Stroke Looking Out, While We Are Looking In

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Stroke Looking Out, While We Are Looking In

  1. 1. Jeremy Blanchard, MD, FCCP Kadlec Medical Associates Intensivist Program, Medical Director
  2. 2.  Introduction: the importance of stroke  Clinical presentation: recognition and the pre- hospital care  Triaging stroke  Etiology of stroke  Treatment options  Summary
  3. 3.  It is estimated 700,000 people in the U.S. have a stroke each year.  200,000 of these are reoccurring strokes  This does not account for TIA’s (transient ischemic attacks).  Stroke is the 3rd leading cause of death in the U.S. and the leading cause of adult disability. Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  4. 4.  The total cost of stroke from 2005-2050 in 2005 dollars is projected to be over $2.2 trillion. Brown, et al. Projected Costs of Ischemic Stroke in the United States. Neurology 2006; 67:1390-1395.
  5. 5.  The definitions differentiating stroke and TIA are of less importance because the they are representative of different degrees of disability of the same disease process and require the same interventions for prevention of a second episode.  If the neurological deficit lasts less than 24 hours then the episode is defined as a TIA, if greater then 24 hours then it is defined as a stroke. Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  6. 6.  Importance of definitions:  It allows the inclusion of a homogenous population in a clinical research trial.  Essential for validity of results  Thus, these definitions effect the care we provide.  New definition of TIA: “a brief episode of neurological dysfunction caused by a focal disturbance of brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of infarction. •Albers, et al. Transient Ischemic Attack: Proposal for a New Definition. NEJM 2002; 284:2901-2906. •Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  7. 7.  Hypertension (HTN)  It is estimated 50 million Americans have HTN.  30-40% stroke risk reduction with blood pressure (BP) lowering.  Systolic BP reductions have been associated with:  Weight loss  Consumption of a diet rich in fruits, vegetables, and low fat dairy products  Regular aerobic physical activity  Limited alcohol consumption Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  8. 8.  Diabetes Mellitus  Present in 15-33% of patients presenting with stroke.  Lipids  Unlike heart disease the clinical research done in stroke has shown only a weak association between forms of hyperlipidemia and stroke occurrence.  AHA recommends treatment with lipid lowering drugs as standard care, especially in patients with CHD or symptomatic atherosclerotic disease with a comorbid stroke. Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  9. 9.  Cigarette Smoking  There is strong and convincing evidence that cigarette smoking is a major independent risk factor for stroke.  This risk is present in all ages, sexes, and among different racial/ethnic groups.  Randomized, controlled trials are not available because of ethical issues.  The risk of stroke decreases with cessation of smoking and is gone in five years. Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  10. 10.  Alcohol Consumption  Controversial  Evidence exists that chronic, heavy drinking is associated with all types of stroke.  No more than 2 drinks per day for men and 1 drink per day for nonpregnent women may be associated with a reduced risk of stroke. Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  11. 11.  Cincinnati Pre-hospital Stroke Scale (CPSS)  Tests 3 physical findings: 1. Facial droop (have patient smile or try to show teeth) a. Sometimes comparing to a picture (drivers license can be helpful) 2. Arm weakness (synonymous with pronator drift, have the patient close their eyes and hold out both arms) 3. Abnormal speech (have patient say, “you can’t teach an old dog new tricks”)  One finding on the CPSS indicates 72% probability of stroke, three abnormal findings increase probability to 85%. American Heart Association. Advanced Cardiovascular Life Support: Professional Provider Manual . Copy right 2005.
  12. 12.  Los Angeles Pre-hospital Stroke Screen (LAPSS)  Six criteria: age > 45 yrs., Lack of a history of seizures, duration of symptoms < 24 hours, patient not normally wheel chair/bed bound, blood glucose between 60-400, obvious asymmetry (unilateral) in smile/grimace, grip or arm strength (pronator drift).  If all six are answered yes there is a 97% chance of stroke. American Heart Association. Advanced Cardiovascular Life Support: Professional Provider Manual . Copy right 2005.
  13. 13.  Identify Signs and Symptoms-CPSS, LAPSS  Support ABCs-Oxygen if needed  Establish time of stroke if possible-essential for future treatment options  The last time the patient was known to be normal or at neurological baseline.  Alert hospital  Assess neurological status-initial and monitor during transport.  Check glucose American Heart Association. Advanced Cardiovascular Life Support: Professional Provider Manual . Copy right 2005.
  14. 14. Exam is consistent with stroke , CT of Head, no evidence of hemorrhage Supportive care Therapy Options: •Intravenous thrombolytics •Intra-arterial thrombolysis •Mechanical clot disruption
  15. 15.  Extracranial carotid disease  For patients with recent TIA or stroke within the last 6 months and ipsilateral severe (70-99%) stenosis, a carotid endarterectomy by a surgeon with a < 6% perioperative morbidity and mortality is recommended.  Extracranial vertebrobasilar disease  Endovascular treatment with stents, angioplasty or coiling may be considered for repeating symptoms despite medical therapy. Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  16. 16.  Cardiogenic embolism  Responsible for approximately 20% of ischemic strokes.  Nonvalvular atrial fibrillation in ½ of the cases.  Valvular heart disease ¼ of the cases.  Left ventricular mural thrombus 1/3 of patients  Arterial Dissection  50% of patients with dissections of the carotid or vertebral arteries have no clear history of antecedent neck trauma.  Recurrent stroke rate is low in this etiology of stroke. Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  17. 17.  Patent foramen ovale  Present in 27% of the general population  Hyperhomocysteinemia  Hypercoagulable states  Sickle cell disease Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  18. 18.  Recombinant tissue plasminogen activator (rtPA)  Intravenous rtPA 0.9 mg/kg maximum dose of 90 mg for selected patients who may be treated within 3 hours of ischemic stroke onset.  Major side effects include bleeding and angioedema  If the patient is hypertensive (SBP >185, DBP >110) the patient may be eligible is blood pressure is able to be safely lowered with antihypertensive and stays stable. Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  19. 19.  Diagnosis of ischemic stroke causing a neurological deficit.  Neurological signs should not be clearing spontaneously.  Neurological signs should not be minor or isolated.  The symptoms of the stroke should not be suggestive of a SAH  Onset < 3 hours  No head trauma, prior stroke, nor MI in the last 3 months  No GI or urinary hemorrhage in the last 21 days  No major surgery in last 14 days  No arterial puncture at a noncompressible site in the previous 7 days  No history of previous intracranial hemorrhage  SBP < 185 Hg and DBP < 110  No evidence of active bleeding or acute trauma  INR < 1.7, aPTT in normal range  Platelet count > 100,000  Blood glucose > 50 mg/dl  No seizure with postictal residual neurological impairment  CT does not show > 1/3 of cerebral hemisphere involvement  The patient and family members understand the potential risks and benefits from treatment Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  20. 20.  Recombinant prourokinase appears to be of some benefit in treatment of carefully selected patients with acute ischemic stroke secondary to occlusion of the middle cerebral artery (MCA).  Not FDA approved and not clinically available  rtPA is used instead of prourokinase  It is selected for patients presenting < 6 hours with MCA occlusion who are not otherwise candidates for intravenous thrombolysis (is a consideration in patients with recent major surgery). Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449.
  21. 21.  Mechanical Embolus Removal in Cerebral Embolism (MERCI procedure)  FDA approved  Clinical utility in improving outcomes of stroke is not as of yet established.  Similar results in one study to the prourokinase treatment study.
  22. 22.  Stroke is the 3rd leading cause of death in the U.S. and the leading cause of adult disability.  Time is brain.  Establishing the suspicion of the diagnosis allows the receiving institution to prepare for a stroke team activation.  Therapies are being developed to allow alternatives to patients who don’t qualify for thrombolytics.
  23. 23. 1. Sacco, et al. Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: a Statement for Healthcare Professionals from the American Heart Association/American Stroke Association Council on Stroke. Circ 2006; 113:e409-449. 2. Albers, et al. Transient Ischemic Attack: Proposal for a New Definition. NEJM 2002; 284:2901-2906. 3. Brown, et al. Projected Costs of Ischemic Stroke in the United States. Neurology 2006; 67:1390-1395. 4. American Heart Association. Advanced Cardiovascular Life Support: Professional Provider Manual . Copy right 2005.

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