CNS Alphabet Soup: CVA, ICH, SAH Patient Case Presentations, ED Diagnosis and Management

CNS Alphabet Soup:CVA, ICH, SAHPatient Case Presentations, ED Diagnosis and Management

New York ACEP Scientific AssemblyLake George, NYJuly 5-7, 2006

Thank you to AstraZeneca for their support of this educational session

Panelists • Andy Jagoda, MD, FACEP Mount Sinai School of Medicine • Daniel Labovitz MD, MS • New York University School of Medicine • Peter L. Shearer, MD, FACEP Mount Sinai School of Medicine • Edward P. Sloan, MD, MPH, FACEP University of Illinois at Chicago

Disclosures • Andy Jagoda, MD • AstraZeneca, FERNE • Daniel Labovitz MD, MS • On site • Peter L. Shearer, MD, FACEP • None • Edward P. Sloan, MD, MPH • FERNE

Global Objectives • Improve ED neuro patient care • Minimize morbidity and mortality • Expedite disposition • Optimize resource utilization • Enhance our job satisfaction

Session Activities • Present relevant clinical cases • Poll the audience about care • Discuss the questions • Understand areas of consensus • Explore areas of uncertainty • Go forth and prosper

Case Presentation • 38 year-old female complains of the “worst headache of her life” • Diffuse head pain, some nausea • No ENT sx, no neck pain • No sudden onset, no fever • Hx headaches in the past, Migraine Hx? • Hx prior CT, years ago, negative

Case Presentation • VS 158/70 RR 18 P 96 Temp 98.6 • Prefers to lie quiet with eyes closed • ENT normal • Pupils OK, mild photophobia? • No meningismus • Cardiopulmonary exam OK • Mental Status OK • Neurological Exam • Awake and alert, MS OK • No focal weakness, sensory LT OK • Speech, vision, gait OK

Question: Cephalgia What is your assessment of SAH risk in headache patients?

Question: Cephalgia I consider “worst headache of life” presentations to be consistent with SAH, requiring complete evaluation

Question: Cephalgia B. I only consider thunderclap headache to be significant for SAH risk, even if patients state a worst headache

Question: Cephalgia C. I do not strongly rely on the description of the headache, instead relying on the physical exam at the time of the patient presentation.

Question: Cephalgia D. I have no opinion on this matter.

Question: Cephalgia Worst headache signifies SAH Thunderclap headaches means SAH Description less important, physical exam at presentation most important No opinion

Question: CT & SAH Regarding the diagnostic accuracy of cranial CT in excluding SAH, I believe the following:

Question: CT & SAH CT, even new generation scanners, cannot exclude SAH, requiring LP in all at risk patients

Question: CT & SAH B. I believe that CT can exclude SAH, but I still tend to LP all at risk patients

Question: CT & SAH C.I believe that new generation scanners can exclude SAH with adequate sensitivity such that LP is not indicated with a negative CT unless the headache patient is at high risk for SAH

Question: CT & SAH D. I have no opinion on this matter.

Question: CT & SAH CT doesn’t exclude SAH, LP risk pts CT excludes SAH, but I LP anyways New generation CT excludes SAH No opinion

Question: CT, LP Negative My approach to moderate to high risk headache pts when the CT and LP are negative and the symptoms have resolved is as follows:

Question: CT, LP Negative A.If both are negative, I discharge home if symptoms resolve because SAH risk is minimal.

Question: CT, LP Negative B.Further workup is required, even if both are negative. I arrange for a MRA, CTA or angiogram from the ED

Question: CT, LP Negative C.Further work-up is required, and I admit to neurology for this to be done

Question: CT, LP Negative D.I do whatever the PMD or neurology consultant requests for this patient

Question: CT, LP Negative Discharge home as able Further work-up in the ED Admit for further work-up Do whatever consultant, PMD want

Question: Traumatic Tap An LP is performed, with 10,000 RBCs in tube 1 and 5,500 RBCs in tube 4. Your interpretation of this CSF is as follows:

Question: Traumatic Tap A.This is clearly evidence of a SAH because of the large number of RBCs noted in tubes I and 4, even if moderate clearing of RBCs occurs in tube 4.

Question: Traumatic Tap B.This is a confusing LP, and a repeat (delayed) LP must be performed in order to attempt to detect xanthrochromia.

Question: Traumatic Tap C.Because there is nearly 50% clearing by tube 4, and because the overall number of RBCs is relatively low, this is likely a traumatic tap. I would do no other testing to exclude SAH.

Question: Traumatic Tap D.I do not know how to interpret this LP or what I would do next for this patient.

Question: Traumatic Tap This clearly confirms a SAH Confusing, repeat LP indicated This clearly is a traumatic tap I don’t know what it means

Question: Sx Resolution Regarding symptom resolution in cephalgia patients with suspected SAH, I believe the following:

Question: Sx Resolution A.Symptom resolution suggest to me that a SAH is highly unlikely.

Question: Sx Resolution B.Symptom resolution only signifies low risk for SAH if I have not used narcotics to cause the symptoms to resolve.

Question: Sx Resolution C.Symptom resolution is unreliable for excluding significant pathologies such as SAH. As such, I disregard this clinical factor in determining diagnosis, treatment and disposition plan.

Question: Sx Resolution D.I have no opinion about the relationship between symptom resolution and SAH risk.

Question: Sx Resolution Headache resolution: low risk SAH Low risk SAH only if no narcotics Symptom resolution does not suggest a benign headache etiology No opinion, don’t know relationship

Question: Stroke and ICH A stroke patient presents with an intracerebral hemorrhage of the left temporal lobe of 4 cm diameter associated with mild edema and mass effect. What might be your management of this stroke patient?

Question: Stroke and ICH I would admit this patient to neurosurgery for further orders.

Question: Stroke and ICH B. I would transfer this patient to another hospital because I don’t have neurosurgery coverage and/or it is our institution’s protocol.

Question: Stroke and ICH C. I would be able to manage BP, ICP, the airway, and ICH complications in the ED prior to disposition to another service for admission.

Question: Stroke and ICH D. Not only could I manage the complications, I am aware of published ICH management guidelines, and would follow these guidelines in managing this patient.

Question: Stroke and ICH A. Admit to neurosurgery. B. Transfer for neurosurgery care. C. I can manage pt prior to transfer. D. I know the published ICH guidelines and how to Rx.

Question: ICH and Clopidogrel This left temporal lobe 4 cm diameter ICH associated with mild edema and mass effect occurs in a patient on clopidogrel. What might be your management of this stroke patient?

Question: ICH and Clopidogrel A. Supportive care only if normal bleeding time B. Infuse prothrombin complex concentrate C. Infuse recombinant FVIIa D. Infuse platelets if the bleeding time is abnormal

Question: ICH and Warfarin This left temporal lobe 4 cm diameter ICH associated with mild edema and mass effect occurs in a patient on warfarin. The INR is 5.9. What might be your management of this stroke patient?

Question: ICH and Warfarin A. Supportive care only Administer vitamin K only Infuse fresh frozen plasma D. Infuse prothrombin complex concentrate E. Infuse recombinant FVIIa

Question: tPA and ICH An ischemic stroke patient is treated with tPA, and then is diagnosed as having an ICH associated with some deterioration in mental status. Your management would be as follows:

CNS Alphabet Soup: CVA, ICH, SAH Patient Case Presentations, ED Diagnosis and Management