STROKE John P. Connolly MD

Medical Director, Resp Care

Lodi Memorial Hospital

Assoc Clin Prof Medicine

UC Davis

STROKE Acute brain disorder of vascular origin accompanied by

neurological dysfunction that persists for longer than 24 hours…

Stroke 1990

One death every 4 seconds in the US…

Circulation 2013

TIA

Less than 24 hours

“clinical reversibility”

1/3 of TIAs are associated with cerebral infarction

TIME IS BRAIN TISSUE

Each minute of cerebral infarction results in destruction of 1.9 million neurons and 7.5 miles of myelinated nerves…

Stroke 2006

CLASSIFICATION

Ischemic Stroke 87%

80% thrombotic

20% embolic

Hemorrhagic Stroke 13%

97% intracerebral

3% subdural

INITIAL EVALUATION

Clinical diagnosis

most are unilateral/ no LOC

if coma –> hemorrhagic CVA

brainstem CVA

non-convulsive seizure

Left hemispheric damage -> aphasia

disturbance in comprehension/formation of language

receptive

expressive

global

contralateral weakness – can be due to seizure

hemiparesis can result from hepatic encephalopathy or sepsis

Suspected CVA

30% will have another condition

Seizures

Sepsis

Metabolic encephalopathies

Space occupying lesions

…..in that order

NIH Stroke Scale…NIHSS

11 different aspects of performance with a number from 0 to 3 or 4

Total score 0 to 41

>22=poor prognosis

<10=unlikely to be CVA

IMAGING

CT…reliable for intracranial hemorrhage

close to 100% sensitive

not sensitive for ischemic CVA…especially early

MRI…diffusion weighted

hyperdense regions of ischemia

can detect ischemia after 5-10 minutes

time consuming….cooperation issues

ECHO…echocardiography can identify source of cerebral emboli

identify patent foramen ovale

THROMOLYTIC THERAPY

Selection criteria

inclusion

exclusion

relative exclusion

Time limit recently expanded to 4-5 hours

Balance against 6-7% incidence of cerebral hemorrhage with lytic Rx

Time of stroke onset can be difficult to pinpoint

HBP as an exclusion…>185S/>110D

labetalol, nicardipine, nitroprusside

THROMBOLYSIS

As early as possible

rtPA 0.9 mg/kg up to 90 mg

10% in 1-2 minutes/ remained over 60 minutes

No anticoagulant or antiplatelet agent for 24 hours

Then only SQ heparin for DVT prophylaxis

and

ASA 325 given 24-48 hours after CVA then 81 mg a day

OTHER THERAPY

Oxygen…if O2 is ok then no benefit

toxic oxygen metabolites promote cerebral vasoconstriction

only if sat < 94%

BP Control…HBP in 60-65% of CVAs

usually corrects in 48-72 hours

correction only id >220S/>120D or acute MI

labetalol, nicardipine, nitroprusside(can increase ICP)

Fever Control…fever in 30%

can be infection or due to tissue necrosis

intracranial blood

fever harmful to brain tissue

GUIDELINES REVIEWED

AHA/ASA Guidelines for the early management of patients with acute ischemic stroke Stroke 2013 44: 870-947

AHA/ASA Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack Stroke 2014 45: 2160-2236

AHA/ASA Palliative and end of life care in stroke Stroke 2014 45: 1887-1916

Early Management of CVA

“5 suddens”….weakness, speech, visual loss, headache, dizziness

“FAST”…face, arm, speech, time

http://mmcneuro.files.wordpress.com/2013/01/stroke.gif

EMS

Prehospital Stroke Screen

LA prehospital Stroke Screen

Cincinnati Prehospital Stroke Scale

Stroke Center Transport

Primary Stroke Center

Comprehensive Stroke Center/neuro critical care

Emergency time…eval and begin fibrinolytic rx <60 min of ED arrival

NECT or MRI < 45 minutes

assess BG but no delay for ECG, CXR, troponin

General Support

Correct hypoxemia ?supplemental O2

Supine position

Cardiac Monitoring

BP control

Intubation for unconsciousness or bulbar dysfunction

Correct hypovolemia and hypoglycemia 140-180

Temperature < 38 degrees

rtPA {Alteplase}

With normal or early ischemic change on imaging

If frank hypodensity >1/3 MCA no rtPA

Unclear use…mild deficits

improving CVA symptoms

surgery< 3 months

recent MI

Maybe harmful in pts on dabigatran, apixaban, rivaroxiban

Other lytics…not recommended (streptokinase) or investigational

rtPA

0.9 mg/kg up to 90 mg IV within 3 hours

Door to needle < 60 minutes

Can treat 3-4.5 hours with more exclusions

With BP control <185/110

Complications…angioedema, bleeding

Management Decisions

Endovascular interventions

inter-arterial rtPA…no FDA approval

mechanical thrombectomy

emergency angioplasty and stenting

Anticoagulation

within 24 hours of rtPA…not recommended

ASA 24 hours later ok

glycoprotein 2b/3a inhibitors not recommended

abciximab,eptifibatide, tirofiban

Management Decisions

Volume expansion, vasodilators, induced hypertension…no

Albumin, hemodilution…no

Some use of vasopressors to support BP

Neuroprotective agents

statins…should be continued, ? Started

hypothermia…not proven

transcranial infrared laser…no

hyperbaric oxygen….only for air embolism

drugs…EtOH, Magnesium, Caffeine…not established

General Care

Specialized Stroke Units

Infection therapy/DVT prophylaxis

Swallow eval before po intake

Early mobilization

No benefit to specialized nutritional therapy or prophylactic antibiotics

Surgical intervention…emergent CEA not established

Treatment of Complications

Brain edema/Increased ICP…peaks 3-4 days after CVA

restriction free water

avoid excess glucose

minimize hypoxemia and hypercarbia

treat hyperthermia

elevate HOB 20-30 degrees

avoid antihypertensive agents causing cerebral vasodilation

Treatment of increased ICP

hyperventilation, hypertonic saline, osmotic diuretics

Interventricular CSF drainage

Steroids not recommended

decompressive surgery…effective…decisions based on volume of tissue infarcted and midline shift

Treatment of Complications

Hemorrhagic transformation

within 24 hours of rtPA

most fatal hemorrhages within 12 hours

optimal management debated

?cryoprecipitate

? tranexamic acid

Seizures….standard anti-epileptic therapy

prophylactic anticonvulsants not indicated

Acute hydrocephalus

placement of ventricular drain

Palliative Care

Secondary Prevention of CVA

Control of Risk Factors

Intervention for vascular obstruction

Antithrombotic therapy for cardioembolic stroke

Antiplatelet therapy for noncardioembolic stroke

Special circumstances

Risk Factor Control

HBP…risk for CVA rises directly with BP>115 syst

No benefit to systolic <120

BP Rx if >140/90 several days post CVA

lacunar infarct – goal<130 syst

Lipids…statin to LDL-C <100

DM…screen all CVA patients with HgbA1C

Risk Factor Control

Obesity…BMI< 30 usefulness of weight loss uncertain for secondary prevention

Risk for CVA rises above BMI 20

Metabolic Syndrome…overweight, trig, low HDL-C, high BP, high BG

….20% of adults over 20

Physical Inactivity … 40 minutes 3-4x a week

….supervision by PT or Rehab after CVA

Nutrition…over or under, routine supplements not helpful

vitamins not helpful, Mediterranean diet possibly helpful

Risk Factor Control

OSA…very high incidence…sleep studies

Cigarettes…strong risk for 1st CVA

second hand smoke increases risk

EtOH…light to moderate decreases 1st ischemic CVA risk

increased risk of hemorrhagic CVA with any EtOH

heavy EtOH increases risk for both types

Extracranial Carotid / VertebrobasilarDisease

CEA for > 70% stenosis

Not recommended for < 50%

Carotid Angioplasty and stent vs. CEA

Older patients…CEA better

Younger…equivalent

Optimal Medical Therapy

Vertebrobasilar…medical therapy, BP lowering, lipid control

Stenting vs VB endarterectomy considered

Intracranial Disease and Cardioembolic Disease

Atherosclerosis…>50% ASA> warfarin

BP control and high Intensity statin therapy

>70% add clopidogrel for 90 days

Cardioembolism…Afib is main risk

warfarin, apixaban, dabigatran, for nonvalvular afib

rivaroxaban also reasonable

anticoagulation and antiplatelet Rx if CAD

Cardiac Disease

Acute MI/LV Thrombus…VKA for 3 months

or apixaban dabigatran rivaroxaban

Cardiomyopathy…LVAD…VKA

EF< 35% anticoagulation and antiplatelet

Valvular Heart Dz…MV Disease plus Afib…VKA

MV Disease without Afib…consider VKA

CVA/TIA on VKA…add ASA

Prosthetic Heart Valves…Mechanical AV/MV….VKA plus ASA 81

Bioprosthetic…ASA

if CVA …add VK

Non-cardioembolic CVA/ Aortic Arch/ ICH

Antiplatelet agents

ASA and dipyridamole or clopidogrel

?Add VKA….unclear importance

Aortic Arch Atheroma

antiplatelet therapy and statin

VKA or surgery not recommended

Arterial Dissection

??surgery …Antiplatelet therapy or anticoagulation considered

ICH…controversy…high risk of bleed…antiplatelet therapy

restart anticoagulation > 1 week

Other risks

PFO

Hyperhomocystinemia

Thrombophilia

Antiphospholipid antibodies

HbSS

Venous sinus thrombosis

Pregnancy risks

LMWH or UFH every 12 hours

or heparin until the 13th week followed by VKA

Palliative/End of Life Care

2010…130,000 CVA deaths/ >5% of all deaths

50% in hospital

35% SNFs

15% home/other

20% of CVAs to SNF

30% of CVAs permanently disabled

Grief/ Pain/ Non-pain Issues

Anticipatory and acute grief

Complicated grief/depression…1-2 months later

more severe if acute loss

Pain…central post stroke pain….1-12%

hemiplegic shoulder pain

post-CVA spasticity

Non-pain…fatigue, incontinence, seizures, sexual dysfunction, sleep disordered breathing, depression, anxiety/delirium, emotional lability

Palliative Care/ Prognosis & Decision Making

“what is a good outcome”

Aspects of recovery most important to patient and family

Decision making…Surrogate Decision Makers

Cultural and Religious preferences

Bereavement Services Available

Preference Sensitive Decisions…DNR/DNI

Swallowing Care

Decompressive Craniectomy, etc.

Access to Palliative Care

Interdisciplinary

Collaborative/patient centered communication

Services available

Peace and dignity

Access…any CVA affecting daily functioning or reducing life expectancy

Goals of care…communication, best available science, acknowledge uncertainty, changes in preferences over time

A final Word…Paul Marino MD (2014)

Number of Strokes each year in US 700,000

Number of Ischemic Strokes (88%) 616,000

Number of Stroke Patients receiving lytic therapy 12,320

Number of pts who benefit from lytic Rx (1 in 9) 1,369

Percent of strokes that benefit from lytic RX 0.2%