1. When stroke strikes, strike the stroke. By Mikhail Serebrennik, MD Dept. of Radiology, Trinity Health

2. What is stroke? An act of hitting a small dimpled white ball with an iron club A high-voltage discharge of atmospheric electricity What this presenter almost had when he found out he wasn’t going to sleep in today

3. Correct terminology The word “stroke” is imprecise Ischemic infarction – death of tissue due to interruption of blood supply – Can be arterial, venous or due to hypotension/hypoxia – Distinction is important for workup and treatment – Arterial: atherosclerosis, vasculitis, embolus, spasm – Venous: dehydration, blood disorders (hypercoagulable state, polycythemia), infection (meningitis) – Hypotension/hypoxia: cardiac arrest, blood loss, drowning Intracerebral hemorrhage – HTN, amyloid angiopathy, trauma, coagulopathy, AVM Extraaxial hemorrhage is not included in this discussion

4. Signs and Symptoms Watch for these signs and symptoms if you think you or someone else may be having a stroke. Note when signs and symptoms begin, because the length of time they have been present may guide treatment decisions. Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination. Trouble with speaking and understanding. You may experience confusion. You may slur your words or be unable to find the right words to explain what is happening to you (aphasia). Try to repeat a simple sentence. If you can't, you may be having a stroke. Paralysis or numbness on one side of your body or face. You may develop sudden numbness, weakness or paralysis on one side of your body. Try to raise both your arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your mouth may droop when you try to smile. Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision, or you may see double. Headache. A sudden, severe "bolt out of the blue" headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke. Ref: Mayo Clinic website

5. Diagnostic tests History and physical examination; question witnesses. Cheap and effective but not enough to guide modern therapy. Look for what is missing! CT scan: very good for quick evaluation for hemorrhage. May not pick up very recent onset infarctions. MRI: sensitive to even hyper-acute infarctions (DWI) and very small hemorrhages (GRE/T2*). Can also do MRA head and neck while patient is in the magnet. Expensive, taxes time and resources.

6. But who cares? Infarcted tissue is dead and cannot be saved, right?

7. But who cares? Infarcted tissue is dead and cannot be saved, right? Yes, but…

8. More about infarctions ischemia

9. It’s all about the penumbra pen·um·bra noun \pə-ˈnəm-brə\ plural pen·um·brae or pen·um·bras Definition of PENUMBRA 1 a : a space of partial illumination (as in an eclipse) between the perfect shadow on all sides and the full light b : a shaded region surrounding the dark central portion of a sunspot 2 : a surrounding or adjoining region in which something exists in a lesser degree : fringefringe

10. Restricted diffusion = dead brain 1.Interruption of blood supply 2.Membrane failure (No ATP – breakdown of Na-K pump – Na stays in cells – cells suck in water and undergo cytotoxic edema) 3.Cells swell up, intercellular space shrinks 4.Water molecules cannot move and 5.They return signal to receiver

11. Diffusion-perfusion mismatch Radiologyassistant.nl

12. What goes on in the affected brain

13. Pay attention to detail, document, communicate Time is brain Early diagnosis is key Keep your mind, eyes and hands on the patient Take notes and compare them with prior notes to find subtle changes Communicate with the treating physician!

14. Case 1 89 y.o. male with syncope

15. Case 1 MRI performed, DWI

16. Case 1 US carotid

17. Society of Radiologists in Ultrasound 2003 Consensus Panel Gray-Scale and Doppler US Criteria for Diagnosis of ICA Stenosis

18. Case 1 10 days later Before stent

19. Case 1 After stent

20. Case 1 After stent US

21. How is the brain perfused? http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case4/CerebralCirc.htm

22. How is the brain perfused? http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case4/CerebralCirc.htm

23. Where is perfusion the weakest? http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case4/CerebralCirc.htm

24. At the watershed zones. http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case4/CerebralCirc.htm

25. Case 2 52 y.o. male, agonal respirations

26. Case 2 Acute or chronic?

27. Case 2

29. Case 2 CT cannot always tell acuity. Use DWI and ADC mapping

30. Case 2 T2 and FLAIR do not differentiate between acute and chronic Now go back and check the ADC map again…

31. Case 2 5 days later…

32. Case 2 Understand tissue at risk!

33. Case 3 84 yo male AMS, confusion

34. Case 3

38. Case 3 – 10 days later…

39. Case 4 – 36 y.o. female

40. Case 4

43. Not much on the CT, but…

44. Case 4

45. OK, maybe something on DWI/ADC… Anything on MRA?

46. Case 4

49. Case 4 – two weeks later…

51. Is there anything?

52. Case 4 – two weeks later… Yes.

53. Case 4 – two weeks later… There is.

54. Case 4 – two weeks later… By the way… Did you see this?

55. Case 4 – But why is this happening?

56. Ahh, I see…

57. Case 4 – 2 more days…

58. Case 4 – another 6 days.

59. Case 4 – diagnosis? ?

60. Case 4 Wallenberg’s syndrome is a neurological condition caused by a stroke in the vertebral or posterior inferior cerebellar artery of the brain stem. Symptoms include difficulties with swallowing, hoarseness, dizziness, nausea and vomiting, rapid involuntary movements of the eyes (nystagmus), and problems with balance and gait coordination. Some individuals will experience a lack of pain and temperature sensation on only one side of the face, or a pattern of symptoms on opposite sides of the body – such as paralysis or numbness in the right side of the face, with weak or numb limbs on the left side. Uncontrollable hiccups may also occur, and some individuals will lose their sense of taste on one side of the tongue, while preserving taste sensations on the other side. Some people with Wallenberg’s syndrome report that the world seems to be tilted in an unsettling way, which makes it difficult to keep their balance when they walk.

61. Thank you! Questions or comments: ms2606@gmail.com (701) 857-5220