Selected Neurological Emergencies

1. Selected Neurological Emergencies Robert D. Welch, MD, MS Department of Emergency Medicine DMC/WSU School of Medicine

2. Goals • Describe features related to the evaluation and management of patients with possible TIA/stroke • Describe features related to the evaluation and management of patients with TBI • Describe features related to the evaluation and management of patients with status epilepticus (Likely will not get to this)

3. Is the Patient Having a Stroke? • Goldstein and Simel. JAMA 2005;293(19) • Review and data synthesis of the reliability of history and physical exam for diagnosis and prognosis of patients with suspected stroke • Premise: Probability of stroke for those with neurologically important symptoms is 10%

4. 3 Most Useful Findings - NIHSS • Facial paresis • Arm drift • Abnormal speech Kothari, et al. Acad Emerg Med 1997

5. Presence of any of the 3 Findings • Done by physicians in ED • Accuracy for Stroke or TIA • Sensitivity 100% (95% - 100%) • Specificity 88% (82% - 91%) • Positive LR 7.9 (5.6 - 11) • Negative LR 0 (0 – 0.12)

6. Cincinnati Pre-Hospital Stroke Scale • Same 3 features • Evaluated docs and medics • Exam not done in field

8. LA Pre-Hospital Stroke Screen • Age > 45 years • No seizure history • Not wheelchair or bedridden • Glucose 60 – 400 mg/dl • Unilateral deficit (at least 1 of 3) • Arm drift • Handgrip • Facial paresis

9. What is the Real Diagnosis? • LAPSS study only 8% of 441 patients transported with symptoms had final diagnosis of stroke/TIA • 10% of all patients* in studies transported by ambulance had stroke • Probably less for “walk-ins” • Another study (821 patients with initial diagnosis stroke) - 13% were ultimately diagnosed with other conditions* *Other Implications for need to rapidly tPA patients

10. Why Important? • EMS treats 30% - 60% acute strokes • The majority of patients arriving within 3 hours utilize EMS (Not sure of the 4.5 hour window) • EMS use is associated with faster time Sx onset to hospital arrival

11. Stroke Symptoms and Location • Anatomic related symptoms • Clinical classifications • NIHSS (will not review since all have access but please do it) • Why important – outcomes better with tPA in smaller and lacunar infarcts

13. Oxfordshire Classification:Subtypes of Cerebral Infarction • Total anterior circulation infarction syndrome • A combination of new higher cerebral dysfunction (ie, dysphasia, dyscalculia, visuospatial disorder) • Homonymous visual field defect • Ipsilateral motor and/or sensory deficit of at least 2 areas of the face, arm, and leg • Partial anterior circulation infarction syndrome • Only 2 of the 3 components of the TACS syndrome are present • Higher cerebral dysfunction alone, or with a motor/sensory deficit more restricted than thoseclassified as LACS (ie, confined to 1 limb or to face and hand, but not to the whole arm).

14. Lacunar infarction syndrome (LACS) • Pure motor stroke, pure sensory stroke, sensori-motor stroke, or ataxic hemiparesis • Posterior circulation infarction syndrome includes any of the following: • Ipsilateral cranial nerve palsy with contralateral motor and/or sensory deficit • Bilateral motor and/or sensory deficit • Disorder of conjugate eye movement • Cerebellar dysfunction without ipsilateral long-tract deficit (ie, ataxic hemiparesis) • Isolated homonymous visual field defect

15. CT Imaging • Non-enhanced CT (NECT) • Gross assessment for hemorrhage and other abnormalities • CT angiography and CTA-SI [source image] • Vascular pathology and cerebral blood volume • CT perfusion • Maps CBF and blood volume • Ischemic but potentially viable tissue • Radiation and contrast exposure

16. MRI • DWI-MR • Most accurate for acute ischemic stroke • Now the recommended study • PWI-MR • Viable vs non-viable tissue • Not much in 2009 imaging guidelines

17. 2009 ASA Guidelines - Imaging • NECT or MRI if within 3 hours before giving tPA • DWI-MR or CTA-SI are more definitive • Vascular study probably indicated if does not delay tPA administration • > 3 hours use CTA or DWI-MR

18. 2010 Neurology Imaging Guidelines • DWI-MR is accurate and superior to NECT for the diagnosis of ischemic stroke and should be the imaging study of choice for those presetning within 12 hours of symptoms • Insufficient evidence for PWI-MR for diagnosis of acute ischemic stroke • Logistics and cost of MR will enter into decision making process as to which study to use

19. Therapy • Good general supportive care • Treat Hypertension • Avoid fever (hypothermia?) • Avoid hypotension • Treat hypoglycemia and avoid hyperglycemia (ongoing study) • Reperfusion

23. Outcomes of tPA Therapy • Tx Within 3 hours of Sx onset • Complete (or near complete) recovery 38% (tPA) vs. 21% (placebo) at 3 months • Three month mortality same • Not saving lives, but better functional outcomes • Symptomatic ICH was 10-fold higher in tPA group (6.4% vs. 0.6%) • Intra-Cranial Hemorrhage • Sever systemic hemorrhage < 1%

24. Outcome of tPA Therapy • tPA in the 3 – 4.5 hour window • Favorable outcome (MRSS) at 3 months • OR 1.34 (1.02 – 1.76) • # needed to treat = 14 • No difference in mortality • Symptomatic ICH • 2.2% (tPA) vs. 0.2% (placebo) • 7.9% vs. 3.5% using NINDS trial definition

25. Pooled Data Results • Published in 2010 • tPA vs. Placebo within 6 hours • NINDS • ATLANTIS • ECASS • EPITHET • Outcome mRS (favorable vs. unfavorable)

26. Odds ratio for favorable outcome at 3-months OR 2.6 (1.4 – 4.5) 0 to 90 min OR 1.6 (1.1 – 2.4) 91 to 180 min OR 1.3 (1.1 – 1.7) 181 to 270 min OR 1.2 (0.9 - 1.6) 271 to 360 min Number needed to treat for favorable outcome NNT 4.5 0 to 90 min NNT 9.0 91 to 180 min NNT 14.1 181 to 270 min NNT 21.4 271 to 360 min

27. Side Effect Profile • Treatment 10x more likely to help than harm • 1 of 15 develop “excessive” bleeding into brain • 1 harmed for every 30 treated • Factors associated with increased risk of ICH • All have no clear definition or are confounded • Early CT changes (brain edema or mass effect) • Stoke severity • Age

28. Safety of tPA in Stroke Mimics • 512 “stroke” cases treated within 3 hours • 106 (21%) had no infarct noted on subsequent imaging • 69 (14%) were stroke mimics • 37 (7%) were determined to be imaging negative cerebral ischemia • Results • None had ICH, systemic hemorrhage • Low-risk in mimics and imaging negative ischemia

29. Management if ICH • T&C, PT, PTT, Fibrinogen, PLT • Reverse effects of tPA and anti-platelet meds • 10 units cryoprecipitate • 6 to 8 units platelets • If given heparin use 1 mg protamine for every 100 units heparin given in preceding 4 hours

30. Other Reperfusion Methods • Use of advanced imaging (MRI) to select patients (longer time window) • Combined IV and IA tPA(IMS 3 study stopped due to futility) • IA thrombolytic therapy • Mechanical • MERCI clot retrieval system – (wire through clot then corkscrew-like device deployed to retrieve clot) • IA Ultrasound • Endovascular angioplasty and stenting

31. Neuroprotective Therapy • Experimental studies suggest this is possible • However, there are no proven therapy as of this time • Issues: • Many studies enroll too late (> 6 hours)

33. ALIAS is 5 hours

34. Carotid and Basilar Artery Dissection • Symptoms can be similar to ischemic stroke • Factors differentiating from ischemic stroke: • Super Severe Headache and neck pain (pain is the most common initial symptom) • Horner’s syndrome or other cranial nerves • Vertigo, nausea and vomiting, and dysarthria may be seen if basilar artery dissection present

35. Case # 1 Mr. H • Older man with acute partial anterior circulation symptoms

36. Older man with partial anterior circulation Sxs Dense MCA sign

37. Mr. H - 1 day and weeks later

38. Case #2 Mrs. Y • Older lady with similar partial acute anterior circulation symptoms

39. Hyperdense MCA sign

40. Mrs. Y - Same day post-tPA and intervention

41. Mrs. Y - Next day

42. Acute Traumatic Brain Injury – Past Failures and Future Prospects

43. Requisite Review • Scope of TBI • 1.4 million suffer TBI each year • 1.1 million treated and released from EDs • > 235,000 hospitalized • > 50,000 die • Many more are permanently disabled (80,000 to 90,000?) • Progressive Mortality Reduction over 30 yrs. • 50% • 35% • 25% • Even lower (guidelines?)

44. Comparison of Annual Incidence Spinal Cord Injuries Breast Cancer Multiple Sclerosis Traumatic Brain Injury HIV/AIDS

45. Injuries to Fatalities Ratio(requiring professional medical assistance) • Football = 65,000 injuries/fatality • Golf = 33,000

46. Injuries to Fatalities Ratio(requiring professional medical assistance) • Sailing = 200

47. Injuries to Fatalities Ratio(requiring professional medical assistance) • Caving/Rock Climbing = 16

48. Injuries to Fatalities Ratio(requiring professional medical assistance) • Aviation = 2

49. Mortality in TBI • Decreased by almost 50% since late 1800s • No clear-cut decrease since 1990 • Is this correct? Stein SC, et al. 150 Years of Treating Severe Traumatic Brain Injury: A Systematic Review of Progress in Mortality. J Neurotrauma 2010; 27:1343–1353

50. Mortality reduction prior to 1930 appears to relate to the rejection of ill-advised techniques and treatments 1930 to 1970 there were major technical advances in the treatment of trauma in general and TBI in particular but the lack of further reduction in mortality noted between 1930 and 1970 may reflect the increased prominence of high-velocity motor vehicle crashes as a cause of severe TBI Improvement in survival from 1970 to 1990 likely resulted from the introduction of CT scanning and ICP monitoring, as well as the more focused supportive care Lack of significant decreases in mortality from 1990 – 2006 is more difficult to explain. TBI treatment guidelines appear to improved outcomes but this not reflected in overall analysis of TBI patients.