting, neck pain Symptoms: “drop attack” with sudden inability to walk or stand, often a/w vertigo, HA, nausea/vomiting, neck pain Diagnosis: MRI, MRA as bone artifact obscures CT Diagnosis: MRI, MRA as bone artifact obscures CT Cerebral edema develops w/in 6-12 hrs → increased brainstem pressure and decreased LOC Cerebral edema develops w/in 6-12 hrs → increased brainstem pressure and decreased LOC Treatment: decrease ICP and emergent surgical decompression Treatment: decrease ICP and emergent surgical decompression

33 Lacunar Infarction Lacunar Infarction Infarction of small penetrating arteries in pons and basal ganglia Infarction of small penetrating arteries in pons and basal ganglia Associated with chronic HTN present in 80-90% Associated with chronic HTN present in 80-90% Pure motor or sensory deficits Pure motor or sensory deficits Arterial Dissection Arterial Dissection Often a/w severe trauma, headache, and neck pain hours to days prior to onset of neuro symptoms Often a/w severe trauma, headache, and neck pain hours to days prior to onset of neuro symptoms HTN risk factor for spontaneous dissection HTN risk factor for spontaneous dissection Ischemic Stroke Syndrome

34 Intracerebral Hemorrhage Intracerebral Hemorrhage ICH – sudden onset HA, N/V, elevated BP ICH – sudden onset HA, N/V, elevated BP Progressive focal neurologic deficits over minutes Progressive focal neurologic deficits over minutes Patients may rapidly deteriorate Patients may rapidly deteriorate Exertion commonly triggers symptoms Exertion commonly triggers symptoms Bleeding localized to putamen, thalamus, Bleeding localized to putamen, thalamus, pons-pinpoint pupils, and cerebellum Hemorrhagic Syndromes

35 Cerebellar Hemorrhage Cerebellar Hemorrhage Sudden onset dizziness, vomiting, truncal ataxia, inability to walk Sudden onset dizziness, vomiting, truncal ataxia, inability to walk Possible gaze palsies and increasing stupor Possible gaze palsies and increasing stupor Treatment: urgent surgical decompression or hematoma evacuation Treatment: urgent surgical decompression or hematoma evacuation

36 Hemorrhagic Syndrome Subarachnoid hemorrhage Subarachnoid hemorrhage Severe HA, vomiting, decreasing LOC Severe HA, vomiting, decreasing LOC HA- often occipital or nuchal in location HA- often occipital or nuchal in location Sudden onset of symptoms– history may reveal activities a/w ↑ HTN such as defecation, coughing or intercourse Sudden onset of symptoms– history may reveal activities a/w ↑ HTN such as defecation, coughing or intercourse

37 Diagnosis-Critical Pathway History History Last moment patient known to be normal Last moment patient known to be normal Initial orders Initial orders ECG, Cardiac Enzymes, CBC, Coags, Type/Screen, Lytes, glucose, Renal function studies, +/- drug screen, Noncontrast CT-head ECG, Cardiac Enzymes, CBC, Coags, Type/Screen, Lytes, glucose, Renal function studies, +/- drug screen, Noncontrast CT-head Review alteplase inclusion/exclusion criteria Review alteplase inclusion/exclusion criteria

38 Diagnostic Tests Emergent noncontrast CT of head Emergent noncontrast CT of head Differentiate hemorrhage vs ischemia Differentiate hemorrhage vs ischemia MOST ischemic strokes (-) by CT for at least 6 hrs MOST ischemic strokes (-) by CT for at least 6 hrs Hypodensity indicating infarct seen hrs Hypodensity indicating infarct seen hrs Can identify hemorrhage greater than 1cm, and 95% of SAH Can identify hemorrhage greater than 1cm, and 95% of SAH If CT (-) but still considering SAH may do L.P. If CT (-) but still considering SAH may do L.P.

39 Depending on circumstances, other helpful tests Depending on circumstances, other helpful tests Echocardiogram – identifies mural thrombus, tumor, valvular vegetations in suspected cardioembolic stroke Echocardiogram – identifies mural thrombus, tumor, valvular vegetations in suspected cardioembolic stroke Carotid duplex -for known/suspected high grade stenosis Carotid duplex -for known/suspected high grade stenosis Angiography – “gold standard” identifies occlusion or stenosis of large and small vessels of head/neck, dissections and aneurysms Angiography – “gold standard” identifies occlusion or stenosis of large and small vessels of head/neck, dissections and aneurysms MRI scan – identifies posterior circulation strokes better and ischemic strokes earlier than CT MRI scan – identifies posterior circulation strokes better and ischemic strokes earlier than CT Emergent MRI- considered for suspected brainstem lesion or dural sinus thrombosis Emergent MRI- considered for suspected brainstem lesion or dural sinus thrombosis MRA scan – identifies large vessel occlusions – may replace angiography in the future MRA scan – identifies large vessel occlusions – may replace angiography in the future Diagnostic Tests

40 Differential Diagnosis Ddx of Acute Stroke (not inclusive) Ddx of Acute Stroke (not inclusive) Epidural/subdural hematoma Epidural/subdural hematoma Hyponatremia Hyponatremia Brain tumor/abscess Brain tumor/abscess Postictal paralysis (Todd paralysis) Postictal paralysis (Todd paralysis) Hypertensive encephalopathy Hypertensive encephalopathy Meningitis/encephalitis Meningitis/encephalitis Hyperosmotic coma Hyperosmotic coma

41 Wernicke Encephalopathy Wernicke Encephalopathy Drug toxicity (lithium, phenytoin, carbamazepine) Drug toxicity (lithium, phenytoin, carbamazepine) Complicated Migraine Complicated Migraine Bells palsy Bells palsy Multiple sclerosis Multiple sclerosis Meniere’s disease Meniere’s disease Labyrinthitis Labyrinthitis Differential Diagnosis Cont.

42 Special Populations In Stroke Sickle Cell Disease (SCD) Sickle Cell Disease (SCD) Most common cause of ischemic stroke in children Most common cause of ischemic stroke in children 10% of patients with Sickle Cell Disease have stroke by age 20 10% of patients with Sickle Cell Disease have stroke by age 20 SCD-↑ frequency of cerebral aneurysm—think SAH SCD-↑ frequency of cerebral aneurysm—think SAH Treatment: emergent simple or exchange transfusion to decrease HbS to < 30%, thus improving blood flow and oxygen delivery to infarct zone Treatment: emergent simple or exchange transfusion to decrease HbS to < 30%, thus improving blood flow and oxygen delivery to infarct zone

43 Young Adults (age 15 to 50) Young Adults (age 15 to 50) 20% of ischemic strokes due to arterial dissection 20% of ischemic strokes due to arterial dissection Often preceded by minor trauma Often preceded by minor trauma Cardioembolic etiologies- MVP, rheumatic heart disease, or paradoxical embolism Cardioembolic etiologies- MVP, rheumatic heart disease, or paradoxical embolism Migrainous stroke- infarction a/w typical attack Migrainous stroke- infarction a/w typical attack Air embolism-scuba diving or recent invasive procedure Air embolism-scuba diving or recent invasive procedure Drugs: heroin, cocaine, amphetamines Drugs: heroin, cocaine, amphetamines Special Populations In Stroke

44 Pregnancy Pregnancy ↑risk during peripartum and up to 6 weeks postpartum ↑risk during peripartum and up to 6 weeks postpartum Contributors to risk-preeclampsia/eclampsia, decrease in blood vol. and hormonal status following birth Contributors to risk-preeclampsia/eclampsia, decrease in blood vol. and hormonal status following birth Special Populations In Stroke

45 Ischemic Stroke Management General Management General Management A, B, Cs A, B, Cs IV, oxygen, monitor, elevate head of bed slightly IV, oxygen, monitor, elevate head of bed slightly E.D. protocols/Notify stroke team E.D. protocols/Notify stroke team Treat dehydration and hypotension Treat dehydration and hypotension Avoid overhydration – cerebral edema Avoid overhydration – cerebral edema Avoid IVF with glucose – except if hypoglycemic Avoid IVF with glucose – except if hypoglycemic Fever – worsens neurologic deficits Fever – worsens neurologic deficits

46 Ischemic Stroke Management Hypertension Hypertension Treatment indicated for SBP > 220 mm Hg or mean arterial pressure > 130 mm Hg Treatment indicated for SBP > 220 mm Hg or mean arterial pressure > 130 mm Hg Lowering BP too much reduces perfusion to penumbra converting reversible injury to infarction Lowering BP too much reduces perfusion to penumbra converting reversible injury to infarction Use easily titratable Rx (labetalol or enalaprilat) Use easily titratable Rx (labetalol or enalaprilat) SL Ca-channel blockers should be avoided SL Ca-channel blockers should be avoided

47 Management of HTN cont. Thrombolytic candidates- use NTG paste or Labetalol to reduce BP < 185/115 to allow tx Thrombolytic candidates- use NTG paste or Labetalol to reduce BP < 185/115 to allow tx Requirements for more aggressive treatment exclude the use of tissue plasminogen activator. Requirements for more aggressive treatment exclude the use of tissue plasminogen activator.

48 Thrombolysis Background NIH/NINDS study NIH/NINDS study 624 patients, RDBPC trial IV tPA vs placebo 624 patients, RDBPC trial IV tPA vs placebo Treatment w/in 3 hrs of onset Treatment w/in 3 hrs of onset At 3 months pts tx’d with tPA were at least 30% more likely to have minimal/no disability…absolute favorable outcome in percent At 3 months pts tx’d with tPA were at least 30% more likely to have minimal/no disability…absolute favorable outcome in percent 6.4% of patients treated with tPA developed symptomatic ICH compared with 0.6% in placebo group 6.4% of patients treated with tPA developed symptomatic ICH compared with 0.6% in placebo group Mortality rate at 3 months not significantly different Mortality rate at 3 months not significantly different tPA group had significantly less disability tPA group had significantly less disability FDA approved in 1996 FDA approved in 1996

49 tPA Dose and Complications IV tPA –Total dose 0.9 mg/kg, max. 90mg IV tPA –Total dose 0.9 mg/kg, max. 90mg 10% as bolus, remaining infusion over 60 min. 10% as bolus, remaining infusion over 60 min. BP and Neuro checks q 15 min x 2 hrs initially BP and Neuro checks q 15 min x 2 hrs initially Treatment must begin w/in 3 hrs of symptoms and meet inclusion and exclusion criteria Treatment must begin w/in 3 hrs of symptoms and meet inclusion and exclusion criteria No ASA or heparin given x 24 hrs after tx No ASA or heparin given x 24 hrs after tx

50 Emergent Mngt of HTN during/following rtPA in Acute Stroke Monitor BP closely Monitor BP closely q 15 min x 2 hrs, then q 30 min x 6 hrs, then q 60 min for 24 hr Total q 15 min x 2 hrs, then q 30 min x 6 hrs, then q 60 min for 24 hr Total If SBP or DBP mmHg If SBP or DBP mmHg 10 mg labetalol IVP q min, max 150 mg 10 mg labetalol IVP q min, max 150 mg If SBP > 230 or DBP mmHg If SBP > 230 or DBP mmHg 10 mg labetalol may repeat q min, max 150 mg 10 mg labetalol may repeat q min, max 150 mg If BP not controlled by labetalol then consider nitroprusside ( mcg/kg/min), continuous arterial monitoring advised If BP not controlled by labetalol then consider nitroprusside ( mcg/kg/min), continuous arterial monitoring advised If DBP > 140 mmHg If DBP > 140 mmHg Infuse sodium nitroprusside ( mcg/kg/min), continuous arterial monitoring advised Infuse sodium nitroprusside ( mcg/kg/min), continuous arterial monitoring advised

51 IV Thrombolysis Criteria in Ischemic Stroke Inclusion criteria Inclusion criteria Age 18 years or older Age 18 years or older Time since onset well established to be < 3 hrs Time since onset well established to be < 3 hrs Clinical diagnosis of ischemic stroke Clinical diagnosis of ischemic stroke

52 Exclusion criteria Exclusion criteria Minor/rapidly improving neurologic signs Minor/rapidly improving neurologic signs Evidence of intracranial hemorrhage on pretreatment noncontrast head CT Evidence of intracranial hemorrhage on pretreatment noncontrast head CT History of intracranial hemorrhage History of intracranial hemorrhage High suspicion of SAH despite normal CT High suspicion of SAH despite normal CT GI or GU bleeding within last 21 days GI or GU bleeding within last 21 days Criteria for IV Thrombolysis cont.

53 Exclusion criteria Exclusion criteria Known bleeding diathesis Known bleeding diathesis Platelet count < 100,000 /mm 3 Platelet count < 100,000 /mm 3 Heparin within 48 hours and has an elevated PTT Heparin within 48 hours and has an elevated PTT Current use of anticoagulation or PT > 15 seconds or INR > 1.7 Current use of anticoagulation or PT > 15 seconds or INR > 1.7 Criteria for IV Thrombolysis cont.

54 Exclusion criteria Exclusion criteria Intracranial surgery, serious head trauma or previous stroke within 3 months Intracranial surgery, serious head trauma or previous stroke within 3 months Major surgery within 14 days Major surgery within 14 days Recent arterial puncture at non compressible site Recent arterial puncture at non compressible site Lumbar puncture within 7 days Lumbar puncture within 7 days Seizure at onset of stroke Seizure at onset of stroke Criteria for IV Thrombolysis cont.

55 Exclusion criteria Exclusion criteria History of ICH, AVM or aneurysm History of ICH, AVM or aneurysm Recent MI Recent MI Sustained pretreatment systolic pressure > 185 mmHg or diastolic pressure > 110 mmHg despite aggressive treatment to reduce BP to within these limits Sustained pretreatment systolic pressure > 185 mmHg or diastolic pressure > 110 mmHg despite aggressive treatment to reduce BP to within these limits Blood glucose 400 mg/dL Blood glucose 400 mg/dL Criteria for IV Thrombolysis cont.

56 Drug Therapy in Ischemic Stroke Majority of pts not thrombolytic candidates Majority of pts not thrombolytic candidates Antiplatelet agents-cornerstone for 2° prevention Antiplatelet agents-cornerstone for 2° prevention Antiplatelet agents Antiplatelet agents ASA: ↓ risk 20-25% vs placebo ASA: ↓ risk 20-25% vs placebo mg dose and will not interfere with tPA therapy mg dose and will not interfere with tPA therapy Dipyridamole: alone (200mg BID) ↓ risk 15% Dipyridamole: alone (200mg BID) ↓ risk 15% Plavix: (75 mg qd) 0.5% absolute annual risk reduction when compared to ASA Plavix: (75 mg qd) 0.5% absolute annual risk reduction when compared to ASA Good Rx for pts who cannot tolerate or fail ASA Good Rx for pts who cannot tolerate or fail ASA

57 Heparin: unproven Heparin: unproven Pts may expect fewer strokes but benefit is offset by increased ICH Pts may expect fewer strokes but benefit is offset by increased ICH Similar results with LMWH Similar results with LMWH Use of UFH, LMWH, or heparinoids to tx a specific stroke subtype or TIA cannot be recommended based on available evidence. Use of UFH, LMWH, or heparinoids to tx a specific stroke subtype or TIA cannot be recommended based on available evidence. Anticoagulants

58 TIA Management Admit-Evaluate for cardiac sources of emboli or high grade stenosis of carotid arteries Admit-Evaluate for cardiac sources of emboli or high grade stenosis of carotid arteries Rx: ASA Rx: ASA UFH-for high risk of recurrence UFH-for high risk of recurrence Known high grade stenosis in appropriate distribution of symptoms, cardioembolic source, Crescendo TIAs, TIAs despite antiplatelet therapy Known high grade stenosis in appropriate distribution of symptoms, cardioembolic source, Crescendo TIAs, TIAs despite antiplatelet therapy Urgent CEA for TIAs that resolve in 70% stenosis of carotid artery Urgent CEA for TIAs that resolve in 70% stenosis of carotid artery

59 Treat HTN >220 mm Hg systolic or > 120 mm Hg diastolic using labetalol or nitroprusside Treat HTN >220 mm Hg systolic or > 120 mm Hg diastolic using labetalol or nitroprusside Reduce gradually to prehemorrhage levels Reduce gradually to prehemorrhage levels Elevate HOB to 30° Elevate HOB to 30° Hyperventilation-target PaCO mm Hg Hyperventilation-target PaCO mm Hg Osmotherapy Osmotherapy Mannitol ( g/kg IV), and lasix (10 mg IV)– target serum osmolality ≤ 310 mOsm/kg Mannitol ( g/kg IV), and lasix (10 mg IV)– target serum osmolality ≤ 310 mOsm/kg Hyperventilation/osmotherapy used for signs of progressive ↑ ICP Hyperventilation/osmotherapy used for signs of progressive ↑ ICP i.e. mass effect, midline shift or herniation i.e. mass effect, midline shift or herniation Steroids – not recommended Steroids – not recommended ICH Management

60 ICH Management cont. ICP Monitoring considered if GCS < 9 ICP Monitoring considered if GCS < 9 Consider seizure prophylaxis with phenytoin Consider seizure prophylaxis with phenytoin Surgery – controversial Surgery – controversial Depends on neuro status of pt, size and location of hemorrhage Depends on neuro status of pt, size and location of hemorrhage Best benefit in cerebellar hemorrhage Best benefit in cerebellar hemorrhage

61 SAH Management Major complications w/in 1 st 24 hrs Major complications w/in 1 st 24 hrs Rebleeding and vasospasm Rebleeding and vasospasm To ↓ rebleed risk: reduce SBP to 160 mm Hg and/or maintain MAP of 110 mm Hg To ↓ rebleed risk: reduce SBP to 160 mm Hg and/or maintain MAP of 110 mm Hg Cerebral ischemia 2° to vasospasm occurs 2-21 days after aneurysm rupture Cerebral ischemia 2° to vasospasm occurs 2-21 days after aneurysm rupture Nimodipine 60 mg PO q 6 hr-↓ incidence and severity of vasospasms Nimodipine 60 mg PO q 6 hr-↓ incidence and severity of vasospasms Prophylactic treatment of pain, N/V and seizures Prophylactic treatment of pain, N/V and seizures Obtain Neurosurgical consultation Obtain Neurosurgical consultation

62 Summary of Emergency Department Role Stabilization- A,B,Cs Stabilization- A,B,Cs Quick accurate diagnosis-hx, PE/neuro exam Quick accurate diagnosis-hx, PE/neuro exam Determine appropriateness of fibrinolytics Determine appropriateness of fibrinolytics NIH stroke scale NIH stroke scale Early neurology/neurosurgery consult Early neurology/neurosurgery consult Manage blood pressure appropriately Manage blood pressure appropriately

63 Free HANDi Stroke Rx for PDA Free HANDi Stroke Rx for PDA program includes: program includes: An NIHSS calculator An NIHSS calculator Indications and Contraindications for t-PA use Indications and Contraindications for t-PA use A t-PA dosing calculator A t-PA dosing calculator Sample orders for patients receiving t-PA Sample orders for patients receiving t-PA References References

64 HANDi Stroke Rx To download and install HANDi Stroke Rx, follow these simple instructions: 1. On your computer, open your web browsing program such as Netscape Navigator or Microsoft Internet Explorer. 2. Go to the FERNE website, 3. Click on the “Download the Stroke Management Program for Handhelds” button. 4. From the “Software” page, select the “NIHSS, Stroke Management, and t- PA Administration” link. 5. Select the type of computer system you are running (IBM/PC or Macintosh) from the Handheld Computer Stroke Program screen. 6. Input your name and address on the “Handheld Computer Stroke Program Download” page, then click the “Submit” button. Follow the operating system-specific instructions for the remainder of the installation process.

65 Questions 1. T/F -Seizure at onset of stroke wouldn’t preclude use of tPA. 1. T/F -Seizure at onset of stroke wouldn’t preclude use of tPA. 2. T/F -Maximum dose of tPA is 100 mg 2. T/F -Maximum dose of tPA is 100 mg 3. T/F –The use of heparin after tPA is prohibited for 24 hours. 3. T/F –The use of heparin after tPA is prohibited for 24 hours. 4. T/F –Middle Cerebral artery occlusion in the dominant hemisphere may be associated with receptive or expressive aphasia. 4. T/F –Middle Cerebral artery occlusion in the dominant hemisphere may be associated with receptive or expressive aphasia. 5. T/F –Asians, Blacks and Caucasians are at increased risk for intracerebral hemorrhage. 5. T/F –Asians, Blacks and Caucasians are at increased risk for intracerebral hemorrhage.

66 Answers 1. F- seizures at onset is a contraindication to tPA 1. F- seizures at onset is a contraindication to tPA 2. F – max dose is 90 mg 2. F – max dose is 90 mg 3. T 3. T 4. T 4. T 5. F – Only Asians and Blacks 5. F – Only Asians and Blacks


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