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i schemic stroke

i schemic stroke. Alison Smock, MD Department of Neurology Medical University of South Carolina. definitions. Transient ischemic attack A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction

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i schemic stroke

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  1. ischemic stroke Alison Smock, MD Department of Neurology Medical University of South Carolina

  2. definitions • Transient ischemic attack • A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction • Tissue-based definition rather than time-based definition • Stroke • Infarction of the central nervous system • May be symptomatic or silent • May not be evident by MRI Stroke. 2009;40:2276-2293

  3. epidemiology • Transient Ischemic Attack • Estimated prevalence of self-reported physician-diagnosis TIA is approximately 2.3% (translates to ~5 million people) • Incidence of TIA increases with age and varies by sex and race/ethnicity • Men, blacks, and Mexican Americans have higher rates of TIA their their female and non-Hispanic white counterparts • Approximately 15% of all strokes are heralded by a TIA • 10-15% of patients have a stroke within 3 months, with half occurring within 48 hours Circulation. 2013;127:e6-e245 Stroke. 2009;40:2276-2293

  4. epidemiology • TIA • ABCD2 score • Clinical score to determine the risk for stroke within the first 2 days following a TIA Lancet. 2007;369:283-292.

  5. epidemiology Lancet. 207;369:283-292

  6. epidemiology • Stroke prevalence • Estimated 6.8 million Americans ≥20 years of age have had a stroke (2007-2010 data) • Overall stroke prevalence during this period is an estimated 2.8% • Older adults, blacks, people with lower levels of education, and people living in the southeastern United States had higher stroke prevalence Circulation. 2013;127:e6-e245

  7. epidemiology • Stroke incidence • Each year, ~795,000 people experience a new or recurrent stroke (610,000 are first attacks, 185,000 are recurrent) • Of all strokes, 87% are ischemic, 10% are ICH, 3% are SAH • Each year, ~55,000 more women than men have a stroke • Women have a higher lifetime risk of stroke than men • Women have a lower age-adjusted stroke incidence than men • White women 45-84 yo have lower stroke risk than white men, but women >85 yo have elevated risk compared to white men • Analysis of data from FHS and GCNKSS suggests that stroke incidence is declining over time Circulation. 2013;127:e6-e245

  8. epidemiology • Stroke mortality • In 2009, stroke accounted for 1 of every 19 deaths in the US • When considered separately from other CVDs, stroke ranks No. 4 among all causes of death • From 1999 to 2009, the annual stroke death rate decreased36.9% and the actual number of stroke deaths declined22.9% Circulation. 2013;127:e6-e245

  9. epidemiology Circulation. 2013;127:e6-e245

  10. http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319832.pdfhttp://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319832.pdf

  11. Circulation. 2013;127:e6-e245

  12. so why does it matter? • Disability • Stroke is the leading cause of serious long-term disability in the United States • In the NHLBI’s FHS, among ischemic stroke survivors who were ≥65yo, the following disabilities were observed at 6 months after stroke: • 50% had some hemiparesis • 30% were unable to walk without some assistance • 46% had cognitive deficits • 35% had depressive symptoms • 19% had aphasia • 26% were dependent in ADLs • 26% were institutionalized in a nursing home Circulation. 2013;127:e6-e245

  13. etiology

  14. etiology of ischemic stroke • TOAST criteria • Thrombosis or embolism due to atherosclerosis of a large artery • Embolism of cardiac origin • Occlusion of a small blood vessel • Other determined causes • Dissection • Aneurysm • Vasculitis • Undetermined cause (cryptogenic or incomplete investigation)

  15. risk factors traditional other Hypertension Hyperlipidemia Diabetes mellitus Smoking Coronary artery disease Heart failure Cardiac arrhythmias Chronic kidney disease Physical inactivity Drug use History of prior stroke Family history Underlying rheumatologic disease Hypercoagulable states CNS infection Sepsis Sleep apnea Circulation. 2013;127:e6-e245

  16. etiology and presenting symptoms • Large vessel strokes (ICA, MCA, ACA, PCA) • Cardio-embolic • Atherosclerosis • Artery-artery embolism • Dissections • Aneurysms • Small vessel strokes • Uncontrolled hypertension • Uncontrolled diabetes • Uncontrolled hyperlipidemia • Smoking • Sympathomimetics

  17. http://www.cixip.com/index.php/page/content/id/1007

  18. Carotids

  19. Internal Carotids and MCAs

  20. http://www.studyblue.com/notes/note/n/airway-77-93/deck/3078597http://www.studyblue.com/notes/note/n/airway-77-93/deck/3078597

  21. Circle of Willis

  22. large vessel stroke syndromes – cortical • MCA – dominant hemisphere • Contralateral hemiparesis (face/arm > leg) • Contralateral hemisensory changes • Head and eye deviation toward stroke • Contralateral hemianopia • Language difficulty • Alexia • Agraphia • Acalculia • Apraxia

  23. large vessel stroke syndromes – cortical • MCA – non-dominant hemisphere • Contralateral hemiparesis (face/arm > leg) • Contralateral hemisensory changes • Neglect/extinction • Anosognosia • Loss of prosody of speech • Flat affect • ACA • Crural paresis > arm paresis • Frontal signs (eg, abulia)

  24. large vessel stroke syndromes – cortical • Posterior Circulation • ECVA/ICVA • Dizziness/Vertigo • Cranial nerve lesions • Cerebellar symptoms • PCA • Homonymous hemianopia • Hemisensory changes (lateral thalamus) • Left PCA – alexia without agraphia, Gerstmann (acalculia, agraphia, finger agnosia, R/L disorientation) • Right PCA – prosopagnosia, visual neglect • Bilateral – cortical blindness (Anton’s syndrome)

  25. http://www.neuropenews.org/?attachment_id=2010

  26. large vessel stroke syndromes – cortical • Basilar artery • Typically presents as ischemia in the pons • Asymmetric but bilateral motor and reflex abnormalities • Bulbar involvement • Respiratory involvement • “Tip of the Basilar” • Decreased LOC • Oculomotor/pupillary abnormalities

  27. small vessel stroke syndromes – subcortical • Pure motor • Corona radiata, posterior limb of the internal capsule, pons, medulla • Pure sensory • Thalamus • Sensorimotor • Thalamus, basal ganglia • Ataxic hemiparesis • Corona radiata, anterior limb of the internal capsule • Dysarthria-clumsy hand syndrome • Upper pons, junction between CR and IC

  28. acute stroke

  29. FDA approved options • (r)tPA (recombinant) tissue plasminogen activator – Gold Standard • Approved for use within 3 hours of onset of neurologic deficits in a defined population of patients • Aspirin 325mg • Approved for use in patients who do not receive tPA who do not have any contraindications (drug allergy) and 24 hours after receiving tPA if there is no hemorrhage on 24h post-tPA CT/MRI scan

  30. tPA mechanism of action http://www.cvpharmacology.com/thrombolytic/thrombolytic.htm

  31. tPA – evidence based medicine • National Institute of Neurological Disorders and Stroke (NINDS) tPATrial • NEJM.1995;333:1581-1587 • European Cooperative Acute Stroke Study (ECASS) I • JAMA 1995;274(13):1017-25 • ECASS II • Lancet. 1998;352(9136):1245-51 • ECASS III • NEJM. 2008;359:1317-1329

  32. tPA • What do you need to give IV tPA • Last known normal • Focal neurologic deficits by physical examination • Non-contrasted head CT • Finger stick blood glucose

  33. thrombectomy • Indications • Large vessel strokes (even after receiving IV tPA) • Outside of the window for IV tPA • Imaging suggestive of penumbra • Contraindications • Matched deficit on CTP

  34. stroke = brain attack • Why should you call a BAT • Sudden development of focal neurologic findings • Why you should NOT call a BAT • Altered mental status (without focal neurologic findings) • To get a faster head CT • Who gets paged – it is an emergency after all… • Neurology residents on call • All vascular neurology attendings • All NSICU attendings • All neuroradiology attendings • On call radiology residents • All neurointerventional radiologists • NIR techs and nurses • CT techs • NSICU, 9E and 9W charge nurses

  35. stroke = brain attack • What information is helpful to us? • Last known normal • Symptoms that prompted the BAT • Reason for admission • Current medications • Current labs – including finger stick • Recent vitals • DNR/DNI status

  36. MUSC policy for calling a BAT • Altered mental status • MET is called first, then the MET resident can determine if a BAT is warranted • “If an in-patient is experiencing a change in mental status or confusion the Medical Emergency Team (MET) should be paged to the bedside to assess the patient – not the Brain Attack Team!” • “Once the Medical Emergency Team (MET) has assessed the patient and determines that a BAT should be called, at that time the BAT will respond.”

  37. VA policy for calling a BAT • Regular hours (730a-530p weekdays) • There is always a neurology resident in house, simply page them • After hours • If there is an inpatient that has stroke-like symptoms, the upper level medicine resident is expected to evaluate the patient (ie NIHSS), speak with the neurology resident on call if there is concern for acute stroke and the neurology resident will help direct care while going over to the VA

  38. standard inpatient work up • Neuroimaging • 24 hour post tPA scan • MRI if indicated • Vessel imaging • CTA vs MRA vs carotid dopplers • Labs • A1c, lipids, UA, UDS • When are TFTs indicated • When is B12/folate/RPR indicated • TTE • Agitated saline? • PT/OT/SLP consults

  39. primary prevention

  40. non-modifiable risk factors • Age • Risk of ischemic stroke and ICH doubles for each successive decade after age 55 • Gender • More prevalent in men than in women • Low Birth Weight • Race/Ethnicity • Genetics • A meta-analysis of cohort studies showed that a positive family history of stroke increases risk of stroke by approximately 30% [OR 1.3; 95% CI, 1.2 to 1.5, P < 0.00001] • Cardioembolic stroke is the least heritable type of stroke compared with other ischemic stroke subtypes

  41. modifiable risk factors • Hypertension • Cigarette smoking • Diabetes • Dyslipidemia • Atrial fibrillation • Other cardiac conditions • Asymptomatic carotid stenosis • Sickle cell disease • Postmenopausal hormone therapy • Oral contraceptives • Diet and nutrition • Physical inactivity • Obesity and body fat distribution

  42. secondary prevention

  43. modifiable risk factors • Hypertension • <120/80 • Diabetes • A1c <7% • Lipids • LDL-c <70mg/dL • Treatment with niacin or gemfibrozil in patients with low HDL-c • Cigarette smoking • Advisement to quit • Avoid environmental/passive smoking • Cessation • Physical activity

  44. interventional approaches to patients with large artery atherosclerosis • Symptomatic extracranial carotid disease • CEA recommended if: • Patients with recent TIA or ischemic stroke within the past 6 months and ipsilateral severe (70-99%) stenosis • Patients with recent TIA or ischemic stroke and ipsilateral moderate (50-69%) stenosis, depending on patient-specific risk factors (age, sex, comorbidities) • Indicated for patients with TIA or stroke, surgery within 2 weeks is reasonable rather than delaying surgery • CAS indicated if: • Alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention with ICA stenosis >70%

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