PPT STROKE
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PPT STROKE
- 1. Diagnosis and Management of Acute Stroke Briana Witherspoon DNP, ACNP-BC
- 2. Stroke Objectives • Review etiology of strokes • Identify likely location/type of stroke based of physical exam • Acute management of ischemic stroke • Acute management of hemorrhagic stroke
- 3. Stroke Fast Facts • Affects ~ 800, 000 people per year • Leading cause of disability, cognitive impairment, and death in the United States • Accounts for 1.7% of national health expenditures. • Estimated U.S. cost for 2012 = $71.5 billion – Mostly hospital (esp. LOS) & post stroke costs – Appropriate use of IV t-PA s long-term cost – Appropriate billing for AIS w/ thrombolysis ( hospital reimbursement from $5k to $11.5k) Stroke. 2013;44:2361-2375
- 4. Where We’re Headed • By 2030 ~ 4% of the US population over the age of 18 is projected to have had a stroke • Between 2012 and 2030, total direct stroke- related medical costs are expected to increase from $71.55 billion to $183.13 billion • Total annual costs of stroke are projected to increase to $240.67 billion by 2030, an increase of 129% Stroke. 2013;44:2361-2375
- 5. Three Stroke Types Ischemic Stroke Clot occluding artery 85% Intracerebral Hemorrhage Bleeding into brain 10% Subarachnoid Hemorrhage Bleeding around brain 5% www.acponline.org/about_acp/chapters/o k/gordon.ppt
- 7. NIHSS • NIHSS (National Institute of Health Stroke Scale) – Standardized method used by health care professionals to measure the level of impairment caused by a stroke – Purpose • Main use is as a clinical assessment tool to determine whether the degree of disability is severe enough to warrant the use of tPA • Another important use of the NIHSS is in research, where it allows for the objective comparison of efficacy across different stroke treatments and rehabilitation interventions – Scores are totaled to determine level of severity – Can also serve as a tool to determine if a change in exam has occurred
- 8. Breaking Down the Scale • 13 item scoring system, 7 minute exam • Integrates neurologic exam components • CN (visual), motor, sensory, cerebellar, inattention, language, LOC • Maximum score is 42, signifying severe stroke • Minimum score is 0, a normal exam • Scores greater than 15-20 are more severe
- 9. NIHSS cont. • NIHSS Interpretation Stroke Scale Stroke Severity 0 No Stroke 1-4 Minor Stroke 5-15 Moderate Stroke 15-20 Moderate/Severe Stroke 21-42 Severe Stroke
- 10. NIHSS and Outcome Prediction • NIHSS below 12-14 will have an 80% good or excellent outcome • NIHSS above 20-26 will have less than a 20% good or excellent outcome • Lacunar infarct patients had the best outcomes Adams HP Neurology 1999;53:126-131 Baseline NIH Stroke Scale score strongly predicts outcome after stroke (TOAST)
- 11. Etiology of Ischemic Strokes LARGE VESSEL THROMBOTIC: Virchow’s Triad…. • Blood vessel injury - HTN, Atherosclerosis, Vasculitis • Stasis/turbulent blood flow - Atherosclerosis, A. fib., Valve disorders • Hypercoagulable state - Increased number of platelets - Deficiency of anti-coagulation factors - Presence of pro-coagulation factors - Cancer
- 12. Etiology Of Ischemic Stroke: LARGE VESSEL EMBOLIC: • The Heart – Valve diseases, A. Fib, Dilated cardiomyopathy, Myxoma • Arterial Circulation (artery to artery emboli) – Atherosclerosis of carotid, Arterial dissection, Vasculitis • The Venous Circulation – PFO w/R to L shunt, Emboli
- 13. Determining the Location • Large Vessel: – Look for cortical signs • Small Vessel: – No cortical signs on exam • Posterior Circulation: – Crossed signs – Cranial nerve findings • Watershed: – Look at watershed and borderzone areas – Hypo-perfusion
- 14. Cortical Signs RIGHT BRAIN: LEFT BRAIN: - Right gaze preference - Left gaze preference - Neglect - Aphasia • If present, think LARGE VESSEL stroke
- 15. Large Vessel Stroke Syndromes • MCA: – Arm>leg weakness – LMCA cognitive: Aphasia – RMCA cognitive: Neglect,, topographical difficulty, apraxia, constructional impairment • ACA: – Leg>arm weakness, grasp – Cognitive: muteness, perseveration, abulia, disinhibition • PCA: – Hemianopia – Cognitive: memory loss/confusion, alexia • Cerebellum: – Ipsilateral ataxia
- 16. Aphasia • Broca’s – Expressive aphasia – Left posterior inferior frontal gyrus • Wernicke’s – Receptive aphasia – Posterior part of the superior temporal gyrus – Located on the dominant side (left) of the brain
- 17. Case 1 • 74 year old African American female with sudden onset of left-sided weakness • She was at church when she noted left facial droop • History of HTN and atrial fibrillation • Meds: Losartan
- 18. Case 1 • BP- 172/89, P– 104, T- 98.0, RR– 22, O2- 94% • General exam: Unremarkable except irregular rate and rhythm • NEURO EXAM: - Speech dysarthric but language intact - Right gaze preference - Left facial droop - Left- sided hemiplegia - Neglect
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- 23. Case 1 • Right MCA infarct, most likely cardioembolic from atrial fibrillation • Patient underwent mechanical thrombectomy with intra-arterial verapamil, clot removal successful • Excellent recovery – patient was discharged 48 hours later on Coumadin
- 24. Determining the Location • Large Vessel: – Look for cortical signs • Small Vessel: – No cortical signs on exam • Posterior Circulation: – Crossed signs – Cranial nerve findings • Watershed: – Look for watershed pattern – S/S of Hypo-perfusion
- 25. Etiology of Stroke SMALL VESSEL (Lacunes <1.5cm) •Risk Factors – HTN – HLD – DM – Tobacco Use – Sleep apnea
- 26. Case 2 • 85 year old male who woke up with left face, arm, and leg numbness • History of HTN, DM, and tobacco use • Meds: Insulin, aspirin
- 27. Case 2 • BP- 168/96, P– 92 • General exam: Unremarkable, RRR • NEURO EXAM: - Decreased sensation on left face, arm, and leg
- 28. Case 2
- 29. Case 2 • Right thalamic lacunar infarct • Not a candidate for intervention (WHY?) • Discharged to rehab 72 hours after admission
- 30. Determining the Location • Large Vessel: – Look for cortical signs • Small Vessel: – No cortical signs on exam • Posterior Circulation: – Crossed signs – Cranial nerve findings • Watershed: – Look at watershed and borderzone areas – Hypo-perfusion
- 31. Brainstem Stroke Syndromes • Rarely presents with an isolated symptom • Usually a combination of cranial nerve abnormalities, and crossed motor/sensory findings such as: – Double vision – Facial numbness and/or weakness – Slurred speech – Difficulty swallowing – Ataxia – Vertigo – Nausea and vomiting – Hoarseness
- 32. Case 3 • 55 year old male with acute onset of right sided numbness and tingling, left sided face pain and numbness, gait imbalance, nausea/vomiting, vertigo, swallowing difficulties, and hoarse speech • History of CAD s/p CABG, DM2, HTN, HLD, OSA • Meds: Aspirin, plavix, insulin, lipitor, metoprolol, lisinopril
- 33. Case 3 • NEURO EXAM: BP- 194/102, P– 105 • General exam: Unremarkable, RRR • NEURO EXAM: - Decreased sensation on left face - Decreased sensation on right body - Left ataxia on FNF, and unsteady gait - Voice hoarse - Nystagmus
- 34. Case 3
- 35. Case 3
- 36. Case 3 • Brainstem Stroke • Received IV tPa • Post-tPa symptoms greatly improved regained sensation, ataxia resolved • Discharged home with out patient PT/OT
- 37. Determining the Location • Large Vessel: – Look for cortical signs • Small Vessel: – No cortical signs on exam • Posterior Circulation: – Crossed signs – Cranial nerve findings • Watershed: – Look for the watershed pattern – Think about reasons of hypo-perfusion • Hypotension • Stenosed vessel, etc
- 38. Case 4 • 56 year old female who upon waking post-op after elective surgery was found to have L sided weakness and neglect • History of HTN • Meds - Lisinopril
- 39. Case 4 • BP- 132/74, P– 84 • General exam: Unremarkable, RRR • NEURO EXAM: - Left face, arm, and leg weakness - Neglect - DTR’s brisk on the left, toe up on left
- 40. Case 4
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- 46. Case 4
- 47. Case 4 • Right hemisphere watershed infarct secondary to hypoperfusion in the setting of Right ICA stenosis • On review of anesthesia records, blood pressure dropped to 82/54 during the procedure • Patient was discharged to in-patient rehab
- 49. Etiology of ICH • Traumatic • Spontaneous – Hypertensive – Amyloid angiopathy – Aneurysmal rupture – Arteriovenous malformation rupture – Bleeding into tumor – Cocaine and amphetamine use
- 51. Hypertensive ICH • Spontaneous rupture of a small artery deep in the brain • Typical sites – Basal Ganglia – Cerebellum – Pons • Typical clinical presentation – Patient typically awake and often stressed, then abrupt onset of symptoms with acute decompensation
- 52. Ganglionic Bleed • Contralateral hemiparesis • Hemisensory loss • Homonymous hemianopia • Conjugate deviation of eyes toward the side of the bleed or downward • AMS (stupor, coma)
- 54. Cerebellar Hemorrhage • Vomiting (more common in ICH than SAH or Ischemic CVA) • Ataxia • Eye deviation toward the opposite side of the bleed • Small sluggish pupils • AMS
- 56. Pontine Hemorrhage • Pin-point but reactive pupils • Abrupt onset of coma • Decerebrate posturing or flaccidity • Ataxic breathing pattern
- 58. Subarachnoid Hemorrhage • “Worst headache of my life” • AMS • Photophobia • Nuchal rigidity • Seizures • Nausea and vomiting
- 60. Management
- 61. Airway • Most likely related to decreased level of consciousness (LOC), dysarthria, dysphagia • GCS < 8 - INTUBATE • Avoid Hyperventilation or Hypoventilation • NPO until swallow assessment completed- high aspiration risk • Begin mobilization as soon as clinically safe • Keep HOB greater than 30 degrees
- 62. Stroke Algorithm
- 63. Imaging CT scan • Non- contrast CTH remains the gold standard as it is superior for showing IVH and ICH • CT with contrast may help identify aneurysms, AVMs, or tumors but is not required to determine whether or not the patient is a tPa candidate MRI • Superior for showing underlying structural lesions • Contraindications
- 64. Acute (4 hours) Infarction Subtle blurring of gray-white junction & sulcal effacement Subacute (4 days) Infarction Obvious dark changes & “mass effect” (e.g., ventricle compression) RR L L www.acponline.org/about_acp/chapters/o k/gordon.ppt
- 65. Multimodal Imaging Multimodal CT • Typically includes non- contrast CT, perfusion CT, and CTA • Two types of perfusion CT – Whole brain perfusion CT – Dynamic perfusion CT Multimodal MRI • Standard MRI sequences ( T1 weighted, T2 weighted, and proton density) are relatively insensitive to changes in cerebral ischemia • Multimodal adds diffuse- weighted imaging (DWI) and PWI (perfusion- weighted imaging)
- 66. tPa Fast Facts • Tissue plasminogen activator • “clot buster” • IV tpa window 3 hours • IA tpa window 4.5 hours • Disability risk ↓ 30% despite ~5% symptomatic ICH risk Contraindications • Hemorrhage • SBP > 185 or DBP > 110 • Recent surgery, trauma or stroke • Coagulopathy • Seizure at onset of symptoms • NIHSS >21 • Age? • Glucose < 50
- 67. Mechanical Thrombolysis • Often used in adjunct with tPa • MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Retrieval System is a corkscrew-like apparatus designed to remove clots from vessels • PENUMBRA system aspirates the clot
- 68. Blood Pressure Management •BP Management – The goal is to maintain cerebral perfusion!! – CPP = MAP – ICP (needs to be at least 70) – Higher BP goals with Ischemic stroke – Lower BP goals with Hemorrhagic stroke (avoid hemorrhagic expansion, especially in AVMs and aneurysms)
- 69. BP-AIS Relationship • BP increase is due to arterial occlusion (i.e., an effort to perfuse penumbra) • Failure to recanalize (w/ or w/o thrombolytic therapy) results in high BP and poor neuro outcomes • Lowering BP starves penumbra, worsens outcomes Penumbra Core Clot in Artery www.acponline.org/about_acp/chapters/o k/gordon.ppt
- 70. Save the Penumbra!! CEREBRAL BLOOD FLOW (ml/100g/min) CBF < 8 CBF 8-18 TIME (hours) 1 2 3 20 15 10 5 PENUMBRA CORE Neuronal dysfunction Neuronal death Normal function www.acponline.org/about_acp/chapters/o k/gordon.ppt
- 71. Supportive Therapy • Glucose Management – Infarction size and edema increase with acute and chronic hyperglycemia – Hyperglycemia is an independent risk factor for hemorrhage when stroke is treated with t-PA • Antiepileptic Drugs – Seizures are common after hemorrhagic CVAs – ICH related seizures are generally non-convulsive and are associated to with higher NIHSS scores, a midline shift, and tend to predict poorer outcomes
- 72. Hyperthermia • Treat fevers! – Evidence shows that fevers > 37.5 C that persists for > 24 hrs correlates with ventricular extension and is found in 83% of patients with poor outcomes
- 73. References • Adams, H., del Zappo, G., Alberts, M., Bhatt, D., Brass, L., Furlan, A., Grubb, R., & Higashida, R. (2007). Guidelines for the early management of adults with ischemic stroke. Stroke, 38, 1655-1711. • BradleyGWalter,DaroffBRobert,FenichelMGerald,Jancovic,Joseph;Neurologyinclinicalpractice,principlesofdiagnosis andmanagement.PhiladelphiaElsevier,2004. • Castillo, J., Leira, R., Garcia, M., Serena, J., Blanco, M. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004: 35: 520-526. • Goals for Management of Patients With Suspected Stroke Algorithm. http://circ.ahajournals.org/content/112/24_suppl/IV-111/F1.expansion.html. Accessed May 8, 2012 • Gordon, D. L. (n.d.). Update in stroke management . Retrieved from www.acponline.org/about_acp/chapters/ok/gordon.ppt • Hesselink, J. Imaging of cerebral hemorrhages and AV malformations. http://spinwarp.ucsd.edu/neuroweb/Text/br-740.htm. accessed May 10, 2012.
- 74. Questions?
Editor's Notes
- The National Institute of Health Stroke Scale is the industry standard It is also a research tool that allows us to quantify our clinical exam
- As you can see the scale is broken down into several components that allow the clinician to complete a quick but thorough exam. Note that the maximum score is 42
- Study done by Adams and his colleagues used the Barthel Index (BI) and the Glasgow Outcome Scale (GOS) to assess over 1200 patients’ outcomes at 7 days and 3 months. Between 70% and 80% of patients who have suffered a lacunar stroke are functionally independent at 1 year, compared with fewer than 50% of patients who have had a nonlacunar stroke.
- Cortical Signs
- Abulia - Loss or impairment of the ability to make decisions or act independently Anosonosia - complete unawareness or denial of a neurologic deficit.
- Maintaining adequate tissue oxygenation is imperative in the setting of both types of strokes, with your overall goal being to prevent hypoxia and potential worsening of the cerebral injury. Obviously, patients with decreased mental status and brain stem dysfunction have the greatest risk of airway compromise. Patients who require intubation have poorer prognosis, as approximately 50% of them will be dead within 30 days after their stroke.
- Included in the algorithm are critical time goals set by the National Institute of Neurological Disorders (NINDS) for in-hospital assessment and management. These time goals are based on findings from large studies of stroke victims: Immediate general assessment by a stoke team, emergency physician, or other expert within 10 minutes of arrival, including the order for an urgent CT scan Neurologic assessment by stroke team and CT scan performed within 25 minutes of arrival Interpretation of CT scan within 45 minutes of ED arrival Initiation of fibrinolytic therapy, if appropriate, within 1 hour of hospital arrival and 3 hours from onset of symptoms Door-to-admission time of 3 hours
- Interestingly, although the head CT is considered the standard for patients with suspected strokes, it is used to not to confirm an acute ischemic stroke but instead rule out other causes of the patient’s condition. CTs are actually relatively insensitive for in detecting acute and small corical infarctions especially in the posterior fossa region. However, if there is evidence of early edema or mass effect noted on the intial head ct, the patients risk of hemorrhagic conversion increases by approximately 8 fold.
- Both types of perfusion CT are highly sensitive and specific for detecting cerebral ischemia. There have also been studies that performed that suggest that CT perfusions may be able to differentiate between reversible and irreversible ischemia or in other words, successfully identify the pneumbra. By adding DWI to the standard MRI sequence, clinicians are able to visualize ischemic regions of the brain within minutes of symptom onset. It actually has a high sensitivity of approximately 88-100 % and high specificity of 95-100% for detecting ischemic lesions.
- MERCI Symptomatic ICH occurred in 9.8% of patients overall, and a favorable outcome, (a modified Rankin score of 2 or less), was seen in 36% of patients at 90 days. PENUMBRA- recanalization rate for patients treated with the Penumbra system, measured for the target vessel, was 81.6%. Symptomatic intracranial hemorrhages occurred in 11.2% of patients. A modified Rankin score of 2 or less at 90 days was seen in 25% of patients.
- For the most part, ICH stroke guidelines recommend using IV medications to lower SBP &lt; 160 while still maintaining adequate MAP and CPP Ischemic strokes are a bit trickier to manage. One must keep in mind that the patient’s blood pressure will lower on its own by approximately 25 – 30 % within the first 24 hours. Furthermore aggressive treatment of hypertension in ischemic strokes has been shown to worsen neurological function by reducing perfusion pressure Castillo and collegues performed a study in 2004 that showed that a drop in either SBP or DBP &gt; 20 points were associated with higher rates of mortality and larger volumes of infarctions. They also noted that early administration of antihypertensinve medications to patients with SBP &gt; 180 was associated with an increased risk of death. **** CHHIPS trial *** According to the guidelines, sbp should be reduced by 15 – 25% within the first day as excessively high blood pressures are associated with an increased risk of hemorrhagic conversion.
- In AIS, high BP is a response, not a cause—don’t lower it!
- Elevated glucose levels at the time of admission predicts an increased 28 day mortality rate in both diabetic and non-diabetic patients. Study done by Vespa and collegues done in 2003 showed that 18 / 63 patients ( 28% ) of patients in a neuro ICU seized on EEG within 72 hours of admission ICH stroke guidelines recommend IV medications to quickly stop seizures. Benzos tend to be first line choice, followed by IV phenytoin or fos-phenytoin, Brief period of prophylactic AED therapy has been shown to redice the risk of early seizures esp in patient with lobar hemorrhage.
- Fevers tend to be more common in basal ganglia and lobar ICHs and patients with IVH. Scwartz and collegues published a study in 200 that stated patients who survived the first 72 hours after hospital admission, the duration of fever is realted to outcome and is a an independent prognostic factor in stroke patients. However, although there have been several studies done, to date there is no recommended drug or dose of medication that is recommended in the treatment of fevers in stroke patients. Guidelines currently recommend that clinicians seek out a souce (don’t just assume that the fever is neurogenic in nature) and treat accordingly.