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%
