1. Acute Stroke Evaluation Gabriel A. Vidal, MD Vascular Neurology Ochsner Medical Center October 14 th, 2009

2. Objectives Review the history of stroke Discuss importance of evaluation of strokes emergently Summarize important historical data about strokes Briefly present the acute treatment options Describe acute stroke and TIA measuring scales Identify a basic group of tests that should be done urgently for the evaluation of acute strokes Compare acute stroke to stroke mimics

3. History of Stroke Hippocrates (460 to 370 BC) was first to describe the phenomenon of sudden paralysis that is associated with ischemia –Apoplexy, from the Greek word meaning "struck down with violence”, first appeared in Hippocratic writings to describe this phenomenon 2,3 In 1658, in his Apoplexia, Johann Jacob Wepfer (1620–1695) identified hemorrhagic stroke –Identified the main arteries supplying the brain –Identified the cause of ischemic stroke when he suggested that apoplexy might be caused by a blockage to those vessels. 1

4. Epidemiology Second leading cause of death in the Western world –After heart disease and before cancer 4 –Causes 10% of deaths worldwide 5 –Disability affects 75% of stroke survivors enough to decrease their employability 6 –30 to 50% of stroke survivors suffer post stroke depression 7 Prior to 1995 there were no acute therapies for acute stroke

5. Important Medical History History of the Present Illness –Time of symptom onset –Evolution of symptoms –Convulsion or loss of consciousness at onset –Headache –Chest pain at onset Medical History –Prior intracerebral hemorrhage –Recent stroke –Recent head trauma or loss of consciousness –Recent myocardial infarction Surgical History –Recent surgical procedures –Arterial puncture Review of Systems –Gastrointestinal or genitourinary bleeding Medications –Anticoagulant therapy

6. Time of Symptom Onset Patient last seen acting normal –Patient may have mild symptoms at onset Difficult onset –Patient woke up with symptoms  LKN: when he went to bed (if seen by someone) =Specially if aphasic –Patient seen well while resting  LKN: before he went to rest (if seen by someone)

7. Why is TIME so IMPORTANT? Time directed therapeutics –Improved outcomes –Reduced complications What if the patient goes back to normal while in the ER and symptoms re-start? –Clock re-starts

8. Identifying Stroke Syndromes

9. Acute Therapies IV t-PA –(1995) NINDS t-PA trial  IV t-PA given within 3 hours of onset of symptoms  30% relative risk reduction of disability at 3 months  6% symptomatic hemorrhagic complication –(2008) ECASS-III  IV t-PA given within 4.5 hours of onset of symptoms  Significantly better outcomes with IV t-PA vs placebo without more complications  Selected patients –(2009) Analysis of ECASS-III  Benefit per 100 patients treated was 16.3 and harm per 100 was 2.7

11. Other Therapies IA t-PA –Can be used up to 6 hours Mechanical thrombectomy –MERCI & PENUMBRA –May be used up to 8 hours for MCA strokes & up to 12 hours for basilar artery strokes Combination (IV t-PA w other therapies) –Promising results –In clinical trials (IMS III)

12. NIH Stroke Scale Systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit Originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials Widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome Valid for predicting lesion size and can serve as a measure of stroke severity 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction

13. NIH Stroke Scale 1a. Level of Consciousness (0-3) 1b. LOC Questions (0-2) 1c. LOC Commands (0-2) 2. Best Gaze (0-2) 3. Visual (0-3) 4. Facial Palsy (0-3) 5 & 6. Motor Arm and Leg (0-4) 7. Limb Ataxia (0-2) 8. Sensory (0-2) 9. Best Language (0-3) 10. Dysarthria (0-2) 11. Extinction and Inattention (formerly Neglect) (0-2)

15. Other Scoring Scales Cincinnati Stroke Scale Los Angeles Prehospital Stroke Screen (LAPSS) ABCD2 Score –Predicts risk of stroke in patients with TIA

16. ABCD 2 Score

17. Basic Stroke Labs CBC w diff –Platelet count may affect therapy CMP –Blood sugar  stroke mimics –Renal function  contrast, BP management –Liver function  statins, coagulation profile Coagulation times –PT, PTT, INR  coagulopathies, anticoagulation therapy, contraindications of certain therapies based on INR values

18. Imaging CT head –Ischemic vs hemorrhagic CT Angiogram –Head and neck MRI brain MR Angiogram –Head and neck Conventional angiography

19. Stroke Mimics Post-ictal deficits (Todd paralysis) Hypoglycemia Migraine (hemiplegic, with aura) Hypertensive encephalopathy Reactivation of prior deficits Mass lesions Subarachnoid hemorrhage Peripheral vestibulopathy Conversion reaction Non-convulsive status epilepticus (basilar stroke) Metabolic encephalopathies

20. References 1. National Institute of Neurological Disorders and Stroke (NINDS) (1999). "Stroke: Hope Through Research". National Institutes of Health. National Institute of Neurological Disorders and Stroke (NINDS)Stroke: Hope Through Research 2. Thompson JE (01 Aug 1996). "The evolution of surgery for the treatment and prevention of stroke. The Willis Lecture". Stroke 27 (8): 1427–34.The evolution of surgery for the treatment and prevention of stroke. The Willis Lecture 3. Kopito, Jeff (September 2001). "A Stroke in TimeA Stroke in Time 4. Donnan GA, Fisher M, Macleod M, Davis SM (May 2008). "Stroke". Lancet 371 (9624): 1612–23. 5. The World health report 2004. Annex Table 2: Deaths by cause, sex and mortality stratum in WHO regions, estimates for 2002. Geneva: World Health Organization. 2004. The World health report 2004. Annex Table 2: Deaths by cause, sex and mortality stratum in WHO regions, estimates for 2002. 6. Coffey C. Edward, Cummings Jeffrey L, Starkstein Sergio, Robinson Robert (2000). Stroke - the American Psychiatric Press Textbook of Geriatric Neuropsychiatry (Second ed.). Washington DC: American Psychiatric Press. pp. 601–617. 7. Senelick Richard C., Rossi, Peter W., Dougherty, Karla (1994). Living with Stroke: A Guide for Families. Contemporary Books, Chicago.