Stroke Diagnosis, Evaluation, And Treatment of

7/27/2019 Stroke Diagnosis, Evaluation, And Treatment of

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2 broad categories of stroke:

Ischemia

Inadequate blood supply (oxygen & nutrients) to an areaof the brain

Hemorrhage-

Leakage of blood into the closed cranial cavity

Direct damage to tissue by compression/edema


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Incidence

~700K per year (~200K are recurrent)

80-90% are ischemic Male:Female ratio 1.25:1

Ratio reverses after age 80

Higher rates in Blacks, Hispanics, & NativeAmericans


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Heart disease

AFib, Valvular Dz, MI, endocarditis

Hypertension

Smoking Diabetes/Metabolic Syndrome Dyslipidemia Pregnancy Drug Abuse/Meds Bleeding Disorders/Anticoagulant Use


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Thrombosis In situ arterial obstruction

Arteriosclerosis, dissection, FMD

Superimposed thrombosis

Embolism Arterial obstruction from debris from another

source Systemic Hypoperfusion

Circulatory collapse

Multiorgan involvement


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Large Vessel Disease

Common & InternalCarotids

Circle of Willis & proximalbranches

Small Vessel Disease

Penetrating arteries

Lacunar Stroke

Stuttering course
http://en.wikipedia.org/wiki/Image:Gray513.png


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Cardiac Atrial fibrillation

Heart valves, atrial thrombus, recent MI, dilatedCM, endocarditis, recent CABG Aortic Arterial (e.g. carotids)

Other/Unknown DVT- Paradoxical embolus

Abrupt onset, rapid improvement


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Shock

Cardiogenic, septic, hypovolemic

Sx are more diffuse/nonfocal Border-zone regions

Cortical blindness

Stupor Proximal Weakness


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IntracerebralHemorrhage (ICH) Bleeding within the brain

tissue Forms a hematoma

Growth stopped bytamponade or leaking intothe ventricles or CSF

Headache, vomiting,delirium

Progressive sx


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HTN Trauma Bleeding Disorder

Inherited Acquired, i.e. meds

Amyloid

Drug use

Cocaine

Amphetamines

AVMs Bleeding into tumor Vasculitis


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SubarachnoidHemorrhage (SAH)

Bleeding into CSF on outer

aspect of brain Quick rise in ICP

Sudden onset headache in97%

Aneurysm & AVMs aremost common cause
http://www.strokecenter.org/pat/viewer/sah/sah_coronal_berry_2_500.jpg


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Seizure with ToddsParalysis

Syncope

Migraine Head Trauma Brain tumor

Metabolic Causes

Hypoglycemia

Hyponatremia

Intoxication Uremia/ARF

Hepatic Encephalopathy

Conversion Disorder


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Vital signs

Temperature, Pulse, Blood Pressure

Pulses Carotid Bruit Cardiac Exam Funduscopic exam Skin exam Signs of trauma


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Neurologic Exam

Level of consciousness/GCS

Language/Speech Cranial nerves

Vertigo, diplopia, ataxia

Visual deficits Weakness/Paralysis

Reflexes/ Babinski


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Patients are awarded points based on eye opening, best verbal response,and best motor response. The patient's GCS score can range from 3/15 to15/15

Eye opening score: 4, eyes open; 3, eyes open to speech; 2, eyes open inresponse to pain; 1, no eye opening

Best verbal response score: 5, alert and oriented; 4, confused; 3,responds with inappropriate words; 2, makes incomprehensible sounds;1, no verbal response

Best motor response score: 6, obeys commands; 5, localizes pain; 4,responds to pain with normal flexion/withdrawal; 3, responds to pain

with abnormal flexion; 2, extends in response to pain; 1, no response topain


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CBC with platelets Electrolytes, Bun, Cr Glucose

LFTs PT/PTT O2 Sat ECG Chest XRay

ESR Blood Cultures ANA

Tox screen Alcohol level Blood type & cross Urine/Serum HCG Hypercoaguability Profile


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CT Scan

R/O Bleed

Sensitivity much better after 24 hrs forischemic stroke

Early signs (


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MRI

T1/T2 images, DWI

Provides immediate

evaluation of ischemia Not available for

emergency use in manysettings


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Carotid U/S for stenosis If ASVD, but no stenosis

Risk Factor Modification If stenosis, consider

Carotid Endarterectomy

?Carotid Stenting Vertigo & Syncope are not considered

symptomatic


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100% occlusion

No treatment

70-99% occlusion

If good 5-yr survival & risks


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Sudden onset of neurologic dysfunction thatlasts less than 24 hrs, brought on bypresumed transient ischemia to a portion ofthe brain

May be better to describe as sx


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Transient Sx Associated with Infarction No established diagnostic criteria

In one case series, 15% of TSI pts had arecurrent stroke in-hospital vs. 0% in TIAgroup.


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Could consider home if able to expediteurgent outpatient work-up

AHA does not make a recommendation re:hospitalization One study suggested cost-effective if 24-hr

stroke risk is >5%


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NASCET trial suggested 90-day stroke risk of 20% with non-retinal TIAs (higher than for true stroke)

2000 JAMA study

5% risk w/in 2 days 11% risk w/in 90 days

Higher risk with age >60, DM, sx >10 min, weakness, speechimpairment

2004 Neurology study: 21% risk of stroke/MI/death within 1

year of TIA


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Age >60 = 1 pt Blood Pressure >140/90 = 1 Clinical Features

Unilateral weakness = 2 Isolated speech deficit = 1

Other = 0

Duration

>60 minutes = 2

10-59 minutes = 1


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Risk factor modification Antithrombotic therapy

Anticoagulant therapy


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Hypertension

Goal 80 may not benefit as much & aggressive BP

lowering may increase mortality

Diuretic +/- ACEI as 1st line


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Smoking

Stop it

Diabetes

Goal A1c


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Dyslipidemia

Evidence not as strong as may think, but still a

good idea, especially given other vascular disease SPARCL Study

Atorvastatin 80 mg/day in pts 1-6 months from CVA/TIA

Mean LDL reduction 56

Endpoint was stroke: 16% RRR, but only 2.2% ARR (NNT~50)


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Dyslipidemia, continued

For average-risk patient, goal LDL


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Lifestyle Modification

Weight loss

Exercise Dietary changes

Reduce alcohol intake, especially heavydrinkers

?Homocysteine

Consider B12, B6, Folate (MVI doses OK)


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Aspirin

20-25% reduction in stroke (& MI or other vascular

death) Standard doses of 81-325 mg as good as higher

doses

81 mg dose just as good and less risk of bleeding

ASA-non-responders?


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Clopidogrel (Plavix)

8% RRR vs. ASA for stroke/MI/Vasc death

5.3% vs. 5.8%: NNT ~200 All for only $100+/month

?2nd-line therapy or ASA-allergic patients

No increased bleeding vs. ASA, but combo should

be avoided

No neutropenia (like ticlopidine)


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Dipyridamole

Alone 50-100 mg TID

Aggrenox (200mg ER-DP & 25mg ASA) BID 2 studies have shown ~3% ARR (NNT 33) over ASA

alone for stroke prevention

Some guidelines are suggesting this a 1st line

therapy over ASA alone for stroke prevention

Cost >$100/month


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Warfarin has only been proven effective inprimary prevention of stroke in the setting ofatrial fibrillation

AF is responsible for 1/6th of all strokes inpatients older than 60

Risk reduction

Warfarin about 3 times as effective as ASA Absolute annual risk reduction of ~3%

Low Risk patients may consider ASA rx


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Highest Risk: Prior Stroke or TIA High Risk: Any of the following

Prior thromboembolism Female >75 yo

SBP >160

Heart failure

Moderate Risk: None of above, but HTN Low Risk: None of the above, no HTN


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Thrombolysis Blood Pressure Management

Antithrombotic Therapy Management of Medical Complications


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Time-sensitive

Studies show that thrombolytics must be given

within 3 hours of symptom onset

Effective

NINDS- Complete or near-complete recovery at 3

months post-event (38% vs. 21%, NNT=6)

No difference in mortality

Harmful

At least 6% risk of ICH


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Alteplase (tPA) 0.9 mg/kg dose up to 90 mg

10% as IV bolus, then 60 min infusion Multiple exclusion criteria Obtain informed consent (if possible)

"There is a treatment for your stroke called alteplase that must be given within three hours

after the stroke started. It is a 'clot-buster' drug that can lead to a complete or near-completereversal of a stroke in about one of every three patients treated. However, it has a major risk,since it can cause severe bleeding in the brain in about one of every 15 patients. If bleedingoccurs in the brain, it can be fatal. When used to treat large numbers of stroke patients, onaverage the potential benefits of this treatment outweigh the risks; however, in anyindividual patient it is a very personal decision."


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Stroke/head trauma


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Guidelines for In-Hospital Evaluation Physician Evaluation: 10 minutes

Stroke Team Contact: 15 minutes

Imaging: 25 minutes

Interpretation: 45 minutes

Thrombolysis Started: 60 minutes

?Coagulopathy- Dont wait for labs unless onCoumadin, Heparin, or Dialysis


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Early Treatment

Less severe symptoms

Younger Age Lack of systolic HTN Normoglycemia


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Blood flow in dilated, post-obstructive bloodvessels is BP-dependent

Aggressive BP lowering canincrease

mortality In one study, a fall in SBP >20 in first 24 hrs

was the most likely factor associated with

neurologic deterioration This does NOT apply to hemorrhagic stroke


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Do not treat BP unless >220/120, unless Given thrombolytics (goal


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ASA

IST- ASA 300 mg within 48 hrs

Reduced 14 day recurrent stroke (NNT=100)

Reduced nonfatal stroke & death (NNT=100)

CAST- ASA 160 mg within 48 hrs

Reduced mortality at 4 weeks (NNT=166)

Slight increased risk of hemorrhagic stroke


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Heparin (LMWH) No clear benefit over ASA alone

Reduced recurrent ischemic strokes by 9/1000 patients,

but increased hemorrhagic strokes by same number

?Effective in some subsets

Stroke-in-evolution or Progressive Stroke

Many patients show neurologic deterioration in 1st

24hrs

No studies effectively define this population or prove abenefit


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Acute Coronary Syndromes/Heart Failure Infections

Aspiration pneumonia UTI

Venous thromboembolism Consider DVT prophylaxis for all patients

SCDs for pts with bleeds Heparin or Lovenox SQ for others

Malnutrition/Dehydration (consider Adv Directives) Decubitus ulcers Contractures

CONSIDER EARLY MOBILIZATION IN ALL PATIENTS!


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Accounts for ~8% of all strokes Presenting sx

Headache (~50%) Seizures (7-9%)

Delirium/Altered LOC

Focal neuro sx (depends on area of brain)


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Mortality 35-50%

Half of deaths in 1st 24 hours

Prognosis Size & location of hemorrhage

Age

Glasgow Coma Score

Comorbid conditions

Prior antiplatelet/anticoagulant therapy


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Neurosurgery Constant monitoring

Bedrest Pain control Reverse coagulopathies

Vitamin K, Fresh Frozen Plasma, Platelets

ICP control

Mannitol, Induced Coma, Hyperventilation


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Blood pressure management Surgery

Indicated for cerebellar bleeds >3 cm Supratentorial bleeds more controversial

Depends on size, location, LOC, comorbidities

Recombinant activated factor VII

(rFVIIa) therapy Small studies show promise, but concern for pro-

thrombotic effects
http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833http://www.ncbi.nlm.nih.gov/pubmed/16972833


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High mortality rate, ~50%

10% pre-hospital

25% within 24 hrs 45% within 30 days

Prognostic Factors

Level of consciousness

Age

Amount of blood on CT


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Diagnosis

Head CT

(+) in 92% of cases w/in 24 hrs

Most sensitive in first 12 hrs

Lumbar Puncture

Not necessary for diagnosis but consider if clinical

suspicion & negative head CT Elevated pressure & RBCs

Xanthochromia: pink/yellow tint due to RBC breakdown


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Neurosurgical ICU Constant monitoring Bedrest Pain control Reverse coagulopathies DVT Prophylaxis (SCDs)

Blood Pressure Management Management of Aneurysms/AVMs

Stroke Diagnosis, Evaluation, And Treatment of

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