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STROKE: Diagnostics and TreatmentsModule III

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Initial stroke evaluation: Questions asked if initial Computed Tomography (CT) shows no hemorrhage Where is the lesion?

Cortical, sub-cortical, brainstem; right or left What vascular territory?

Anterior, middle, posterior, watershed Large or small vessel

What is the cause? Embolic or other

What is the embolic source? Heart, aorta, carotid or vertebral, intracranial

arteries

*TIA workup often mirrors that for ischemic stroke

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Imaging the brain and the arteries

CT is good for initial evaluation to rule out hemorrhage and assess for size of stroke

Magnetic Resonance Imaging (MRI) is more sensitive Imaging the arteries

Carotid ultrasound Magnetic resonance angiography (MRA) CT angiography (CTA) Catheter arteriography Tran-esophageal echocardiography (TEE) images heart and aorta

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CT angiography (CTA) CTA visualizes blood flow in arterial

vessels serving the brain CTA is less invasive and a more patient-

friendly procedure than catheter angiography

Contrast material is injected into a small peripheral vein

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CT Angiography:

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Magnetic Resonance Imaging (MRI):

Diffusion weighted images show all strokes from minutes to several weeks old

Helpful for all partial, anterior, posterior and lacunar syndromes

Magnetic resonance angiography usually completed if no CTA done

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MRI: Different sequences of the same individual with acute ischemic infarct:

T2 flair :evidence of small vessel disease in Sub-cortical & periventricular white matter

Diffusion weighted: acute infarct in posterior limb of the internal capsule and insular cortex (lacunar stroke)

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MRI: Left parietal infarct:

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Stroke Work Up: Labs Complete blood count (CBC), Erythrocyte sedimentation

rate (ESR), Prothrombin time (PT), Partial thromboplastin time (PTT), lipid profile

Younger patients: Antiphospholipid antibodies, Leiden factor V, Protein

C, S, Lupus anticoagulant, homocysteine (abnormalities indicate a hypercoaguable state)

Toxicology Syphilis Sickle cell Family history of bleeding:

Thrombotic risk profile

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Work Up: Transthoracic echocardiogram (TTE) vs. Tran-esophageal (TEE)

Seen on both TTE andTEE: Enlarged left atrium (> 40

mm) Akinetic segment Valve disease Dilating cardiomyopathy

Seen only on TEE:

Atrial septal defect, atrial septal aneurysm, patent foramen ovale

Mural thrombus Aortic atheroma

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Stroke Treatment: Antiplatelets and Anticoagulants

Aspirin (ASA) is the gold standard In selected cases, Plavix and Aggrenox are

used ASA is the bedrock of stroke prevention;

reduces stroke risk by approximately 15% Other Antiplatelet drugs are very expensive

and offer little to no extra benefit

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Combination of Medications Aspirin and Plavix often used after acute

coronary events and coronary/carotid stenting and less commonly used after stroke

Aspirin and Warfarin are used in selected cases

Aggrenox (combination of aspirin and Dipyridamole) is sometimes used after stroke

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Treatment: Heparin

Possible uses:Suspected hypercoaguable statesLow blood flow states from significant

large vessel stenosisArterial dissectionsCardiac embolic source, which has high risk

of occurrence

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Treatment: Coumadin Proven for cardiac embolic source in

Atrial fibrillationBut commonly used for Left ventricular thrombusDilated cardiomyopathyRecent myocardial infarction (MI)

Unproven if no embolic source found Unproven for minor embolic risk factors

Patent foramen ovale (PFO), Atrial septal aneurysm (ASA), aortic thrombi

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Contraindications: For Heparin and Coumadin

Recent gastrointestinal bleed Recent intracerebral hemorrhage Vitamin K deficiency Abnormal platelet levels Frequent falls Sometimes age

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Contraindications: For Antiplatelet Medications

Active bleeding Gastrointestinal lesions (ulcers) Recent intracerebral hemorrhage Allergy/sensitivity to drug Caution with liver and kidney impairment

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Treatment: Carotid Endarterectomy A surgical procedure in which atherosclerotic

deposits are removed from one of the carotid arteries

Definite: Symptomatic (TIA or minor stroke) and >70% carotid stenosis

Risk of stroke and benefit of surgery weighed Indicators: multiple atherosclerotic risk factors,

symptomatic ischemia, high grade stenosis and hospital morbidity/mortality rate <6%

http://my.mmc.org/C10/VascularCenter/default.aspx

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Stenting and Balloon AngioplastyCarotid and vertebral arteries are candidates Micro-catheters and devices such as balloons,

platinum coils, liquid adhesive, and stents are used; the interventional radiologist navigates from the femoral artery or vein to treat the abnormal target vessels

Assisted by real-time, bi-plane digital-subtraction angiography and real-time fluoroscopy

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Carotid Stenosis: Stent Placement and Balloon Angioplasty

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New Interventions for Clot Removal: Merci Retrieval

Merci retrieval: Uses angiography and femoral approach is the most common

The Merci Balloon is maneuvered up to the carotid artery in the neck A guide wire and the micro-catheter are placed just beyond the clot and

the retriever device is deployed to engage and ensnare the clot Once the clot is captured, a balloon guide catheter is inflated to

temporarily arrest forward flow while the clot is being withdrawn The clot is then pulled into the balloon guide catheter and completely

out of the body. The balloon is then deflated, and blood flow is restored.

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1. Strokes caused by cardio-embolism often occur as a result of atrial fibrillation. Mr. CJ has this heart rhythm. The rate is controlled with a beta blocker. The cardiologist and neurologist agree that he also needs this medication to prevent another stroke:

a) Aspirin and Plavixb) Warfarin (Coumadin)c) Cardiazemd) Aggrenox

Test questions:

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2. Which one of the following groups of patients who have had symptoms due to carotid stenosis is most likely to benefit from carotid Endarterectomy?

a) Patients with 30% or less stenosisb) Patients with 30%–49% stenosisc) Patients with 50%–69% stenosisd) Patients with 70% or more stenosis, without near occlusion

Test questions: