1. STROKE  John P. Connolly MD  Medical Director, Resp Care  Lodi Memorial Hospital  Assoc Clin Prof Medicine  UC Davis

3. STROKE  Acute brain disorder of vascular origin accompanied by neurological dysfunction that persists for longer than 24 hours…  Stroke 1990  One death every 4 seconds in the US…  Circulation 2013

5. TIA  Less than 24 hours  “clinical reversibility”  1/3 of TIAs are associated with cerebral infarction

6. TIME IS BRAIN TISSUE  Each minute of cerebral infarction results in destruction of 1.9 million neurons and 7.5 miles of myelinated nerves…  Stroke 2006

8. CLASSIFICATION  Ischemic Stroke 87%  80% thrombotic  20% embolic  Hemorrhagic Stroke 13%  97% intracerebral  3% subdural

24. INITIAL EVALUATION  Clinical diagnosis  most are unilateral/ no LOC  if coma –> hemorrhagic CVA  brainstem CVA  non-convulsive seizure  Left hemispheric damage -> aphasia  disturbance in comprehension/formation of language  receptive  expressive  global  contralateral weakness – can be due to seizure  hemiparesis can result from hepatic encephalopathy or sepsis

25. Suspected CVA  30% will have another condition  Seizures  Sepsis  Metabolic encephalopathies  Space occupying lesions  …..in that order

26. NIH Stroke Scale…NIHSS  11 different aspects of performance with a number from 0 to 3 or 4  Total score 0 to 41  >22=poor prognosis  <10=unlikely to be CVA

27. IMAGING  CT…reliable for intracranial hemorrhage  close to 100% sensitive  not sensitive for ischemic CVA…especially early  MRI…diffusion weighted  hyperdense regions of ischemia  can detect ischemia after 5-10 minutes  time consuming….cooperation issues  ECHO…echocardiography can identify source of cerebral emboli  identify patent foramen ovale 

28. THROMOLYTIC THERAPY  Selection criteria  inclusion  exclusion  relative exclusion  Time limit recently expanded to 4-5 hours  Balance against 6-7% incidence of cerebral hemorrhage with lytic Rx  Time of stroke onset can be difficult to pinpoint  HBP as an exclusion…>185S/>110D  labetalol, nicardipine, nitroprusside

29. THROMBOLYSIS  As early as possible  rtPA 0.9 mg/kg up to 90 mg  10% in 1-2 minutes/ remained over 60 minutes  No anticoagulant or antiplatelet agent for 24 hours  Then only SQ heparin for DVT prophylaxis  and  ASA 325 given 24-48 hours after CVA then 81 mg a day

31. OTHER THERAPY  Oxygen…if O2 is ok then no benefit  toxic oxygen metabolites promote cerebral vasoconstriction  only if sat < 94%  BP Control…HBP in 60-65% of CVAs  usually corrects in 48-72 hours  correction only id >220S/>120D or acute MI  labetalol, nicardipine, nitroprusside(can increase ICP)  Fever Control…fever in 30%  can be infection or due to tissue necrosis  intracranial blood  fever harmful to brain tissue

32. GUIDELINES REVIEWED AHA/ASA Guidelines for the early management of patients with acute ischemic stroke Stroke 2013 44: 870-947 AHA/ASA Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack Stroke 2014 45: 2160-2236 AHA/ASA Palliative and end of life care in stroke Stroke 2014 45: 1887-1916

33. Early Management of CVA  “5 suddens”….weakness, speech, visual loss, headache, dizziness  “FAST”…face, arm, speech, time

34. http://mmcneuro.files.wordpress.com/2013/01/stroke.gif

35. EMS  Prehospital Stroke Screen  LA prehospital Stroke Screen  Cincinnati Prehospital Stroke Scale  Stroke Center Transport  Primary Stroke Center  Comprehensive Stroke Center/neuro critical care  Emergency time…eval and begin fibrinolytic rx <60 min of ED arrival  NECT or MRI < 45 minutes  assess BG but no delay for ECG, CXR, troponin

36. General Support  Correct hypoxemia ?supplemental O2  Supine position  Cardiac Monitoring  BP control Intubation for unconsciousness or bulbar dysfunction Correct hypovolemia and hypoglycemia 140-180 Temperature < 38 degrees

37. rtPA {Alteplase}  With normal or early ischemic change on imaging  If frank hypodensity >1/3 MCA  no rtPA  Unclear use…mild deficits  improving CVA symptoms  surgery< 3 months  recent MI  Maybe harmful in pts on dabigatran, apixaban, rivaroxiban  Other lytics…not recommended (streptokinase) or investigational

38. rtPA  0.9 mg/kg up to 90 mg IV within 3 hours  Door to needle < 60 minutes  Can treat 3-4.5 hours with more exclusions  With BP control <185/110  Complications…angioedema, bleeding

39. Management Decisions  Endovascular interventions  inter-arterial rtPA…no FDA approval  mechanical thrombectomy  emergency angioplasty and stenting  Anticoagulation  within 24 hours of rtPA…not recommended  ASA 24 hours later ok  glycoprotein 2b/3a inhibitors not recommended  abciximab,eptifibatide, tirofiban

40. Management Decisions  Volume expansion, vasodilators, induced hypertension…no  Albumin, hemodilution…no  Some use of vasopressors to support BP  Neuroprotective agents  statins…should be continued, ? Started  hypothermia…not proven  transcranial infrared laser…no  hyperbaric oxygen….only for air embolism  drugs…EtOH, Magnesium, Caffeine…not established

41. General Care  Specialized Stroke Units  Infection therapy/DVT prophylaxis  Swallow eval before po intake  Early mobilization  No benefit to specialized nutritional therapy or prophylactic antibiotics  Surgical intervention…emergent CEA not established

42. Treatment of Complications  Brain edema/Increased ICP…peaks 3-4 days after CVA  restriction free water  avoid excess glucose  minimize hypoxemia and hypercarbia  treat hyperthermia  elevate HOB 20-30 degrees  avoid antihypertensive agents causing cerebral vasodilation  Treatment of increased ICP  hyperventilation, hypertonic saline, osmotic diuretics  Interventricular CSF drainage  Steroids not recommended  decompressive surgery…effective…decisions based on volume of tissue infarcted and midline shift

43. Treatment of Complications  Hemorrhagic transformation  within 24 hours of rtPA  most fatal hemorrhages within 12 hours  optimal management debated  ?cryoprecipitate  ? tranexamic acid  Seizures….standard anti-epileptic therapy  prophylactic anticonvulsants not indicated  Acute hydrocephalus  placement of ventricular drain  Palliative Care

44. Secondary Prevention of CVA  Control of Risk Factors  Intervention for vascular obstruction  Antithrombotic therapy for cardioembolic stroke  Antiplatelet therapy for noncardioembolic stroke  Special circumstances

46. Risk Factor Control  HBP…risk for CVA rises directly with BP>115 syst  No benefit to systolic <120  BP Rx if >140/90 several days post CVA  lacunar infarct – goal<130 syst  Lipids…statin to LDL-C <100  DM…screen all CVA patients with HgbA1C

47. Risk Factor Control  Obesity…BMI< 30 usefulness of weight loss uncertain for secondary prevention  Risk for CVA rises above BMI 20  Metabolic Syndrome…overweight, trig, low HDL-C, high BP, high BG  ….20% of adults over 20  Physical Inactivity … 40 minutes 3-4x a week  ….supervision by PT or Rehab after CVA  Nutrition…over or under, routine supplements not helpful  vitamins not helpful, Mediterranean diet possibly helpful

49. Risk Factor Control  OSA…very high incidence…sleep studies  Cigarettes…strong risk for 1 st CVA  second hand smoke increases risk  EtOH…light to moderate decreases 1 st ischemic CVA risk  increased risk of hemorrhagic CVA with any EtOH  heavy EtOH increases risk for both types

50. Extracranial Carotid / VertebrobasilarDisease  CEA for > 70% stenosis  Not recommended for < 50%  Carotid Angioplasty and stent vs. CEA  Older patients…CEA better  Younger…equivalent  Optimal Medical Therapy  Vertebrobasilar…medical therapy, BP lowering, lipid control  Stenting vs VB endarterectomy considered

51. Intracranial Disease and Cardioembolic Disease  Atherosclerosis…>50% ASA> warfarin  BP control and high Intensity statin therapy  >70% add clopidogrel for 90 days  Cardioembolism…Afib is main risk  warfarin, apixaban, dabigatran, for nonvalvular afib  rivaroxaban also reasonable  anticoagulation and antiplatelet Rx if CAD

52. Cardiac Disease  Acute MI/LV Thrombus…VKA for 3 months  or apixaban dabigatran rivaroxaban  Cardiomyopathy…LVAD…VKA  EF< 35% anticoagulation and antiplatelet  Valvular Heart Dz…MV Disease plus Afib…VKA  MV Disease without Afib…consider VKA  CVA/TIA on VKA…add ASA  Prosthetic Heart Valves…Mechanical AV/MV….VKA plus ASA 81  Bioprosthetic…ASA  if CVA …add VK

53. Non-cardioembolic CVA/ Aortic Arch/ ICH  Antiplatelet agents  ASA and dipyridamole or clopidogrel  ?Add VKA….unclear importance  Aortic Arch Atheroma  antiplatelet therapy and statin  VKA or surgery not recommended  Arterial Dissection  ??surgery …Antiplatelet therapy or anticoagulation considered  ICH…controversy…high risk of bleed…antiplatelet therapy  restart anticoagulation > 1 week

54. Other risks  PFO  Hyperhomocystinemia  Thrombophilia  Antiphospholipid antibodies  HbSS  Venous sinus thrombosis  Pregnancy risks  LMWH or UFH every 12 hours  or heparin until the 13 th week followed by VKA

56. Palliative/End of Life Care  2010…130,000 CVA deaths/ >5% of all deaths  50% in hospital  35% SNFs  15% home/other  20% of CVAs  to SNF  30% of CVAs  permanently disabled

57. Grief/ Pain/ Non-pain Issues  Anticipatory and acute grief  Complicated grief/depression…1-2 months later  more severe if acute loss  Pain…central post stroke pain….1-12%  hemiplegic shoulder pain  post-CVA spasticity  Non-pain…fatigue, incontinence, seizures, sexual dysfunction, sleep disordered breathing, depression, anxiety/delirium, emotional lability

59. Palliative Care/ Prognosis & Decision Making  “what is a good outcome”  Aspects of recovery most important to patient and family  Decision making…Surrogate Decision Makers  Cultural and Religious preferences  Bereavement Services Available  Preference Sensitive Decisions…DNR/DNI  Swallowing Care  Decompressive Craniectomy, etc.

61. Access to Palliative Care  Interdisciplinary  Collaborative/patient centered communication  Services available  Peace and dignity  Access…any CVA affecting daily functioning or reducing life expectancy  Goals of care…communication, best available science, acknowledge uncertainty, changes in preferences over time

62. A final Word…Paul Marino MD (2014)  Number of Strokes each year in US 700,000  Number of Ischemic Strokes (88%) 616,000  Number of Stroke Patients receiving lytic therapy 12,320  Number of pts who benefit from lytic Rx (1 in 9) 1,369  Percent of strokes that benefit from lytic RX 0.2%