Recognition and Recognition and Emergency Management Emergency Management

ofofPosterior Circulation Posterior Circulation

StrokeStroke

Todd J. Crocco, MD, FACEPTodd J. Crocco, MD, FACEPProfessorProfessor

WVU Department of Emergency WVU Department of Emergency MedicineMedicine

November 20, 2015November 20, 2015

JBJBMRN#: 070982372MRN#: 070982372

• 45@ time of stroke in December 45@ time of stroke in December 20072007

• Presented with H/A, dizziness, Presented with H/A, dizziness, diplopia, decreased sensation and diplopia, decreased sensation and weakness right arm and leg. weakness right arm and leg.

Initial CT 12/12/2007, 0156Initial CT 12/12/2007, 0156

• Clot at the distal right vertebral artery.Clot at the distal right vertebral artery.

• Narrowing at the origin of the right Narrowing at the origin of the right pica may be secondary to small clot or pica may be secondary to small clot or stenosis.stenosis.

• Area of mild stenosis left vertebral Area of mild stenosis left vertebral artery near origin of the basilar artery artery near origin of the basilar artery adjacent to the right vertebrobasilar adjacent to the right vertebrobasilar junction.junction.

MRI 12/12/2007, 1706MRI 12/12/2007, 1706

• Acute small right lateral medullary Acute small right lateral medullary infarction with what appears to be infarction with what appears to be occluded distal right vertebral artery. occluded distal right vertebral artery. The finding is compatible with The finding is compatible with abnormalities noted with non-abnormalities noted with non-opacification of the distal right opacification of the distal right vertebral artery on CT stroke vertebral artery on CT stroke protocol of 12 December 2007.protocol of 12 December 2007.

Recurrent stroke several days Recurrent stroke several days later…later…

• Readmitted several days after discharge Readmitted several days after discharge with dysphagia and now LEFT arm with dysphagia and now LEFT arm hemiplegia and left leg weaknesshemiplegia and left leg weakness

• CTA 12/21/07 was unchanged as compared CTA 12/21/07 was unchanged as compared to prior examination showing distal right to prior examination showing distal right vertebral artery thrombus, significant vertebral artery thrombus, significant narrowing of the origin of right PICA, and narrowing of the origin of right PICA, and significant stenosis of the proximal basilar significant stenosis of the proximal basilar artery with a 60-70%, which is artery with a 60-70%, which is hemodynamically significant and no hemodynamically significant and no evidence of new thrombus.evidence of new thrombus.

MRI 12/23/2007, 0858MRI 12/23/2007, 0858

• Infarct involving the lower medulla, Infarct involving the lower medulla, which has slightly increased signal which has slightly increased signal than the previous exam, also, now than the previous exam, also, now involving the ventral medullary involving the ventral medullary aspect. There is no hemorrhage aspect. There is no hemorrhage identified.identified.

Reevaluation in 2010Reevaluation in 2010

• CTA 11/12/2010 for recurrent dizzinessCTA 11/12/2010 for recurrent dizziness

• Severe intracranial atherosclerotic Severe intracranial atherosclerotic disease involving the vertebrobasilar disease involving the vertebrobasilar system with a worsening of stenosis at system with a worsening of stenosis at junction of left vertebral artery and junction of left vertebral artery and basilar artery with chronic right distal basilar artery with chronic right distal intracranial vertebral artery occlusion. intracranial vertebral artery occlusion. Stenosis now measures 70% or greater. Stenosis now measures 70% or greater.

MRI 12/7/2010, 1619MRI 12/7/2010, 1619

• 1. Encephalomalacia within the medulla 1. Encephalomalacia within the medulla consistent with tissue loss from remote consistent with tissue loss from remote infarct. There is no evidence to suggest infarct. There is no evidence to suggest acute or evolving infarct on today's acute or evolving infarct on today's examination.examination.

• 2. Loss of flow signal in the right skull 2. Loss of flow signal in the right skull base vertebral artery consistent with base vertebral artery consistent with chronic occlusion depicted on study chronic occlusion depicted on study dated December 21, 2007.dated December 21, 2007.

The turning point…The turning point…

• Recurrent episodes of intermittent Recurrent episodes of intermittent vertigo and lightheadedness several vertigo and lightheadedness several times a week felt to be due to times a week felt to be due to vertebral-basilar insufficiency. vertebral-basilar insufficiency.

• 12/13/10 Enrolled in SAMMPRIS trial. 12/13/10 Enrolled in SAMMPRIS trial. Randomized to medical therapy arm. Randomized to medical therapy arm.

• 5’11’’, 306lb, Haic 8.3, Htn, HLD, 5’11’’, 306lb, Haic 8.3, Htn, HLD, OSA on cpap at night. OSA on cpap at night.

September 2015 follow upSeptember 2015 follow up

• 53 yo WM here for follow up. He is s/p Gastric 53 yo WM here for follow up. He is s/p Gastric bypass (Roux-en-Y) . bypass (Roux-en-Y) .

• Morbid obesity- lost 75 lbs prior to surgery. He Morbid obesity- lost 75 lbs prior to surgery. He has lost 48 lbs more since 12/9/14.has lost 48 lbs more since 12/9/14.

• HTN- his BP has been doing well. He is off HTN- his BP has been doing well. He is off Lisinopril. Lisinopril.

• T2DM- his A1C is 4.1, In July. he is off all meds T2DM- his A1C is 4.1, In July. he is off all meds for this. for this.

• HLD- TC 127 HDL 47 LDL 72 TG 39 off CRESTOR HLD- TC 127 HDL 47 LDL 72 TG 39 off CRESTOR 40 mg a day due to cost since May. He is off 40 mg a day due to cost since May. He is off fenofibrate 54 mg a day. I started Atorvastatin fenofibrate 54 mg a day. I started Atorvastatin 40 mg a day last visit. 40 mg a day last visit.

Posterior Circulation Posterior Circulation IschemiaIschemia

Posterior circulation ischemia can range from fluctuating brainstem symptoms, caused by intermittent insufficiency of the posterior circulation (so-called VBI), to the “locked-in syndrome," which is caused by basilar artery or bilateral vertebral artery occlusion.

Posterior Circulation Ischemia •20% of all strokes

– Up to 20-60% have an unfavorable outcome– New England Medical Center Registry of

Posterior Circulation Strokes•Overall mortality among 407 patients was

reported at only 4%, with 79% having minor or no disability

•Basilar artery occlusion (BAO)– 8-14% of all posterior circulation strokes– Mortality of over 90%

Anatomy & PathophysiologyAnatomy & Pathophysiology

•Etiology thought to be local arterial atherosclerosis (large artery disease) and penetrating artery disease (lacunes)

•New evidence that cardiogenic embolization is more common– 20-50% of posterior circulation strokes

Risk FactorsRisk Factors

•Uncontrollable risk factors include – Age– Gender– Race– Family history of stroke or TIA– Personal history of diabetes

Risk FactorsRisk Factors

•Medical stroke risk factors include– Hypertension– Heart disease (atrial fibrillation or LVH)– Previous stroke or TIA– Previous heart surgery– Carotid artery disease– Peripheral vascular disease– Smoking

Risk FactorsRisk Factors

•Each decade past age 55: 2x

•Past history of stroke or a TIA: 10x

•Atrial fibrillation: 6x

•Smoking: 2x

Risk FactorsRisk Factors

•The most common causes for vertebrobasilar occlusion are atherosclerosis in the elderly, and trauma in the younger population

Signs & SymptomsSigns & Symptoms

•Wide variety of syndromes– Hemi or quadriparesis– Cranial nerve deficits (III-XII)– Respiratory difficulty– Altered sensorium– Vertigo– Ataxia– Multiple cranial nerve signs indicate

involvement of more than one brainstem level

Signs & SymptomsSigns & Symptoms

•"5Ds”– Dizziness – peripheral or central– Diplopia – ophthmalmologic versus

neurologic– Dysarthria– Dysphagia– Dystaxia

Signs & SymptomsSigns & Symptoms

•“Crossed findings”– Cranial findings on the side of the lesion

and motor or sensory findings on the opposite side.

Signs & SymptomsSigns & Symptoms

• The most frequent posterior The most frequent posterior circulation symptoms were dizziness circulation symptoms were dizziness (47%), unilateral limb weakness (47%), unilateral limb weakness (41%), dysarthria (31%), headache (41%), dysarthria (31%), headache (28%), and nausea or vomiting (27%)(28%), and nausea or vomiting (27%)

New England Medical Center Posterior Circulation Registry. Arch Neurol. 2012;69(3):346-351.

Shifting Gears…..Shifting Gears…..

What Does the ED Provide?What Does the ED Provide?

Availability 24/7/365Availability 24/7/365

Speed (when it matters)Speed (when it matters)

Critical care skillsCritical care skills

Very broad clinical knowledgeVery broad clinical knowledge

What Does This Imply?What Does This Imply?

24/7 availability requires a lot of 24/7 availability requires a lot of people and coordinationpeople and coordination

For speed, need to clarify the stakesFor speed, need to clarify the stakes Every specialty has a “special need”Every specialty has a “special need”

Critical care to patients with perceived Critical care to patients with perceived critical needscritical needs

Broad knowledge baseBroad knowledge base needneed specialty backupspecialty backup

Three Important MessagesThree Important Messages

• The ED has limitationsThe ED has limitations– ‘‘You want a piece of me TOO?!’You want a piece of me TOO?!’

• Delays are real – ‘systems’ can fix themDelays are real – ‘systems’ can fix them– Buy-in and perception is neededBuy-in and perception is needed

• Planning and communication is neededPlanning and communication is needed– Develop protocolsDevelop protocols

ED EvaluationED Evaluation

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The ED “Stroke Protocol”The ED “Stroke Protocol”

• Focused history and physical (ABC’s)Focused history and physical (ABC’s)– General and neurologic assessmentGeneral and neurologic assessment

• Fingerstick glucose measurementFingerstick glucose measurement• IV access and STAT labsIV access and STAT labs• Contact stroke team?Contact stroke team?• Patient monitoringPatient monitoring

– Frequent monitoring of VS and neuro examFrequent monitoring of VS and neuro exam– Oxygen and cardiac monitoringOxygen and cardiac monitoring

General Stroke General Stroke ManagementManagement• Activate ‘Stroke Activate ‘Stroke

Team’Team’

• Check glucose & Check glucose & labslabs

• Two large IV linesTwo large IV lines

• Oxygen as neededOxygen as needed

• Cardiac monitorCardiac monitor

• Continuous pulse-oxContinuous pulse-ox

• CT scan….STATCT scan….STAT

• Confirm LSNN timeConfirm LSNN time

• Perform neurologic Perform neurologic examexam

• Get “real” with rt-PA Get “real” with rt-PA – Prepare to mixPrepare to mix– Have pharmacy Have pharmacy

alertedalerted

• Discuss with patient Discuss with patient and family potential and family potential treatmentstreatments

• Begin general Begin general managementmanagement

General Stroke General Stroke ManagementManagement• Cardiac monitorCardiac monitor

– Observe for ischemic changes or atrial Observe for ischemic changes or atrial fibrillationfibrillation

• Intravenous fluidsIntravenous fluids  – Avoid D5W and excessive fluid administrationAvoid D5W and excessive fluid administration– IV normal saline at 50 cc / hr unless otherwise IV normal saline at 50 cc / hr unless otherwise

requiredrequired

• NPONPO– Aspiration risk, avoid PO until swallowing Aspiration risk, avoid PO until swallowing

assessedassessed

• Blood pressureBlood pressure– Function of fibrinolytic eligibilityFunction of fibrinolytic eligibility

Team CommunicationTeam Communication

• Nursing Nursing ED doc ED doc Consultants Consultants

• For the ED team – just like any resuscitationFor the ED team – just like any resuscitation

• ED / Consultant communicationED / Consultant communication

– Absolutely criticalAbsolutely critical– Complementary roles / complementary Complementary roles / complementary

skillsskills– Don’t say yo-yo!Don’t say yo-yo!

NINDS RecommendationsNINDS Recommendations

• Door-to-MD:Door-to-MD: 10 minutes 10 minutes

• Door-to-StrokeDoor-to-Stroke 15 minutes 15 minutes Team notification:Team notification:

• Door-to-CT scan:Door-to-CT scan: 25 minutes 25 minutes

• Door-to-Drug: 60 minutes Door-to-Drug: 60 minutes (80% compliance)(80% compliance)

• Door-to-Admission: 3 hoursDoor-to-Admission: 3 hours

American Heart Association 2005;European Stroke Initiative Executive Committee, Cerebrovasc Dis 2003;16:311–337;

NINDS National Symposium on Acute Stroke, 2003. 3232

Diagnosis & EvaluationDiagnosis & Evaluation

• History and physicalHistory and physical

•Physical exam– Cranial nerve findings– Eye movements – Cerebellar findings combined with

opposite long tract (sensory and motor) signs

Emergency Diagnostic Emergency Diagnostic StudiesStudies

• Brain imaging – CT or MRI?Brain imaging – CT or MRI?

• ElectrocardiogramElectrocardiogram

• Complete blood count and platelet Complete blood count and platelet countcount

• INR and aPTTINR and aPTT

• Blood chemistriesBlood chemistries

• Pulse oximetry, chest x-rayPulse oximetry, chest x-ray

• CSF examination?CSF examination?

Current Treatment OptionsCurrent Treatment Options• Physiologic optimizationPhysiologic optimization

• No thrombolyticsNo thrombolytics– Aspirin Aspirin

• Death / nonfatal strokes reduced 11%Death / nonfatal strokes reduced 11%

– HeparinHeparin

• Intravenous rt-PA Intravenous rt-PA – Risk stratify although all subgroups benefited Risk stratify although all subgroups benefited

from thrombolytics in NINDS from thrombolytics in NINDS

• Other treatmentsOther treatments– Intra-arterial thrombolysis with rt-PAIntra-arterial thrombolysis with rt-PA– Mechanical embolectomyMechanical embolectomy

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ManagementManagement

• IV thrombolytic therapyIV thrombolytic therapy

•Antiplatelet and antithrombotic therapy is often used, with wide variation in treatment regimens

• Intra-arterial thrombolytic therapy has been used successfully for patients with suspected BAO

ManagementManagement

•Traditionally, heparin has been used in the treatment of posterior circulation strokes, based upon uncontrolled trials showing benefit compared to historical controls

Recanalization StrategiesRecanalization Strategies

• FDA cleared interventions:FDA cleared interventions:– IV tPA (0-3 hours)IV tPA (0-3 hours) Approved 1996Approved 1996– IV tPA (3-4.5 hours)IV tPA (3-4.5 hours) Practice Advisory 2010Practice Advisory 2010– Devices Devices Cleared for clot removal 2004Cleared for clot removal 2004

Time Window 0-3 hours 3-4.5 hours 3-6 hours >6 hours

Options•IV tPA•Device

• IV tPA• IA Lytic /

Device

•IA Lytic•Device

• Device

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ConclusionConclusion

•Wide variety of symptoms

•Crossed findings (cranial nerve findings ipsilateral, with motor and sensory findings contralateral)

•5 Ds (dizziness, diplopia, dysarthria, dysphagia, and dystaxia)

•Stroke care is a team sport

Questions?Questions?