Stroke

Definition

Stroke is a sudden brain dysfunction due to a blood vessel problem

Stroke in the United States

Over 780,000 people suffer a stroke in the US each year

By 2020, expected that 1,000,000 Americans will suffer a stroke each year

168,000 deaths per year

Stroke in the United States

Someone has a stroke every 45 seconds

1/3 die, 1/3 become disabled, 1/3 recover

5,800,000 stroke survivors in the US today

3rd leading cause of death – WRONG!!!!

Stroke is now the 5th leading cause of death because of the recognition of signs/symptoms of stroke and early treatment. YOU played a role in decreasing this as a cause of death in the United States!

Emergency Stroke Care

It is a myth that there is not much that can be done for stroke victims

Progress in stroke management has led to:

Improved patient outcomes

Shorter length of hospitalizations and rehabilitations

Decreased referral to nursing homes

Sooner and more frequent return to the work force

Decrease in the incidence of recurrent stroke

Walk vs Cane vs Wheelchair

Pre-Hospital Care

Pre-Hospital care does count!

Responsibilities include obtaining accurate history of symptoms, basic data, physical exam including CPSS, communication with ALS ambulance and notification of the receiving hospital of “stroke code”

Strokes should be looked at with as high a priority as an MI

Ischemic Stroke

Accounts for 80% of all strokes

Most caused by a blood clot that forms in the heart or vascular system and travels up to the brain and plugs an artery

Ischemic Stroke

Most common source of blood clot:

Heart – due to atrial fibrillation, poor ventricular function, or other structural abnormalities

Large arteries like the carotid arteries

Small arteries in the brain damaged by atherosclerosis or other damage

Blood – due to clotting disorders or abnormalities

Hemorrhagic Stroke

Accounts for about 20% of all strokes

Due to blood vessel rupture within the skull not due to trauma

Intracerebral or subarachnoid

Intracerebral Hemorrhage

Defined as bleeding into the brain tissue

Most common cause is chronic hypertension

Other causes include vessel malformation, tumor, and bleeding abnormalities.

Subarachnoid Hemorrhage

Occurs when a blood vessel ruptures and blood spills into the subarachnoid space – between the pia mater and arachnoid membrane

Most common cause is rupture of an aneurysm

Other non-traumatic causes include vessel malformation, tumor, bleeding abnormalities.

Transient Ischemic Attack (TIA)

Ischemic stroke that completely resolves (1 hour)

“Angina” of the brain

Most common cause is thromboembolism

Most patients will go on to have a stroke or recurrent event within 3 months

Transient Ischemic Attack

Among TIA patients who go to ED

5% have stroke w/in 2 days

10% have stroke w/in 3 months

25% have recurrent “event” w/in 3 months

Who is not listed above?!!!

Ischemic Stroke Risk Factors - Nonmodifiable

Advanced age

Male gender

Race (Blacks have nearly 2x risk of first-ever stroke)

Family history of MI or early stroke

Ischemic Stroke Risk Factors - Modifiable

HTN

DM

Hypercholesterolemia

Cigarette smoking

Prior stroke/TIA

Carotid disease, heard disease (a. fib.)

Hypercoagulable states

Cocaine, excessive alchohol

Time is Brain!!!

When a blood vessel is occluded, there is a core of irreversible damage

The penumbra constitutes the zone of reversible ischemia which is salvageable in the first few hours

The most effective agent in saving the penumbra at this time is t-PA

If t-PA is given within 3 hours (even 4.5 hours), the risk of disability is reduced by 30%

The sooner t-PA is given, the better the outcome

The goal for hospitals is to administer TPA within 60 minutes of diagnosing a TPA stroke candidate.

Major Divisions of the Brain

Cerebral cortex (Gray matter) is the computer center of the brain. It consists of nerve cells that control complex functions such as language, mathematics, artistic ability, etc.

Cerebral subcortex (White matter) is composed of nerve fibers that connect the cerebral cortex to the brain stem

Brainstem connects cerebrum and the spinal cord. It contains the cranial nerves to the face and head

Cerebellum coordinates movement

Major Stroke Syndromes

Based on location in the brain

1. Left Hemisphere

2. Right Hemisphere

3. Brainstem

4. Cerebellum

5. Possible Hemorrhage

Left Hemisphere

Controls the movement and sensation of right side of the body

Stroke in Left Hemisphere results in:

o Aphasia

o Right visual field deficit

o Left gaze deviation/preference

o Right hemiparesis

o Right hemisensory loss

Right Hemisphere

Controls the movement and sensation of the left side of the body. It also controls perceptual and spatial abilities.

Stroke in Right Hemisphere results in:

o Left hemi-inattention or neglect

o Left visual field deficit

o Right gaze deviation/preference

o Left hemiparesis

o Left hemisensory losss

Speech should be Fine!

Brainstem

Strokes that occur in the brain stem can be especially devastating due to the compact nature of the area.

Stroke in the Brainstem results in: Eye movement abnormalities – diplopia, dysconjugate gaze,

gaze deviation

Nausea, vomiting, vertigo and tinnitus

Dysarthria – difficulty making speech due to weakness of the muscles of oropharynx

Dysphagia –difficulty swallowing due to weakness of the muscles of the oropharynx

Decreased consciousness

Abnormalities of respirations, pulse, blood pressure possible

Cerebellum

Controls balance and coordination

Strokes in the Cerebellum results in:

Ataxia or dyscoordination

Patients usually have imbalance and walk with a wide-based gait

Hemorrhagic

Cranium is a hard container enclosing brain

Meninges are 3–layered cloth-like coverings of brain and spinal cord

Hemorrhagic stroke suddenly increases intracanialpressure

Hemorrhagic stroke can cause:

Headache

Nausea/vomiting

Decreased level of consciousness

Hemorrhagic

Symptoms suggestive of subarachnoid hemorrhage not usually found with intracerebral hemorrrhage or ischemic stroke:

Intolerance to light

Neck stiffness/pain

Symptoms suggestive of intracerebral hemorrhage:

Focal signs such as hemiparesis (similar to ischemic stroke)

Stroke Mimics

Hypoglycemia – 12.5 g vs 25 g of Dextrose

Posticial state after seizure

Migraine

Tumors

Abscess

Subdural hematoma

CT Scan

Needed for all patients presenting with stroke or stroke symptoms

Necessary prior to administration of thrombolyticsfor stroke

7 D’s: Chain of Survival and Recovery

Detection: stroke onset

Dispatch: EMS activation and response

Delivery: prehospital care to hospital

Door: ED triage

Data: ED evaluation, CT scan

Decision: potential therapies

Drug: therapy – t-PA within 4.5 hours (new treatment options as well)

Pre-Hospital Stroke Care Principles

First do no harm – avoid having glucose, avoid treating hypertension, avoid causing aspiration pneumonia

Report to ED – details of symptom onset, neurologic exam, witness information

Glucose

The rule: Do NOT give glucose-containing solutions to acute stroke patients

Hyperglycemia can worsen patient outcomes, and decreases t-PA efficacy

The exception: Hypoglycemic by fingerstick

(60 dl/mg)

Hypertension

The rule: EMS should not treat hypertension in acute stroke patients

Aspiration Pneumonia

Dysphagia, or difficulty swallowing is a major stroke complication and a poor prognostic sign.

1/3 of patients with dysphagia develop aspiration pneumonia – major cause of morbitdity and mortality

Keep all acute stroke patients NPO and elevate the head of the bed 30◦, turn to side if vomiting.

Oxygen

Goal is to maintain normal oxygen saturations (95%)

Routine use of oxygen has not been shown to of benefit in patients who are not hypoxic

Current recommendations is to give low-flow (2-4L/min).

On-Scene Care

Stroke history and symptom onset

Perform Stroke exam

Prevent aspiration

Prevent hypoxia

Do not delay transport!

En Route Care

Transport urgently

Obtain IV access

Glucose if level less than 60

Screen for t-PA contraindications

Notify ED of possible stroke patient

Cincinnati Pre-Hospital Stroke Scale

Speech

Facial Droop

Arm Drift

t-PA Contraindications

Symptom onset more than 4.5 hours

Head trauma or seizure at onset

Recent surgery, hemorrhage, or AMI

Any history of intracranial hemorrhage

Minor or resolving stroke

Sustained BP > 185/110

MEND Exam

Miami Emergency Neurologic Deficit Exam

3 Parts – Mental Status, Cranial Nerves, Limbs

Mend Exam – Mental Status

Level of Consciousness

Speech (CPSS)

Questions – age and month

Commands – open and close eyes

Aphasia – wrong or inappropriate words

Dysarthria – Slurred Speech

MEND Exam – Cranial Nerves

Facial Droop (CPSS)

Visual Fields

Horizontal Gaze

MEND Exam - Limbs

Motor – Arm Drift (CPSS)

Motor – Leg Drift

Sensory – Arm and Leg

Coordination – Arm and Leg

Information for ED

Basic Data – Age, Gender, Chief Complaint

Symptom Onset – Last time without symptoms, Head trauma, Severe headache, Seizure

Supplemental Information – Recent surgery, trauma, MI, Medications, allergies, BP, Glucose, Witness name, contact info

Neurologic Exam – Consciousness, Speech/language, Visual fields, motor strength

TIME IS BRAIN – SAVE THE PENUMBRA!