STROKE John P. Connolly MD Medical Director, Resp

STROKE John P. Connolly MD Medical Director, Resp

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

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

TIA Less than 24 hours clinical reversibility 1/3 of TIAs are associated with cerebral infarction 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 CLASSIFICATION Ischemic Stroke 87% 80% thrombotic 20% embolic

Hemorrhagic Stroke 13% 97% intracerebral 3% subdural 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 Suspected CVA 30% will have another condition Seizures

Sepsis Metabolic encephalopathies Space occupying lesions ..in that order NIH Stroke ScaleNIHSS

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 IMAGING

CTreliable for intracranial hemorrhage close to 100% sensitive not sensitive for ischemic CVAespecially early MRIdiffusion weighted hyperdense regions of ischemia can detect ischemia after 5-10 minutes

time consuming.cooperation issues ECHOechocardiography can identify source of cerebral emboli identify patent foramen ovale 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 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 OTHER THERAPY Oxygenif O2 is ok then no benefit toxic oxygen metabolites promote cerebral vasoconstriction

only if sat < 94% BP ControlHBP 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 Controlfever in 30% can be infection or due to tissue necrosis intracranial blood fever harmful to brain tissue 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: 18871916 Early Management of CVA 5 suddens.weakness, speech, visual loss, headache, dizziness FASTface, arm, speech, time http://mmcneuro.files.wordpress.com/2013/01/stroke.gif 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 timeeval and begin fibrinolytic rx <60 min of ED arrival NECT or MRI < 45 minutes assess BG but no delay for ECG, CXR, troponin

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 rtPA {Alteplase} With normal or early ischemic change on imaging If frank hypodensity >1/3 MCA no rtPA Unclear usemild deficits

improving CVA symptoms surgery< 3 months recent MI Maybe harmful in pts on dabigatran, apixaban, rivaroxiban

Other lyticsnot recommended (streptokinase) or investigational 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 Complicationsangioedema, bleeding Management Decisions Endovascular interventions inter-arterial rtPAno FDA approval

mechanical thrombectomy emergency angioplasty and stenting Anticoagulation within 24 hours of rtPAnot recommended ASA 24 hours later ok

glycoprotein 2b/3a inhibitors not recommended abciximab,eptifibatide, tirofiban Management Decisions Volume expansion, vasodilators, induced hypertensionno Albumin, hemodilutionno

Some use of vasopressors to support BP Neuroprotective agents statinsshould be continued, ? Started hypothermianot proven

transcranial infrared laserno hyperbaric oxygen.only for air embolism drugsEtOH, Magnesium, Caffeinenot established 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 interventionemergent CEA not established Treatment of Complications Brain edema/Increased ICPpeaks 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 surgeryeffectivedecisions based on volume of tissue infarcted and midline shift 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 Secondary Prevention of CVA Control of Risk Factors Intervention for vascular obstruction

Antithrombotic therapy for cardioembolic stroke Antiplatelet therapy for noncardioembolic stroke Special circumstances Risk Factor Control HBPrisk 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 Lipidsstatin to LDL-C <100 DMscreen all CVA patients with HgbA1C

Risk Factor Control ObesityBMI< 30 usefulness of weight loss uncertain for secondary prevention Risk for CVA rises above BMI 20 Metabolic Syndromeoverweight, 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 Nutritionover or under, routine supplements not helpful vitamins not helpful, Mediterranean diet possibly helpful Risk Factor Control OSAvery high incidencesleep studies

Cigarettesstrong risk for 1st CVA second hand smoke increases risk EtOHlight to moderate decreases 1st ischemic CVA risk increased risk of hemorrhagic CVA with any EtOH heavy EtOH increases risk for both types

Extracranial Carotid / VertebrobasilarDisease CEA for > 70% stenosis Not recommended for < 50% Carotid Angioplasty and stent vs. CEA

Older patientsCEA better Youngerequivalent Optimal Medical Therapy Vertebrobasilarmedical therapy, BP lowering, lipid control Stenting vs VB endarterectomy considered

Intracranial Disease and Cardioembolic Disease Atherosclerosis>50% BP control and high Intensity statin therapy >70% add clopidogrel for 90 days

ASA> warfarin CardioembolismAfib is main risk warfarin, apixaban, dabigatran, for nonvalvular afib rivaroxaban also reasonable anticoagulation and antiplatelet Rx if CAD Cardiac Disease

Acute MI/LV ThrombusVKA for 3 months or apixaban dabigatran rivaroxaban CardiomyopathyLVADVKA EF< 35% anticoagulation and antiplatelet Valvular Heart DzMV Disease plus AfibVKA MV Disease without Afibconsider VKA

CVA/TIA on VKAadd ASA Prosthetic Heart ValvesMechanical AV/MV.VKA plus ASA 81 BioprostheticASA if CVA add VK 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 ICHcontroversyhigh risk of bleedantiplatelet therapy restart anticoagulation > 1 week Other risks PFO

Hyperhomocystinemia Thrombophilia Antiphospholipid antibodies HbSS Venous sinus thrombosis Pregnancy risks

LMWH or UFH every 12 hours or heparin until the 13th week followed by VKA Palliative/End of Life Care 2010130,000 CVA deaths/ >5% of all deaths 50% in hospital

35% SNFs 15% home/other 20% of CVAs to SNF 30% of CVAs permanently disabled Grief/ Pain/ Non-pain Issues

Anticipatory and acute grief Complicated grief/depression1-2 months later more severe if acute loss Paincentral post stroke pain.1-12% hemiplegic shoulder pain

post-CVA spasticity Non-painfatigue, incontinence, seizures, sexual dysfunction, sleep disordered breathing, depression, anxiety/delirium, emotional lability Palliative Care/ Prognosis & Decision Making what is a good outcome

Aspects of recovery most important to patient and family Decision makingSurrogate Decision Makers Cultural and Religious preferences Bereavement Services Available Preference Sensitive DecisionsDNR/DNI

Swallowing Care Decompressive Craniectomy, etc. Access to Palliative Care Interdisciplinary Collaborative/patient centered communication

Services available Peace and dignity Accessany CVA affecting daily functioning or reducing life expectancy Goals of carecommunication, best available science, acknowledge

uncertainty, changes in preferences over time A final WordPaul 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 Number of pts who benefit from lytic Rx (1 in 9) Percent of strokes that benefit from lytic RX 12,320 1,369 0.2%

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