ACVLS 2019 Susana Bowling MD, FAHA, FNCCS · ACVLS 2019 Susana Bowling MD, FAHA, FNCCS •Director...

ACVLS 2019Susana Bowling MD, FAHA, FNCCS • Director of Summa Health System Neuroscience

Institute

• Director of Summa Health Stroke Care Center

• Board Certified Neurologist

• Board Certified Vascular Neurology

• Board Certified Critical Care Neurology

08.15.2019

Communication and Reliability !!!

ADDs

08.15.2019Summa Health 2

Recommendations

• Pay attention

• Go home and read through the hand outs TODAY

• Place the hand outs in a place where you can go back to them in the future

• Go back to the information when you are starting the rotation in neurology or when you are taking call at night and read through it AGAIN

• Practice NIHSS every time you have the opportunity. 3 Summa Health 08.15.2019

SUMMA HEALTH SYSTEMWHAT IS CONSIDER “ACUTE STROKE TEAM”• Acute Ischemic Stroke ( Akron City Hospital ) ( ED and Floors )

• Patient’s seen via tele-stroke at BCH who are being transfer for further interventions

• Acute Stroke Interventional Team ( Akron City Hospital )

• Sub-arachnoid Hemorrhage Program ( Akron City Hospital )This patients will be call as a Stroke Team

• Acute Ischemic Stroke ( Barberton Hospital ) (ED and Floors)

Summa Health 4 08.15.2019

When to call a Stroke TEAM # 1


1 When to call Stroke TEAM • Acute onset of focal neurological deficits for patients :

• Onset symptoms < 4.5 hrs any NIHSS

• Onset symptoms < 24 with NIHSS > or = 5 if baseline function mRS < 2

• SAH (patient evaluated in ED as headache, who’s CTs are found to have SAH

• Patients transferred from BCH, who either • Have received tPA and need to be evaluated upon arrival to the ED to ensure response

and tolerability to the medication (clinically improved or unchanged ) prior to admission to the ICH

• Have received tPA at BCH and had already had a CTA < 6 hrs demonstrating LVO, therefore they need immediate evaluation and activation of Stroke Interventional Team if not done up to that point .

• Where seen at BCH, they may or may have not received tPA, or they are consider “extended window = > 6 hrs. and need CTA . CTP to determine eligibility for endovascular interventions

In any other patient, when in doubt call the stroke neurologist on call to run the case to assist with decision making 08.15.2019

APPROPRIATE TERMS

TIA

STROKE

7 Summa Health 08.15.2019

About CT scanners in the ED

About CT scanners in the ED

08.15.20199 Summa Health

Hand pull,

.\How many people think that having a normal CT in the ED r/o a stroke

Around the room

What do we look for in the CT scanner ?

What do you expect to find in the CT when you get it if the patient is having a stroke .

BE AWARE !!!

NORMAL CT DOES NOT MEAN

NORMAL BRAIN

BE CAREFULL WITH TELLING FAMILIES

THE CT IS NORMAL

LEADS TO CONFUSION

TAKES TIME FOR CHANGES TO BE NOTED

SUBTLE CHANGES EASY TO MISS

PARTICULARLY IN POSTERIOR CIRCULATION08.15.201910

WHAT IS A STROKE STROKE CLASSIFICATION

# 2 -


2 Stroke definition & Classification

Types of Stroke

Stroke occurs when there is a diversion from the normal flow of blood through the arteries to a part of the brain.

We call it “ISCHEMIC” when this flow is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients. 80%

We call it “HEMORRHAGIC” when the blood extravasates the vessels 20%

Hemorrhagic Subarachnoid Hemorrhage Ischemic Stroke


Ischemic Stroke ETIOLOGICAL CLASSIFICATION

# 3


Ischemic Stroke (80%)

AtherothromboticCerebrovascularDisease (20%)

“Cardiogenic” (20%)Lacunar (25%)

3. Stroke Types According to Pathogenesis

Cryptogenic(30%)(30% of this are now found to be caused by PAF)


HEMORRHAGIC Stroke CLASSIFICATION

# 4


4. Classification of HEMORRHAGIC STROKE

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IntracerebralHemorrhage (70%)

Subarachnoid Hemorrhage (30%)

08.15.2019

“Lacunes, Lacunar Infarcts and Small

Vessel Disease”

Mechanism of small vessel infarction • Lacunar etiopathogenesis

• Atherosclerotic

• Athero-thomboembolic

• Embolic (15-20%)

Definition of TRUE Lacunar InfarctOcclusion of the deep penetrating small arterioles

chronically affected by lipohylinosis resulting in thickening of the vessel wall and fibro necrosis


SMALL VESSEL INFARCTION OF EMBOLIC SOURCE


Cardioembolic


Cardioembolic vs AtherothromboticHints to Differentiate


WHAT ARE THE STEPS REQUIRED TO TAKE CARE OF A PATIENT

Take an accurate historyPerform a GOOD Exam

REVIEW of MEDICAL RECORDS REVIEW OF PRIOR TESTING

Decide what is your working diagnosis Decide what TREATMENTS are needed

Decide what TESTING is needed


STROKE RISK ASSESSMENT TESTING

• WHY ARE YOU ORDERING A TEST ? !!!!

• WHAT IS THE QUESTION

• WILL THE RESULTS CHANGE CARE MANAGEMENT

• BENEFIT / RISK NEEDS TO BE FAVORABLE

• IS THIS THE RIGHT TIME TO PERFORM THIS TEST

• WOULD I BE ORFERING IT IF I WAS PAYING FOR IT

• ANY OTHER WAY CHEAPER & SAFER TO GET THE UNSWEAR !!!!


Read the CASE # 5


5. Case :

• 56 yr old man comes for transient aphasia of 2 hr duration now resolved

• Had history of stroke 1 month ago, CTA head and neck where normal except mild carotid stenosis at that time.

• He was found to be on AF and was placed on coumadin then

• IN ED today INR is 1.6

• He has no other complaints.

• What test would you do upon admission to the hospital

o MRI brain ?

o MRA head and neck ?

o ECHOCARDIOGRAM

o TEE

o Carotid ultrasound

o Lipid studies ? Summa Health 24 08.15.2019

ETIOLOGIC CLASSIFICATION

Stroke Subtype

Secondary Prevention

Atherothromboembolic

Cardiogenic

Lacunar

Other

Unknown Etiology

Type I: Incomplete Evaluation

Type II: More than one cause

Type III: Unknown


Name other etiologies of Stroke # 6


6. Some Other Ischemic Stroke Etiologies.

Just to give you an idea.. ( this is out of the scope of this lecture)

• Dissection of vessels, mechanism could be occlusive disease or athero to atheroembolism.

• Arteriopathies ( Familiar, genetic bases ) for example Moya Moya, Cadasil ,Fabry’s

• Arteritis : autoimmune , infectious , for example… Lupus, Primary CNS angiatis, HIV related or HSV …

• Venous thrombosis

• Hematologic, procoagulability disorders… example.. MTHFR, Polycythemia, DIC…

• Drug complications ,(PCCs) , ( Factor VII ), aminocaproic acid.

• Conversion disorders and malingering

• Border-zone infarctions in setting of hypotensive events

• Vasoconstriction Syndromes :

• Drug related .. (cocaine, SSRIs, ) (Fleming’s syndrome )

• Postpartum angiopathy

• RCVCS


CARDIAC RISK ASSESSMENT

Cardiogenic Causes of Stroke # 7


7. Cardiac Causes of Stroke

How can the heart cause stroke’s ?

Embolism

Rhythm

Chambers

Structures (valves)

Hypoperfusion

Low EF

Low CO

Paradoxical events

Congenital / Genetic syndromes


Cardiogenic Causes of Stroke 1

Chamber abnormality

Cardiomegaly

Dilated hypokinetic left

ventricle

Enlarged left atrium ( > 40

mm)

Dilated aortic arch

Enlarged left atrial appendage

Aortic Arch Atheroma

Valvular Disease.

Rheumatic Mitral Stenosis

Infective endocarditis

Non-bacterial thrombotic marantic

endocarditis

Calcific Aortic Stenosis

Bicuspid Aortic Valves

Mitral Annulus Calcification

Myxomatous mitral valvulopathy

with prolapse

Lamb excrescences and or strands

Inflammatory valvulitis

Libman-Sacks endocarditis

Behgets disease

Syphilis


Cardiogenic Causes of Stroke 2

Left ventricular thrombi

Ischemic hearth disease

Acute myocardial infarction (Inf. MI )

Left ventricular akinesia

Left ventricular aneurysm

Non-ischemic cardiomyopathy Viral- cardiomyopathy

Postpartum endocarditis, cardiomyopathy

Hyper-eosinophilic syndrome

Rheumatic

Sarcoidosis

Neuromuscular disorders

ETOH

Catecholamine ( Stung myocardia )

Chagas

Idiopathic dilatations

Hypertrophic sub-aortic

stenosis

Prothrombotic states

DIC

Antiphospholipid Antibody

Essential thrombocythemia

Myeloproliferative disease

Drugs

Crack- cocaine

Doxorubicin

Mitoxantrone

Left Atrial ThrombiSumma Health 31 08.15.2019

Cardiogenic causes of Stroke 3

Left Atrial Thrombi

AF

A flutter

A tachycardia

Sick Sinus Syndrome

Atrial Systole

Enlarged left atrium > 4.0 cm

Atrial septal aneurysm

Miscellaneous

Post Cardiac Catheterization

Post valvuloplasty

Esophageal Atrial Fistula

Paradoxical embolus (

cryptogenic )

Atrial Septal Defects

PFO

Ventricular Septal Defect

Pulmonary Arteriovenous

Fistula


HOW MANY OF YOU THINK THAT ALL STROKES CAUSED BY CARDIAC

CAUSES NEED TO BE TREATED WITH SYSTEMIC

ANTICOAGULATION


Cardiac Stroke Risk Assessment

20% of cardiac emboli go to brain

20% (12- 31%) of strokes are embolic

Not All Cardioembolic Strokes Need AnticoagulationPlatelet aggregates

Thrombus

Platelet-thrombi

Cholesterol

Calcium

Bacterial

Neoplastic cells form Myxomatous material


Paradoxical embolism

• Source of embolism is venous

• Abnormal connection

oPFO

oAVMs ( pulmonary shunting )

• Pelvic veins are common location for deep venous thrombosis,

• Vena Cava Filters DO NOT PROTECT against paradoxical embolism.

• Fat embolism in patients with trauma (think so particularly if noted petechial lesions in the skin classically located in the axilla).


WHAT KIND OF TESTS DO WE DO TO EVALUATE HEART FROM THE

STROKE STAND POINT # 8


#8. Cardiac Risk Assessment• EKG

oAlways Review the EKG done in the ED

• Hospital Telemetry

• ECHO (If not done in last 6 months or new concerns!)oHowever if they are known to have AF and they are already on

anticoagulation … with no new symptoms ECHO most likely is not necessary

• TEEoThose with high suspicion for cardiac embolic source for whom

an abnormal TEE would change management

• Outpatient telemetry • EVENT Recording 30 days

• Loop Recording Summa Health 37 08.15.2019

Vascular Risk Assessment

Name the Studies done for evaluation of vessels

#9


# 9 Vascular Risk Assessment

• CTA head and neck oUsually done in the ED when Stroke Team was called

• MRA head and neck oWhen we do not have a clear image of patients vascular risks

oHead MRA always without contrast,

oNeck MRA preferable with contrast unless contraindicated

oNOT NECESSARY IF PATIENTS ALREADY HAD CTA

• MRVoWhen we suspect venous pathology


# 9 Vascular Risk Assessment

• Carotid ultrasound • When unable to obtain MRAs

• When CT/MRA where insufficient to define severity of stenosis

• As follow up of know intracranial pathology or stents

• When searching for plaque characteristics

• TCDoWhen unable to obtain MRAs

oWhen CT/MRA where insufficient to define severity of stenosis

oAs follow up of know intracranial pathology or stents

o In Sickle Cell Disease

oDetection of Spasm in SAH / trauma patients


Vascular Risk Assessment

• Cerebral angiography

oRemains goal standard for evaluation of cerebral vasculature

oIN acute ischemic stroke, diagnosis and treatment

oIN acute SAH diagnosis and treatment of

oWhen MRA/ Ultrasound data not concordant

oFor intracranial pathology, spasm/ vasculitis/ vascular anomalies


Cerebral Vasculature • More than just the

carotid bifurcation.


Intracranial Endovascular TherapyGoing Beyond the Surgeon’s Scope


ICA Pathology


MRA


DISTAL CAROTID OCCLUSION DUE TO EMBOLISM


Cerebral Vasculature

• Pathology in the vertebral arteries


CVT – cerebral venous thrombosis


Name other stroke risk factors # 10


# 10 OTHER RISK FACTORS

• Uncontrolled riskso Age, 55 or oldero Family history o Gendero Geneticso Prior stroke or TIA

• Controllableo High Blood Pressureo Diabetes o Cigarette Smoking o Alcohol Consumptiono Dyslipidemiao Atrial Fibrillationo Cardiac disease

o Overweight/ Obesity o Physical Inactivity o Sleep apneao Contraception and HRTo Socially Isolated Womeno Adult onset of Asthmao Depressiono Presence of Migraine history,

particularly migraine with aurao Carotid bruit o Illicit drug use o Pregnancy o HIVo Prior history of pregnancy induced

hypertension o Hypercoagulabilityo Fibromuscular dysplasia


DOCUMENTATION


ETIOLOGIC CLASSIFICATION

Stroke Subtype

Secondary Prevention

Atherothromboembolic

Cardiogenic

Lacunar

Other

Unknown Etiology

Type I: Incomplete Evaluation

Type II: More than one cause

Type III: Unknown


When writing diagnosis in the chart this has to reflect the result of our evaluation and THINK DIAGNOSTIC CODES:

• Is this a stroke or TIA? YES / NO . If NOT, write it clearly

• IF ISCHEMIC STROKE

• WHERE IS IT ?

• WHAT was the MECHANISM or CLASSIFICATION

• IF ISCHEMIC with Hemorrhagic transformation, specify the score of HT (see hemorrhage scores)


Hemorrhagic transformation scores per ECASS

• Hemorrhagic transformation :

oAsymptomatic; (no change in clinical exam / NIHSS, or change with an increment of NIHSS < 2 points

oSymptomatic ; Change in the clinical exam resulting in an increase in NIHSS > than 2

• Imaging classification; o HI1; small petechiae

o HI2; more confluent petechial

o PH (Parenchymal Hemorrhage) , with mass effect

• PH1: < 30 5 of the infarcted area with mild space-occupying effect

• PH2: > 30 % of infarcted area with significant space –occupying effect


ICH Need to define the

LOCATION

ETHIOLOGY

SCORE

GCS < 5 (2), 5-12 (1) , > 12 (0 )

AGE > 80 < 80 , (1,0 )

Infratentorial ( 1) , supratectorial (0)

Volume > 30cc (1), < 30cc (0)

Intraventricular (1) , no intraventricular (0)

This translates into a mortality risk in 30 days

1= 13 % , 2= 26% , 3=72% , 4=97% , 5=100%


SAH Need to define the

ETIOLOGY , aneurysm, non aneurysmal, traumatic..

SCORES

Hunt and Hess Scale

Fisher Scale

This translates into a mortality and vasospasm risk


Definition TIA #11


# 11. TIA

Any acute onset of focal neurological deficit

from brain, cord or retina

of presumed vascular origin

which resolves

with no evidence of acute ischemic changes

in imaging evaluation

ABSENCE OF TISSUE INJURY


Definition ACUTE, SUBACUTE, CHRONIC , Transient and persistent

# 12


#12. TIA “ACUTE”- “TRANSIENT”- “FOCAL”

•TIME COURSE OF SYMPTOM ONSEToACUTE : Evolution over seconds or minutes

oSUBACUTE : Evolves over hours or days …(weeks)

oCHRONIC: Evolves over (weeks) months or years.

• DURATION OF SYMPTOMS oTRANSIENT: Symptoms resolved

oPERSISTENT: Symptoms persist


Definition, Focal, Multifocal, Diffused

# 13


#13 Think Like a Neurologist LOCALIZATION

• Where is the lesion?

• FOCAL= strictly confined to a single circumscribed area, usually unilateral

• MULTIFOCAL = more than one focal area, which can be clinically identified and separated.

• DIFFUSE= Symptoms can’t be localized to a focal area but to the entire neuro axis


Is it a Stroke or TIA or NOT ?

Most common inappropriate diagnosis of stroke and TIA are generalized neurologic

conditions and medical conditions

Typically are GLOBAL

Morgenstern, Neurology 2004; 62:895-900


First ROW Samples of TIA mimics


Stroke / TIA Mimics

• Tumors “Pseudo stroke”

• Disorders of metabolism

oGlucose disorders

oDehydration

• Migraine attack

• Seizures

• Conversion

• Infections

• Double jeopardy

• Recurrent symptoms of prior infarction


40 % of stroke teams are false activation

•Consider Seizure • Confusion

• Involuntary movements

• Todd’s Paralysis (prior similar event)

• Positive symptoms

• Decreased level of consciousness > focal deficit

• Having a seizure is not an absolute contraindication for thrombolytics as a stroke can cause a seizure

• Consider No STROKE / TIA• Confusion / encephalopathy

• Altered mental status with no focal findings

• Slurred speech in setting of above or in setting of coexisting medical conditions (hypotension, drugs…)

• Positive symptoms (pain / tingling)

• Generalized weakness or bilateral complaints.

• Exacerbation of prior symptoms


Localization/ Temporal Profile Relationship

ACUTE SUBACUTE CHRONIC

FOCAL VASCULARSeizuresTrauma Pseudostroke ( neoplasm, infections ) PsycheMigraine Panic attack

InfectionsAutoimmune Vitamin deficiencies Neoplastic Psyche

NeoplasmInfections Autoimmune

DIFFUSE VASCULARSAH,POST-ANOXIC

InfectionAutoimmune Metabolic toxic Idiopathic Neoplastic Para neoplastic

DegenerativeCongenital / developmental

Etiologies

V…vascular

I….Infection

T…Trauma

A.. Autoimmune

M…Metabolic/

toxic/ vitamin

deficiencies

I…Idiopathic/

idiosyncratic

N….Neoplastic/

Para

neoplastic

S….Seizures

D—Degenerative

C---Congenital,

Developmental

P---Psyche69 Summa Health 08.15.2019

2nd ROW

SIGNS & SYMPTOMS OF STROKE


Warning Signs of Stroke

• Sudden Weakness of Arm, Leg, Face

• Sudden Sensory Loss

• Sudden Speech Abnormalities

• Sudden and Unusual Headache

• Sudden Vertiginous dizziness or Loss of Balance. (Usually with one other focal complaint.)

• Sudden Loss of Vision (field loss) or Double Vision. (Unusual just blurred vision: dig more into the history and characteristics of the complaint)


Unusual Warning Signs of Stroke / TIA

• Limb shaking TIA’s

• Drop Attacks

• Amaurosis fugax

• Ocular claudication

• RAO

• Dizziness / light headedness

• Abulia

• Agitation


3rd ROWSIGNS and SYMPTOMS SUGGESTING SEIZURE


Consider a Seizure

• Confusion• Involuntary movements• Todd’s Paralysis• Positive symptoms• Decreased level of consciousness > focal

deficit

Having a seizure is not an absolute contraindication for tPA as a stroke can cause a

seizure


Consider No STROKE or TIA

• Confusion / encephalopathy• Altered mental status with no focal

findings• Slurred speech in setting of above or in

setting of coexisting medical conditions (hypotension, drugs…)

• Positive symptoms (pain / tingling)• Generalized weakness or bilateral

complaints. • Exacerbation of prior symptoms


WHO SPEAKS SPANISH IN THIS ROOM?


SPEECH !!! • Dysarthriao Difficulty with the MOTOR production of speech. Patient’s speech appears

garbled (talking with a mouth full of stones or drunk when fully awake)

• Aphasia o Loss of LANGUAGE dictionary. Patients either don’t understand English or

they don’t know how to speak it. Awake and NOT CONFUSED. (You would appear aphasic in Spain if you don’t know Spanish)

• Confusiono Speech is clear and language is normal but patient THOUGHT CONTENT is

wrong. This would typically be associated with decrease in attention, level of consciousness / delirium or dementia.

• Dysphagiao Incoordination / weakness of the SWALLOWING function


NOT Everything that is Quiet is Aphasia

• IF SOMEONE IS TOO ENCEPHALOPATHIC TO TALK THAT IS NOT APHASIA.

• IF THERE IS A REASON WHY PATIENT IS NOT TALKING …

( FOR EXAMPLE UNDER INFLUENCE OF ETOH ) IT IS NOT

APHASIA

• DO NOT USE THE WORD APHASIA TO DESCRIBE CONFUSION

• DO NOT USE THE WORD APHASIA TO DESCRIBE SOMEONE WHO IS NOT TALKING

• DESCRIBE THE COMPLAINTS< SYMPTOMS< DESCRIBED BY PATIENT OR FAMILY


Aphasia

• MOST APHASIC PATIENTS ARE FULLY AWAKE AND AWARE !!!!

• BE CAREFULL WITH STUTTERING . THOUGHT IN RARE CASES STROKE CAN PRESENT WITH STUTTERING IT IS VERY RARE !!! MOST COMMONLY IT’S FAKE !!!


4th Row How do you manage a TIA ?


Management of TIA

• Imaging evaluation within 24 hrs

• Electrocardiography (ASAP)

• Prolonged cardiac monitoring (ASAP)

• Echocardiography (ASAP)

• Admit to hospital if:oSymptoms < 72 hrs and ABCD > 3

oEvaluation can’t be obtained in a timely manner


Cortical Signs # 14


# 14 IDENTIFY LOCATION OF STROKE

“CORTICAL SIGNS”oAphasia (can the patient repeat)

oNeglect

oExtinction

oSpatial disorientation / acalculia

oFace arm v/s face arm and leg

oGraphesthesia, two point discrimination

oHorizontal gaze preference

oHemianopia- visual agnosia-Color agnosia


Lacunar Syndromes # 15


# 15 Lacunar Syndromes

•Small vesselsoPurely motor

oPurely sensory

oDysarthria clumsy hand

oIII nerve + • Contralateral hemiparesis

• Contralateral ataxia

• Contralateral tremor

oAtaxic hemiparesis


Anatomy Anterior Circulation

Xmiclotr.mpg

MCA

M1

M2

Branch

ACA

ICA


Anterior Circulation Signs # 16


#16 Anterior Circulation-RMCA

• Left hemiparesis/hemiplegia

• Left sensory loss

• Dyspraxia

• Neglect

• Face and arm > leg

• Variably, contralateral homonymous hemianopsia

• Impaired contralateral gaze

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Left MCA, left hemisphere # 17


# 17 Anterior Circulation-LMCA

• Language dysfunction

• Right hemiparesis/hemiplegia

• Right sensory loss

• Face, arm > leg

• Variably, contralateral homonymous hemianopsia

• Impaired rightward gaze

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ACA Infarction


Anterior Cerebral Artery

• Hemiparesis/hemiplegia leg > face, arm

• Hemisensory loss leg > face, arm

• Impaired control of micturition

• Abulia or apathy

• Euphoria or disinhibition

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Posterior Circulation Signs # 18


# 18 Posterior Circulation

• Blurred vision/visual loss• Ataxia• Loss of consciousness, waxing waning

consciousness • Nausea/vomiting• Vertigo (rarely isolated)• Nystagmus• Motor or sensory loss in 3-4 limbs• Crossed signs (signs on one side of face

with contralateral side of body)• Deconjugate gaze• Dysarthria, Dysphagia*

o *Rarely is this an isolated symptom

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Anatomy Posterior Circulation

V3

V4

VBDistal R VA

Prox. BA

PCA

AICA

PICA

Top of BA


Top Of Basilar Embolus

Xmiclotr.mpg


Management of Acute Stroke


TIME IS BRAIN…


Occlusive Particle

Penumbra

Recanalization

Reperfusion

Acute Treatment of Stroke Recover The Ischemic Penumbra

Definitive treatment


TRADITIONAL TIMING in Acute Stroke

ER ArrivalDOOR

CT-CTA results

Non C.CT

NIHSS Consent

TPA orderTPA delivery

0:5m. 0:20 0:15m. <30 min

<90 min. ASPECTIA team

ACTIVATION


tPA Eligibility # 19


# 19 New GUIDELINES •tPA•0-3 hrs, ANY NIHSS if disabling < 90

•3-4.5 hrs, ANY NIHSS if disabling< 80 , no prior IS, DM,

•mRS = 0 or 1 08.15.2019Summa Health 102

rTPA eligibility < 3 hrs • MUST ANSWER YES TO ALL CRITERIA

• 1. NIHSS > 1, OR has one of the following:

aphasia or visual field cut.

IF NIHSS LESS THAN 4, must be deficits consider disabling

• 2. Time: Focal neurological deficit onset

< 3 hrs

• 3. Age: > 18 years of age

• 4. Non-contrast CT scan showing no

evidence of either acute hemorrhage or

well established acute infarct.

• 5. Informed consent – VERBAL for 0-3

hours

• MUST ANSWER NO TO ALL CRITERIA• 1. ICH , SAH (including hx ICH or current symptoms suggest

SAH)

• 2. History of stroke or head trauma < 3 months

• 3. Imaging evidence of infarct involving > 1/3 MCA

territory

• 4. Intracranial neoplasm, AVM or aneurysm

• 5. Recent intracranial or intraspinal surgery

• 6. Arterial puncture at a noncompressible site < 7 days

• 7. Systolic BP > 185, D BP > 110, BP not responding to

treatment

• 8. Currently on Coumadin with an INR > 1.7, or received

Heparin within 48 hrs, or with abnormally elevated PTT

• 9. Currently on DOACS in the

last 48 hours

• 10. Platelet count < 100,000/mm3

• 11. Blood Glucose < 50 mg/dl

• RELATIVE EXCLUSION CRITERIA-Consider risk/benefit

• 1. GI, GU tract hemorrhage < 21 days

• 2. Major surgery < 14 days

• 3. Minor or rapidly improving symptoms, NIHSS < 4

• 4. Acute MI within prior 3 months

• 5. Seizure at onsetSumma Health 103 08.15.2019

rTPA eligibility < 4.5 hrs• MUST ANSWER YES TO ALL CRITERIA

• 1. NIHSS > 1, OR has one of the following:

aphasia or visual field cut.

NIHSS 1-4 if disabling symptoms

• 2. Time: Focal neurological deficit onset

> 3hrs but < 4.5 hrs

• 3. Age: 18-80 yrs old

• 4. Non-contrast CT scan showing no

evidence of either acute hemorrhage or

well established acute infarct.

• 5. Verbal informed consent

• MUST ANSWER NO TO ALL CRITERIA• 1. Age > 80

• 2. Patients treated with anticoagulants regardless of INR or

PTT

• 3. NIHSS > 25

• 4. Patients with history of stroke and diabetes

• 5. Imaging evidence of infarct involving > 1/3 MCA territory

• 6. ICH , SAH (including hx ICH or current symptoms suggest

SAH)

• 7. History of stroke or head trauma < 3 months

• 8. Intracranial neoplasm, AVM or aneurysm

• 9. Recent intracranial or intraspinal surgery

• 10. Arterial puncture at a non-compressible site < 7 days

• 11. Systolic BP>185, Diastolic BP>110, BP not responding to

treatment

• 12. Platelet count < 100,000/mm3

• 13. Blood Glucose < 50 mg/dl

• RELATIVE EXCLUSION CRITERIA-Consider risk/benefit

• 1. GI, GU tract hemorrhage < 21 days

• 2. Major surgery < 14 days

• 3. Minor or rapidly improving symptoms, NIHSS < 4

• 4. Acute MI within prior 3 months

• 5. Seizure at onset


Risk/ Benefit based on NIHSS

• NIH stroke scale

o60-70% patients with an NIH <10 have a favorable outcome at one year

o4-16% of patient with a NIH >20 have a favorable outcome.

oHemorrhagic risk after r-tPA;

NIH >20 ---- 17%

NIH <10 ----- 3% (Over all risk of symptomatic hemorrhage with tPA 6 %)


WHAT DO YOU NEED TO KNOW BEFORE GIVING tPA

# 20


# 20 tPA

• BEFORE YOU ORDER/GIVE IT : • Have CLEAR understanding of the last time seen well !!!

• Last time seen well is NOT when the patient was found !!!

• Ask patient if he can talk AND FAMILY , IF YOU MADE FAILED ATTEMPTS TO CALL FAMILY DOCUMENT IT

• Document who told you WHAT ! , ( SISTER, BROTHER, MOTHER.. EMS )

• Ensure absence of contraindications, SEARCH RECORDS !!!.

• PATIENT’s Weight

• Dose is 0.9 mg/kg with a max 90mg.

• 10 % of the total dose is given over 1 min. the rest over 1 hr.


# 21 WHAT DO YOU DO IF THE PATIENT HAS ACUTE CHANGES

AFTER tPA


# 21 tPA

• IF the patient has acute change during infusion . STOP infusion and obtain STAT CT

• IF CT demonstrates bleeding..

oStop tPA

oUse 10 units of cryoprecipitates if thrombolytics used in last 24 hrs.

oIf cryoprecipitates are contraindicated, USE , aminocaproic acid. 45 g IV.


WHAT DO YOU DO IF STROKE TEAM IS CANCELLED

# 22


# 22 IF STROKE TEAM IS CANCELLED

NEEDS TO BE CANCELLED BEFORE IS RUN AS STROKE TEAM !!!!!

IF THE CT IS ALREADY IN THE PROCESS or ALREADY DONE…. Run it and place a final decision of why not tPA

IF STROKE TEAM IS CANCELLED MAKE SURE THAT CT KNOWS ED MD KNOWS ED NURSE KNOWS

PATIENT CARE MAINTAINED BY ED ATTENDING… RESIDENTS WILL BE ABLE TO LEAVE ONCE CLEAR HAND OFF OF CARE TO THE ED ATTENDING 111 Summa Health 08.15.2019

BESIDES tPA what else can you do acutely for patients when having

acute symptoms ( Around the room )


•Supine HOB = 0 – 20 degrees. (not for all patients )

•Supplemental O2, SAT > 94%

•Get a set of vital signs

•Fluid Resuscitation

• If no signs or H/O CHF

• This is not an uncontrolled, unmeasured volume of fluid

•Laboratory Tests

• Most important is Glucose level and INR when patient is known to be on blood thinners

•Transport to CT!!!!!

Treatment of Ischemic Stroke


WHAT ARE THE BP GOALS FOR ACUTE STROKE PATIENTS

# 23


#23 What to do with the Blood Pressure

For acute IS:

No candidate for thrombolytics

220/115

If candidate for thrombolytics

185/110

After thrombolytics

180/105

After revascularization OR IF YOU ARE DEALING WITH ICH /SAH

140/90

After the acute phase

130/80 08.15.2019115 Summa Health

Early ASA in Acute Stroke TreatmentFOR PATIENTS NOT TREATED WITH TPA

Two studies:

Chinese Acute Stroke Trial ( CAST )

International Stroke Trial ( IST )

Each enrolled 20,000 pts

Both demonstrated that early ASA reduced mortality and disability


ENDOVASCULAR TREATMENT


Then came MR CLEAN !!!

MR. CLEAN – 500 pts, NIHSS > 2, Proximal & anterior circulation, < 6 hrsstart, IV tPA, Stent retrievers 81.5% TIBI 2b/3 59% . Absolute difference of 13.5% functional independence at 90 days, and 1.67 OD for better outcomes.

ESCAPE -316 pts < 12 hrs. But only 49 % had treatment > 6 hrs. CT, CTA, ASPECTS score 6-10 , proximal & anterior circulation, no exclusions based on coagulopathy, prior stroke or trauma. Good collaterals, 58% had IV rtPA. < 4.5 hrs TRIAL STOPPED Early due to OR for favorable outcome 3.1 with 53 % patients with mRS 0-2 at 90 days of 53 %. VS 29.3 and mortality 10.4 ( IA ) vs 19.0 control, sICH 3.6 (IA) vs 2.7 % (control). Stent retriever 86 %, TIBI 2b/3,

72.4 %

NEW GUIDELINES 2018

• IV rtPA should receive it < 4.5 hrs (NIHSS > =1 )

• Endovascular therapy THE GAME OF 6s …

oPre mRS 0-2 If independent or with non limited deficits ..

oCausation : Occlusion of the ICA or M1 segment

o> 18 yrs of age

oWith a ASPECT SCORE > or = 6

oLess than 6 hours or 6-24 hours

oNIHSS > or = to 6

oGoal of TICI 2b/3 reperfusion

119

Figure 1. ASPECTS study form adapted from Barber et al.4 Score allows deductions based on

occupancy of lesion in each of 10 ASPECTS regions.

Robert K. Kosior et al. Stroke. 2010;41:455-460

Copyright © American Heart Association, Inc. All rights reserved.

YOU could get a device like this …

• Solitaire stent retriever

• Solumbratechnique

121 Summa Health

And then do this :

ONLY BENEFIT 10 %Of ISCHEMIC STROKE PATIENTS

Up till now the only vessels treated included

ICA

MCA (M1 )

TIME IS BRAIN! YES but not the same for every body

Summa Health Sample Preso124

The difference is physiology

Figure 3. A patient with acute ischemic stroke (Patient 13), a 66-year-old woman with 2 different

slices shown (CT image not registered).

Robert K. Kosior et al. Stroke. 2010;41:455-460

Copyright © American Heart Association, Inc. All rights reserved.

2/2018

08.15.2019

DEFUSE 3 Trial 16 hrs• Inclusion criteria:• Occlusion of internal carotid artery (cervical or intracranial) or proximal

middle cerebral artery• Infarct volume (ischemic core) <70 cc• Ratio of volume of ischemic tissue to initial infarct volume ≥1.8• Absolute volume of potentially reversible ischemia (penumbra) ≥15 cc

• Exclusion criteria:• Limited life expectancy• Pregnancy• Unable to undergo brain imaging• Bleeding abnormality• Seizures at onset• Glucose <50 mg/dl or >400 mg/dl• Platelet count <50,000/cc

Defuse outcomes • Secondary outcomes:

• Functional independence: 45% for endovascular thrombectomy vs. 17% for standard medical therapy (p < 0.001)

• Mortality at 90 days: 14% for endovascular thrombectomy vs. 26% for standard medical therapy (p = 0.05)

• Intracranial hemorrhage: 7% for endovascular thrombectomy vs. 4% for standard medical therapy (p = 0.75)

DAWN Trial 24 hrsTarget MISMATCH regardless of the vessel

• - Patient’s arriving after 6 hrs from symptoms onset up to 24

• - Trial used clinical and IMAGING scores

• - Decision based on target mismatch

• -2 point difference in mRS at 90 in favor of treatment group

• -73 % RRR in dependency for activities of daily living . Number needed to treat 2.0

• -35 % absolute increase in the number of patients achieving functional independence mRS 0-2 , Number needed to treat to achieve endpoint of 2.8

Summa Health 133

New GUIDELINES 2018

Thrombectomy

• 0-6 hrs, • NIHSS > = 6,

• mRS 1,2

• 6-16 HRS • NIHSS > or = 6

• mRS 0 , 1, or 2

• + Imaging criteria

• 16- 24 hrs• NIHSS > or = 10

• mRS = 0 or 1

ACA A1 MCA M1

M2

ICA, T

ACA

ICA

135 Summa Health

What means LVO (Large Vessel Occlusion)?

ACA, A2

Branch

HOW TO RECOGNIZE LVO?

• Aphasia

• Hemineglect

• Head deviation

• GAZE DEVIATION

• Visual loss in half of the world

• Severe FACE and ARM

• High NIHSS

• Decreased LOC

• RACE

• CINCINNATI –

C-STAT

M2 M1 ACA ICA T

PCA BA

Be careful with wake up strokes

Awoke with symptoms

Endovascular option

Awoke without symtoms

tPA options + endovascular optios

Scales CSTAT

ACVLS 2019 Susana Bowling MD, FAHA, FNCCS · ACVLS 2019 Susana Bowling MD, FAHA, FNCCS •Director...

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