Case 3 63 year old male called EMS at 10 pm with a chief complaint of feeling dizzy for 2 hours. No headache, mild nausea, no vision change, no speech change. Symptoms began after dinner; 2 cocktails and 2 glasses of wineSymptoms began after dinner; 2 cocktails and 2 glasses of wine Dizziness described as room spinningDizziness described as room spinning Patient laid down and symptoms did not change, ie, no difference lying down or standingPatient laid down and symptoms did not change, ie, no difference lying down or standing

Case 3 PMHx:PMHx: Alcohol Abuse, quit for 3 years (?!)Alcohol Abuse, quit for 3 years (?!) HypertensionHypertension MedicationsMedications Enalapril, 10 mgEnalapril, 10 mg Aspirin, 81 mgAspirin, 81 mg Social HxSocial Hx Smoking - 1 pack per daySmoking - 1 pack per day ROS: Mild “dizzy spells” for the past 2 weeks, each lasting 5-10 minutesROS: Mild “dizzy spells” for the past 2 weeks, each lasting 5-10 minutes

EMS called Upon arrival at 10:30 - symptoms resolvedUpon arrival at 10:30 - symptoms resolved BP 190 / 110, P 80, RR 14BP 190 / 110, P 80, RR 14 Alert, O x 3Alert, O x 3 No facial droopNo facial droop No UE driftNo UE drift Speech fluentSpeech fluent PERL / EOM intactPERL / EOM intact Gait – patient felt unsteady and preferred to sit downGait – patient felt unsteady and preferred to sit down

Question 1 Can vertigo be the sole presently complaint posterior circulation ischemia? a)Yes b)No

Posterior Circulation Ischemia Prodrome very commonProdrome very common 60 % of patients with basilar artery thrombosis60 % of patients with basilar artery thrombosis Stuttering or progressive onset of symptomsStuttering or progressive onset of symptoms 2 weeks prior to ED presentation2 weeks prior to ED presentation

Emergency Department Presentation Clinical Findings: Depends on the syndromeClinical Findings: Depends on the syndrome Range: asymptomatic to comatoseRange: asymptomatic to comatose The 5 Ds: Dizziness, Diplopia, Dysarthria, Dysphagia, DystaxiaThe 5 Ds: Dizziness, Diplopia, Dysarthria, Dysphagia, Dystaxia Hallmarks: Crossed findingsHallmarks: Crossed findings Cranial nerve deficits - IpsilateralCranial nerve deficits - Ipsilateral Motor / Sensory deficits - ContralateralMotor / Sensory deficits - Contralateral

Posterior Circulation Stroke: Anatomy

Emergency Department Presentation Prodromal Symptoms (in order of frequency)Prodromal Symptoms (in order of frequency) Vertigo and Nausea(30%)Vertigo and Nausea(30%) Headache, Neckache(20%)Headache, Neckache(20%) Hemiparesis(10%)Hemiparesis(10%) Dysarthria, Diplopia(10%)Dysarthria, Diplopia(10%) Hemianopia( 6%)Hemianopia( 6%)

Question 2 Which of the following would you recommend to EMS: a)Do not transport b)Transport to the closest hospital c)Transport to a designated stroke center

Stroke Centers: The Thesis Thrombolytic and other interventions are effective treatments in improving outcomes from acute strokeThrombolytic and other interventions are effective treatments in improving outcomes from acute stroke Failure to adhere to protocols increase morbidity and mortalityFailure to adhere to protocols increase morbidity and mortality

Case 3 Patient is transported to the closest hospitalPatient is transported to the closest hospital BP- 190 / 110, P-80, RR-14, 98%, BS 110BP- 190 / 110, P-80, RR-14, 98%, BS 110 Alert, Ox3; NADAlert, Ox3; NAD Neck: no bruitNeck: no bruit Heart and lungs: “normal”Heart and lungs: “normal” CN: “intact”CN: “intact” Sensation: “intact”Sensation: “intact” Gait: “normal”Gait: “normal” ECG: normal sinus rhythmECG: normal sinus rhythm

Question 3 Which of the following would you recommend? a)Discharge with PMD follow up b)Discharge on increased aspirin c)Discharge on clopidogrel d)Discharge on dipyridamole e)Admit to the hospital

Case 3 Discharge diagnosis: “Dizziness – resolved”Discharge diagnosis: “Dizziness – resolved” Limit alcohol useLimit alcohol use Return to ED if symptoms reoccurReturn to ED if symptoms reoccur Call your doctor in the amCall your doctor in the am

TIA and Stroke Johnston, et al. JAMA 2000; 284:2901Johnston, et al. JAMA 2000; 284:2901 Follow-up of 1707 ED patients diagnosed with TIAFollow-up of 1707 ED patients diagnosed with TIA Stroke rate at 90 days was 10.5%Stroke rate at 90 days was 10.5% Half of these occurred in the first 48 hours after ED presentationHalf of these occurred in the first 48 hours after ED presentation Gladstone, et al. CMAJ 2004; 170: Gladstone, et al. CMAJ 2004; 170: consecutive patients with TIA371 consecutive patients with TIA 8% ischemic stroke in 30 days; ½ within 48 hours8% ischemic stroke in 30 days; ½ within 48 hours 12% in motor deficit group12% in motor deficit group

ED Disposition Consider ED discharge if:Consider ED discharge if: Further testing will not change treatmentFurther testing will not change treatment Prior work-upPrior work-up Not a candidate for CEA or anticoagulationNot a candidate for CEA or anticoagulation ECGECG Cardiac echoCardiac echo Carotid ultrasoundCarotid ultrasound

Management: Antiplatelet Therapy AspirinAspirin Compared with placebo in patients with minor stroke/TIACompared with placebo in patients with minor stroke/TIA Relative risk of composite endpoint reduced by 13% to 17%Relative risk of composite endpoint reduced by 13% to 17% Dose of aspirin probably not importantDose of aspirin probably not important Lower dose gives lower incidence of GI side effects.Lower dose gives lower incidence of GI side effects.

Management Cochrane Systematic Review: September 2004Cochrane Systematic Review: September 2004 Clopidogrel and TiclopidineClopidogrel and Ticlopidine Effective in reducing composite endpoint of morbidity and mortality from vascular diseaseEffective in reducing composite endpoint of morbidity and mortality from vascular disease Less GI complications than ASALess GI complications than ASA More skin rash and neurtopenia with ticlopidineMore skin rash and neurtopenia with ticlopidine

Management: Dipyridamole Meta-analysis. Stroke 2005; 36: Meta-analysis. Stroke 2005; 36: Small absolute risk reduction for stroke compared with ASA aloneSmall absolute risk reduction for stroke compared with ASA alone Recommended if symptomatic on ASARecommended if symptomatic on ASA

TIA Management Discharged patients should receive ASA mg/dayDischarged patients should receive ASA mg/day Based on cost and small absolute benefit of other agentsBased on cost and small absolute benefit of other agents Patients with TIA on ASA should have change in agentPatients with TIA on ASA should have change in agent Dipyridamole plus ASADipyridamole plus ASA ClopidogrelClopidogrel Increase dose of ASA to 1300 mg/dayIncrease dose of ASA to 1300 mg/day

Case 3 While waiting in the waiting room for a taxi, the patient acutely developed vertigo, left sided facial droop, right sided weakness, slurred speechWhile waiting in the waiting room for a taxi, the patient acutely developed vertigo, left sided facial droop, right sided weakness, slurred speech Alert but decreased gagAlert but decreased gag BP 210 / 115, P 110, RR 14, POx 92% RABP 210 / 115, P 110, RR 14, POx 92% RA BS 110BS 110 A decision is made to aero-medical transport to a stroke centerA decision is made to aero-medical transport to a stroke center

Question 4 Repeat BPs over the next 15 minute remain 220 / 120. What do you recommend? a)No BP intervention b)Clonidine.2 mg po c)Labetolol 10 mg IV d)Nitroprusside.5 ug / kg / min

Question 5 BP is treated with labetolol and decreases to 180 / 100. Would you intubate this patient before transport? a)No b)Yes: Ativan / Ketamine / Suc c)Yes: Fentanyl / Etomidate / Roc d)Yes: Etomidate / Suc

Case 3 The patient arrives at the stroke center 45 minutes from the onset of symptomsThe patient arrives at the stroke center 45 minutes from the onset of symptoms BP 160 / 90BP 160 / 90 Patient is intubated, left facial droop present, not moving right sidePatient is intubated, left facial droop present, not moving right side CT is done and read within 90 minutes of symptom onset – no infarct, edema, hemorrhageCT is done and read within 90 minutes of symptom onset – no infarct, edema, hemorrhage

Question 6 Which of the following do you recommend? a)Nothing b)Induced hypothermia to 32 degrees c)Intravenous tPA d)Intra-arterial tPA e)Other

Case Study: Outcome Patient received intravenous thrombolysisPatient received intravenous thrombolysis Significant early improvement but without complete resolution of symptomsSignificant early improvement but without complete resolution of symptoms On day 4, the NIHSS score was 10On day 4, the NIHSS score was 10 MRA : Left superior cerebellar artery and both anterior-inferior cerebellar arteries were non- visualizedMRA : Left superior cerebellar artery and both anterior-inferior cerebellar arteries were non- visualized Cardiac evaluation was negativeCardiac evaluation was negative He was transferred to rehab on coumadinHe was transferred to rehab on coumadin