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  1. 1. TIA and CVARobert K. O’Sullivan, PA-C, MPASClinical Medicine IIMay 20, 2011
  2. 2. ObjectivesDefine Transient Ischemic Attack (TIA)Define Cerebral Vascular Accident (CVA)Identify the Anterior and Posterior CerebralVascular SupplyDistinguish the Pathophysiological differencesbetween Ischemic and Hemorrhagic strokes
  3. 3. Objectives (continued) Discuss the Epidemiology and Risk Factors for Ischemic & Hemorrhagic strokes For TIA & CVA’s, describe the significant historical and physical exam findings, appropriate diagnostic investigations, emergency treatment, rehab & prevention
  4. 4. (more) Objectives (we’re flyin’ now) As they relate to TIA’s/CVA, Discuss the significance of... Atherosclerosis Drug Abuse Venous Thrombosis Migraine Hematological disorders Cardiogenic Embolism Hypertension
  5. 5. Yet more Objectives (really???) Discuss Stroke Syndromes, including... Lucunar Infarctions Cerebral Infarctions Intracerebral Hemorrhage Subarachnoid Hemorrhage Intercranial Aneurism Arteriovenous Malformations Intracranial Venous thrombosis
  6. 6. Pre-Lecture QuestionsWhat artery is most commonly involved in a stroke?Define the abbreviation: FAST!What are the main categories of strokes?A 63 y.o. previously healthy man awakens at 6 am withweakness of the left arm and leg and difficulty walking.He arrives at the hospital at 7 am and a CT scan isimmediately performed, the results of which are normal.What dose of t-PA should he receive?
  7. 7. Key Points for TIA/CVA TIA’s & CVA’s are emergencies Patients acutely suffering these disorders need IMMEDIATE MEDICAL ATTENTION Act FAST! (Face, Arm, Speech, Time) It is important for the PA to have a good understanding of neuroanatomy and brain function, because... There are significant risks associated with TIA/ CVA treatments (and patients must understand these risks) Prevention is the best therapy
  8. 8. Anatomy & PhysiologyCerebral ReviewArteriesCoveringsof theBrainSensoryAnatomyFunctionalAnatomy&Physiology
  9. 9. Cerebral Vasculature ReviewFill in the blanks.... A= S= CC= V= IC= EC=
  10. 10. Cerebral Arteries
  11. 11. Internal Cerebral Arteries
  12. 12. Coverings of the Brain
  13. 13. Sensory Anatomy
  14. 14. Neurology DefinitionsAphasia means... Aphagia example poor articulation inability to produce written or spoken language innate difficulty learning mathematics gross lack of coordination of muscle movements difficulty swallowing
  15. 15. Transient Ischemic AttacksTransient IschemicAttack Video
  16. 16. Transient Ischemic AttacksEssential of Diagnosis Focal Neurological Deficit which completely resolves within 24 hours Often associated with risk factors for vascular diseases 40% of all people who have experienced a TIA will go on to have a stroke Nearly half within 2 days
  17. 17. Transient Ischemic AttackEtiology Cardiac sources Vessel wall embolus (most Atrial fibrillation common) Mitral valve stenosis Carotid artery most often the source Mitral valve prolapse Related to thrombus Calcified mitral annulus formation distal to stenosis Ventricular aneurysm Atrial or ventricular clot Valvular vegetation Atrial septal defect
  18. 18. Transient Ischemic AttackEtiology Less common etiologies (age <45 years) Other vascular sources Subclavian Steal Intracranial artery Syndrome thrombus (esp. African- Americans) Hyperviscosity (e.g. polycythemia vera) Aortic arch atherosclerotic plaque Hypercoagulable state Transient hypotension Carotid dissection with carotid stenosis >75% Vertebral artery dissection
  19. 19. Transient Ischemic AttackSigns and symptoms Carotid territory Abrupt onset without Weakness and warning heaviness of contralateral arm, leg, Symptoms vary markedly or face or combination between patients Numbness and paresthesias Bradykinesia, dysphasia, monocular vision loss on ipsilateral side +/- carotid bruit
  20. 20. Transient Ischemic AttackSigns and symptoms Weakness or sensory complaints on one, Vertebrobasilar TIAs both, or alternating sides of the body Vertigo Ataxia Diplopia Dysarthria Dimness or blurring of vision Perioral numbness or paresthesias
  21. 21. Transient Ischemic Attack (TIA)Risk of stroke increases with... Carotid TIAs > vertebrobasilar TIAs Age > 60 years Diabetes TIAs that last longer than 10 minutes Signs and symptoms of weakness, speech impairment, or gait disturbance
  22. 22. Transient Ischemic AttackImaging CT of the head U/S of cerebral circulation Doppler U/S of carotid arteries Arteriography MR angiography less sensitive than conventional arteriography
  23. 23. Transient Ischemic AttackLabs and other studies EKG(why?) Chest x-ray CBC Consider Fasting blood glucose echocardiography or Holter monitor Serum cholesterol Homocysteine level Serologic tests for syphilis (bonus question: Organism that causes syphilis is...Treponema pallidum
  24. 24. Transient Ischemic Attacks Differential diagnosis Focal seizures Classic migraine Hypoglycemic episodes TIA mimick
  25. 25. Treatment of TIA’sTreatment is divided into twochoices... Medical therapy aimed at preventing further attacks or strokes to include... Smoking cessation Treatment of underlying disease (HTN, DM, etc.) Carotid endarterectomy
  26. 26. Carotid Endarterectomy
  27. 27. Treatment of TIAEmbolization from the heart Anticoagulation IV heparin until coumadin level is therapeutic Aspirin may be used for people who cannot tolerate coumadinEmbolization from the cerebrovascular system Aspirin 325 mg daily Plavix (clopidogrel) 75 mg daily if intolerant of aspirin Coumadin for 3-6 months does not provide any benefits over aspirin
  28. 28. Quiz... Which thrombolytic agent is naturally occurringwithin the body (hint: secreted from MAST cells)A. AspirinB. HeparinC. WarfarinD. CoumadinE. Clopidogrel
  29. 29. Cerebral Vascular Accidents (AKA: “the Stroke”)
  30. 30. Cerebrovascular AccidentAKA strokeEssentials of diagnosis Sudden onset of characteristic neurologic deficit Often a history of HTN, DM, valvular heart disease or atherosclerosis Distinctive neurologic signs reflect the region of the brain involved
  31. 31. CVA; the “killer” statsThird leading cause ofdeath in the USGeneral decline inincidence over thepast 30 years87% are ischemic dueto large arteryatherosclerosis,cardioembiolism &other13% due arehemorragic inintracerebral orsubarachnoid locations
  32. 32. CVA Risk Factors include... HTN/Elevated BP Diabetes Mellitus Hyperlipidemia Cigarette smoking Cardiac disease AIDS Drug abuse/EtOH Family history of CVA Elevated blood homocysteine level
  33. 33. Cerebrovascular AccidentClassification of Strokes True or False: Reliable distinction Infarcts between a Thrombotic intracerebral hemorrhage and Embolic ischemic stroke can only be done by neuroimagining Hemorrhages A reading...
  34. 34. Stroke SubtypesLucunar InfarctionsCerebral InfarctionsIntracerebral HemorrhageSubarachnoid HemorrhageIntercranial AneurismArteriovenous MalformationsIntracranial Venous thrombosis
  35. 35. Lacunar InfarctionsSmall lesions (usually < 5 mm)Accounts for approx 25% ofischemic strokesOccurs in distribution ofshort penetrating arteriolesin the basal ganglia, pons,cerebellum, anterior limb ofthe internal capsule, and lesscommonly deep cerebralwhite matterAssociated with poorlycontrolled HTN or diabetes
  36. 36. Lacunar InfarctionsSigns and symptoms Contralateral pure motor or pure sensory deficit Ipsilateral ataxia with crural paresis (weakness) Dysarthria with clumsiness of the hand Deficit may progress over 24-36 hours before stabilizing
  37. 37. Lacunar InfarctionImaging Sometimes seen on CT as small, punched-out, hypodense areas CT often normalPrognosis is usually goodwith partial or completeresolution in 4-6 weeks
  38. 38. Cerebral InfarctionThrombotic or embolicocclusion of a major vesselCerebral ischemia leads torelease of excitatory andother neuropeptides thatincrease Ca++ flux intoneurons causing cell deathand increasing theneurologic deficitAbrupt onset
  39. 39. Cerebral InfarctionObstruction of carotid Occlusion of anteriorcirculation cerebral artery Occlusion of ophthalmic Weakness and artery may cause sensory loss in the amaurosis fugax (can be contralateral leg seen with a TIA as well) May see contralateral grasp reflex, rigidity, abulia, or confusion Urinary incontinence Behavioral changes and memory disturbances
  40. 40. Cerebral InfarctionObstruction of carotid Global aphasia ifcirculation dominant hemisphere involved Occlusion of middle cerebral artery Drowsiness, stupor, and coma Contralateral hemiplegia, Dressing apraxia hemisensory loss, homonymous Constructional and hemianopsia spatial deficits Eyes deviate to side of the lesion
  41. 41. Cerebral InfarctionObstruction of Macular-sparingvertebrobasilar circulation homonymous hemianopia Occlusion of posterior cerebral artery Mild, usually temporary Thalamic syndrome: hemiparesis contralateral hemisensory Occlusion of vertebral disturbance artery followed by development of May be clinically spontaneous pain silent and hyperpathia (what is Hyperpathia?)
  42. 42. Cerebral InfarctionObstruction of If hemiplegia is ofvertebrobasilar circulation pontine origin, eyes are often deviated to Occlusion of both the paralyzed side vertebral arteries or basilar artery Coma with pinpoint pupils Flaccid quadriplegia and sensory loss Variable cranial nerve abnormalities
  43. 43. Cerebral InfarctionObstruction of vertebrobasilar circulation (cont’d) Occlusion of major cerebellar arteries Vertigo Nausea and vomiting Nystagmus Ipsilateral limb ataxia Contralateral spinothalamic sensory loss in the limbs
  44. 44. Cerebral InfarctionImaging CT of the head to exclude cerebral hemorrhage CT preferable to MRI in acute stages Carotid duplex studies MRI (diffusion- weighted more sensitive) and MR angiography
  45. 45. Cerebral Infarction Imaging
  46. 46. Labs for Cerebral Infarction Labs and other studies CBC Sed rate Blood glucose Serologic tests for syphilis Serum cholesterol Serum homocysteine EKG, Echo, Holter monitor Blood cultures
  47. 47. Treatment of Infarctions Ideally, in a stroke care unit Intravenous Thrombolytic Therapy rapid Tissue Plasminogen Activator (rTPA) Supportive Measures Anticoagulants if cardiac cause of emboli Warfarin Physical, occupational and speech therapy
  48. 48. r-TPA TherapyEffective in select patientswith no CT evidence ofhemorrhageStart as soon as possible,not more than 4.5 hrs afteronset (some say only 3 hrs)Contra-indications include: Recent or increased risk for hemorrhage, (i.e. recent trauma, surgery), markedly high BP (>185/110), others...
  49. 49. Cerebral InfarctionPrognosis Prognosis for cerebral infarction is better than for cerebral or subarachnoid hemorrhage Depends on time that elapses before arriving at the hospital – if patient has TPa they are 30% more likely to have no disability at 3 months Loss or consciousness implies a poorer prognosis
  50. 50. Intracerebral Hemorrhage
  51. 51. Intracerebral HemorrhageUsually due to hypertension and presence ofmicroaneurysmsMost frequently in basal gangliaLess commonly in the pons, thalamus, cerebellum, andcerebral white matterUsually occur suddenly and without warning duringactivity
  52. 52. Intracerebral HemorrhageMay also occur with... EtOH Hematologic and Brain tumors bleeding disorders Leukemia Hemophilia DIC Anticoagulant therapy Liver disease Cerebral amyloid angiopathy
  53. 53. Intracerebral HemorrhageSigns and symptoms Initial loss or impairment of consciousness Vomiting and headache Focal signs and symptoms Loss of gaze Cerebellar hemorrhage Nausea and vomiting, disequilibrium, headache Loss of consciousness that may lead to death within 48 hours
  54. 54. Intracerebral HemorrhageImaging CT scan without contrast (determines location and size of the bleed) Superior to MRI in first 48 hours Cerebral angiography if the patient’s condition allows
  55. 55. Intracerebral Hemorrhage Labs and other studies CBC Platelet count Liver function tests Renal function tests Bleeding times LP is contraindicated (may cause a herniation syndrome)
  56. 56. Intracerebral Hemorrhage Treatment Management is generally Treatment of underlying conservative and structural lesions supportive Trials of recombinant Ventricular drainage may activated factor VII be required given with a few hours have been tried (have Decompression of not shown improved superficial hematoma survival) Prompt surgical evacuation of cerebellar hemorrhage
  57. 57. SpontaneousSubarachnoidHemorrhage
  58. 58. Subarachnoid HemorrhageEssentials of diagnosis General considerations Sudden, severe Causes 5 – 10% of headache “the worst strokes headache of my life” Signs of meningeal irritation Obtundation is common Focal deficits are frequently absent
  59. 59. Subarachnoid Hemorrhage Signs and symptoms Sudden onset of “worst headache of my life” Nausea and vomiting Loss or impairment of consciousness Altered mental status Nuchal rigidity and other signs of meningeal irritation Focal neurologic deficits may not be present
  60. 60. Subarachnoid HemorrhageImaging CT scan immediately If CT normal, a lumbar puncture should be done... 12 hours later Look for Xanthochromia (yellowish color to CSF from bilirubin) Once patient is stable, cerebral arteriography MR angiography is less useful
  61. 61. Brain-teaserWhy is blood in CSF non-diagnostic in the case of asubarachnoid hemorrhage?
  62. 62. Subarachnoid Hemorrhage Treatment Conscious patients Confine to bed, avoid exertion or straining Treat symptoms (headache, constipation) Lower BP gradually keeping diastolic above 100 Phenytoin to prevent seizures
  63. 63. Intercranial Aneurisms
  64. 64. Intracranial AneurysmEssentials of diagnosis Subarachnoid hemorrhage or focal deficit Abnormal imaging studiesGeneral considerations “Berry” aneurysms tend to occur at arterial bifurcations May be associated with PKD and coarctation of the aorta
  65. 65. Intracranial AneurysmRisk factors Smoking Hypertension HypercholesterolemiaSigns and symptoms Most are asymptomatic May cause focal neurologic deficit from mass effect
  66. 66. Intracranial AneurysmImaging CT scan will show if a bleed has occurred AngiographyLabs and other studies CSF may show blood EEG EKG
  67. 67. Intracranial AneurysmTreatment Major aim of treatment is to prevent further hemorrhages Definitive treatment requires surgical clipping or coil embolization
  68. 68. Intracranial AneurysmTreatment (continued)... Risk of further hemorrhage is greatest within first 6 months Calcium channel blockers to reduce vasospasm
  69. 69. Arteriovenous (AV) Malformations
  70. 70. Arteriovenous (AV) MalformationsEssentials of diagnosis Sudden onset of subarachnoid and intracerebral hemorrhage Seizures or focal deficitsGeneral considerations Congenital lesions Vary in size May have associated obstructive hydrocephalus
  71. 71. Arteriovenous Malformations Signs and symptoms Infratentorial lesions Supratentorial lesions Often clinically silent Most AV May lead to malformations are progressive or supratentorial relapsing brainstem deficits S/S of hemorrhage, recurrent seizures or headaches Abnormal mental status Meningeal irritation Increased ICP
  72. 72. Arteriovenous (AV) MalformationsImaging CT scan if bleeding present ArteriographyLabs and other studies EEG for patients presenting with seizuresTreatment Surgical treatment to prevent further hemorrhages
  73. 73. Arteriovenous (AV)Treatment Malformations For patients with seizures and no bleeding, anticonvulsants are usually sufficient Definitive surgical treatment excision of AV malformation Embolization if not surgically accessible Injection of vascular occlusive polymer Gamma knife
  74. 74. Intracranial Venous Thrombosis
  75. 75. Intracranial Venous ThrombosisAssociated with... Intracranial or maxillofacial infections Hypercoagulable states Polycythemia Sickle cell disease Pregnancy
  76. 76. Intracranial Venous ThrombosisSigns and symptoms Imaging Headache CT scan, MRI, MR venography Focal or generalized convulsions Drowsiness, confusion Increased ICP Focal neurologic deficits
  77. 77. Intracranial Venous ThrombosisTreatment Anticonvulsants for seizures Dexamethasone to decrease ICP Anticoagulation with heparin followed by coumadin for 6 months Catheter-directed thrombolytic therapy with urokinase and thrombectomy
  78. 78. What we covered...TIA’sCVA’s to include... Anatomy, Physiology & Pathophysiology Definitions Classification of Strokes (Ischemic & Hemorrhage) Stroke Sub-types
  79. 79. Any Questions?