Stroke
David Friedgood, DO
Stroke - definition
• A sudden loss of brain function caused by
blockage or rupture of a blood vessel to the
brain
• Associated Neurologic deficit
– loss of muscular control
– loss of sensation or consciousness
– dizziness
– Speech disturbance / aphasia
– Visual disturbance / diploplia, hemiaopsia
Definitions
• Stroke is a medical emergency
• Prompt recognition, evaluation, and
treatment can minimize brain damage
• Stroke can be treated and prevented
– Risk factor management
• Synonym = Brain Attack
– Avoid ‘CVA’
Transient Ischemic Attack (TIA)
• A TIA is a stroke
– Symptoms usually resolve in minutes
– Symptoms may persist up to 24 hours
• Symptoms of Neurologic deficit similar to
completed stroke
– 2° temporary decrease in local cerebral blood
flow
– May be associated with MRI evidence of acute
ischemia
Statistics
• Stroke is 4th leading cause of death
– 129,180 (CDC 2010, rate – 1.5% decrease from 2009)
• ~ 795,000 strokes in USA (1 every 40 sec.)
– 87% ischemic
– 10% intracranial hemorrhage
– 3% subarachnoid hemorrhage
• 7,000,000 Americans ≥ 20 have had a stroke
• Greater incidence in ♂, but more ♀ with
strokes
Annual rate 1st Stroke
Cinn. / N. Kentucky Stroke Study - 1999
Prevalence of Stroke
2005 – 2008 data
Circ. 2012
Annual age adjusted Stroke
incidence
Kleindorfer, et al – 1993, 1999, 2005
Types of Stroke
• Ischemic
– Embolic
– Thrombotic
– Secondly hemorrhagic
• Intracranial Hemorrhage
• Subarachnoid Hemorrhage
Embolic Stroke
• Most often presents with sudden onset,
maximum Neurologic deficit
• Embolic source:
– Cardiac / Paroxysmal
– Aorta, carotid, vertebral arteries
• Associated with:
– Cardiac arrhythmia – atrial fibrillation
– Myocardial infarction
– Patent Foramen Ovale
Thrombotic Stroke
• Often presents with evolving / fluctuating
Neurologic deficit
• History TIA’s
• Typical patient:
– Chronic vascular disease (vasculopath)
– Multiple stroke risk factors
Secondarily Hemorrhagic Stroke
• Typically a re-perfusion phenomenon after
cerebral ischemia
– ~ 5% of ischemic infarctions
• Increased incidence with:
– t-PA (~ 6%)
– anticoagulation
– anti-platelet therapy (small risk)
• Often results in deterioration of neurologic
status
Intracranial Hemorrhage
• Primary ICH
– 2° hypertensive cerebral-vascular disease
– 2° cerebral amyloid angiopathy
• Vascular anomaly
– AV malformation
– Cavernous angioma
– Venous angioma
– Capillary telangiectasia
• Trauma
82 yo hypertensive ♀ presents with obtundation
and R hemiplegia.
Subarachnoid Hemorrhage
• Intracranial aneurysms (~ 80 %)
– 80% about circle of Willis
– 10% at post. inf. cerebellar a. origin
– Consider mycotic aneurysm if in distal middle
cerebral artery
– May have history of sentinel leaks / headaches
• Post-traumatic
• Rarely 2° other vascular anomalies /
coagulopathies
34 yo ♀ presents with 2nd ‘thunderclap’ headache. She was
lethargic without significant neuro deficit.
Bleeding Management
• Warfarin reversal
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Vitamin K 10 mg IV
FFP (fresh frozen plasma) 2 – 6 units IV
rFactor VIIa 15-90 µg/kg
PCC (prothrombin complex concentrate)
• Factors II, VII, IX, X
• Heparin reversal
– Protamine SO4 10-50 mg IV
• Thrombocytopenia
– Platelet infusion IV
Common Stroke Mimics
• Conversion disorder
– No cranial nerve deficits
– Atypical symptoms in a non-vascular distribution
• Hypertensive encephalopathy
– HA, delirium, ↑ BP (PRES syndrome)
• Hypoglycemia
• Complicated migraine
– History similar events, HA, prodrome / aura
• Seizures
– With post-ictal symptoms
Stroke Risk Factors
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Prior stroke
Age > 55
HTN – 30 – 40 %
DM - 14 – 50 %
Tobacco use – 50 % @ 1 yr.
Dyslipidemia - ~ 25%
Obesity
Estrogen use
Alcoholism
• Substance abuse
– Cocaine, Methamphetamine
• Race - > African-American
• Coagulopathy – SS disease
– Anti-phospholipid syn.
– ↑ homocysteine
• Chronic inflamation /
Vasculitis – Temporal arteritis
• Family history / Congenital
– MELAS syndrome
Cardiac Risk Factors for Stroke
• Arrhythmia
– Atrial fibrillation
• Myocardial infarction
• Valvular disease
– Sub-acute bacterial endocarditis
– Prosthetic heart valve
– Mitral / Aortic disease (increased with Rheumatic valve dis.)
• Patent foramen ovale
• Cardiac surgery
Complications of Stroke
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Paralysis
Sensory loss / Perceptual deficit (Apraxia, Agnosia)
Visual loss / Diploplia
Speech disturbance / Aphasia
Dysphagia / Nutritional deficiency
Memory / Behavioral disturbance
Pain – (Central pain syndrome / allodynia)
Seizures
Stroke Management
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Recognition and pre-hospital
Emergency Room evaluation and Rx
Hospital Care
Rehabilitation
Post-hospital care
Stroke prophylaxis
Stroke Chain of Survival
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Detection
Dispatch
Delivery
Door
Data
Decision
Drug
- Recognition of stroke sign / symptoms
- Call 911, priority EMS dispatch
- Prompt transport / hospital notification
- Immediate ED triage
- Prompt ED evaluation, lab, CT brain
- Diagnosis / decision i.e. appropriate Rx
- Administration of appropriate drugs /
other therapies
Circulation 2007:115:e478-534
Stroke Evaluation
• History and Physical – time of Stroke onset
• Attention to ABC’s
• Urgent Lab:
– CBC, CMP, ESR / CRP, PT, PTT, B-HCG, drug Screen, CK /
troponin, pulse oximetry / ABG’s
• Lab:
– Lipid profile, TSH, coagulopathy screen, etc.
• Brain scan
– CT / CT angiogram
– MRI / MR angiogram
Stroke Evaluation (cont.)
• Urgent:
– EKG, Chest X-ray
• Echocardiogram
– Trans-thoracic, Trans-esophageal
• Carotid / Vertebral US
• Optional:
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MR venogram
TA biopsy, brain biopsy
EEG
Etc.
- Lumbar puncture
- Catheter angiogram
Emergency Stroke Treatment
• Emergency transport to ER with capabilities for
Stroke management
• Address ABC’s, open IV, O2
• Serum Glucose management
• BP management
– Avoid hypotension / Rx hypertension cautiously
• except SAH
– Do not lower BP < 220/120 (185/110 for t-PA)
• Labetalol 10 mg IV (nitropaste, nicardipine)
• ? ASA
• Stroke Scale (NIH stroke scale)
– 0 - 42
ED-Based Care – Time Goals
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Door to physician ≤10 minutes
Door to stroke team ≤15 minutes
Door to CT initiation ≤25 minutes
Door to CT interpretation ≤45 minutes
Door to drug (≥80% compliance) ≤60 minutes
Door to stroke unit admission ≤3 hours
Recombinant Tissue Plasminogen
Activator (t-PA)
• Indicated for acute non-hemorrhagic Stroke
– Up to 3 hrs. after stroke onset
– Extend to 4.5 hrs in selected patients ≤ 80 yo
• Benefit in ~ ⅓ patients
• 2° hemorrhage rate ~ 6 %
• Dose:
– 0.9 mg / kg IV (90 mg max.)
– 10% bolus, remainder over 1 hour
t-PA
• FDA approved 1996
• The National Institute of Neurological Disorders and Stroke
rt-PA Stroke Study Group. Tissue plasminogen activator for
acute ischemic stroke.
N Engl J Med 1995;333:1581–1587
• 624 stroke patients
– ↑ odds favorable outcome - OR 1.9
– Less global disability, neurologic deficits, and increased
ADL’s (34% vs 20%)
– 3 mo to see statistical significance. Persisted at 1 year
– No change in mortality at 3 mo., or 1 yr.
t-PA
• Significant improvement in outcome when
treatment initiated < 90 min.
• Relative safety with treatment up to 4.5 hrs
– Studies excluded: > 80 yo, large strokes, any
anticoagulant use, and diabetics with prior stroke
• Morbidity and mortality significantly increase
with treatment > 4.5 hrs
• FDA maintains 3 hour window
T-PA Side Effects
• Bleeding
• Myocardial rupture
– Treatment within few days of an acute MI
• Angioedema
– 1-5%
– Possibly increased risk with ACE inh
– Rx: antihistamines, steroids Anaphylaxis
• Anaphylaxis - rare
Contraindications to t-PA
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Minor stroke / rapidly clearing symptoms
Major neuro deficits / significant CT edema
Stroke / head trauma within 3 mo.
GI / GU hemorrhage within 21 days
Major surgery within 14 days
History intracranial hemorrhage
Acute trauma / active bleeding
– Plts < 100,000
• Uncontrolled BP > 185/110
Contraindications to t-PA (cont.)
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Symptoms suggesting SAH
Anticoagulation with INR > 1.7
Use of direct thrombin inh., or Xa inhibitors
Blood glucose < 50 or > 400 mg/dl
Acute seizure
Arterial puncture @ non-compressible site < 7 days
Recent LP
Intracranial neoplasm, AVM, aneurysm
Pregnancy
Intra-arterial Thrombolysis
• Option up to 6 hours post Stroke onset (or
later)
• For patients with major stroke and
documented arterial thrombus
– May follow IV t-PA
64 year old diabetic, hypertensive woman presented to ER following a seizure at
dinner. No prior seizures. Had L hemiplegia and confusion on admission. Stroke
Alert called. 2nd seizure in CT.
Endovascular Therapy
• Carotid angioplasty / stenting
– May be an alternative to surgery in selected pts
– Best for patients with previous endarterectomy /
neck radiation therapy
• Vertebral a. angioplasty / stenting
– Reserved for medical failures
• Arterial clot retrieval devices (Merci)
– Reported ‘good’ outcome at 90 days – 33%
– Intracranial hemorrhage rate – 38%
Merci Clot Retrieval
Case Presentation
• 56 yo diabetic, hypertensive ♀ presents with
right hemiplegia and expressive aphasia.
• History untreated paroxysmal atrial fibrillation
• Found by family laying on her bed in night
clothes. Disheveled, incontinent of urine.
CT Scans
Day 1
24 hours
MRI Scan
several hours
after admission
DWI images
Flair
T2 weighted
Case Management
• Not a t-PA candidate
• Started on ASA 81 mg, later switched to Heparin
and Coumadin (INR 2.0 – 3.0)
• Simvastatin 20mg started in hospital
• Speech, Occupational and Physical therapy
started in hospital
• Discharged to Rehabilitation Unit
• Now living at home with family. Moderate
Aphasia and mild R hemiplegia persists
Best treatment for Ischemic Stroke
• Prevention:
– Risk factor management
– Exercise / weight loss
– Avoid tobacco
– Moderate alcohol intake
• Treating hypertension and diabetes mellitus
early is more effective than any medical or
surgical therapy for stroke prophylaxis.
Palliative Care
• Consider for patient’s with devastating /
irreversible brain injury
• Consider prognosis of pre-existing conditions
– Cancer, Dementia
• Consider advanced directives, family /
guardian concerns
• Provide comfort care and Hospice support
Reference
• Guidelines for the Early Management of Patients With Acute Ischemic
Stroke - A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association
Edward C. Jauch, MD, MS, FAHA, Chair; Jeffrey L. Saver, MD, FAHA, Vice Chair;
Harold P. Adams, Jr, MD, FAHA; Askiel Bruno, MD, MS; J.J. (Buddy) Connors, MD;
Bart M. Demaerschalk, MD, MSc; Pooja Khatri, MD, MSc, FAHA;
Paul W. McMullan, Jr, MD, FAHA; Adnan I. Qureshi, MD, FAHA;
Kenneth Rosenfield, MD, FAHA; Phillip A. Scott, MD, FAHA;
Debbie R. Summers, RN, MSN, FAHA; David Z. Wang, DO, FAHA;
Max Wintermark, MD; Howard Yonas, MD; on behalf of the American Heart
Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral
Vascular Disease, and Council on Clinical Cardiology
Stroke. 2013;44:1-78