Stroke 101: Just the Facts…
Deepak S Nair, MD
Vascular Neurology
INI Stroke Center
OSF Saint Francis Medical Center
Questions
• What is Stroke?
• What causes Stroke?
• Can Stroke be treated?
Questions
• What is Stroke?
• What causes Stroke?
• Can Stroke be treated?
Stroke Statistics
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#4 killer in the U.S.
~800,000 strokes in the US/year
220,000 strokes are recurrent
>163,000 deaths (>20%)
4.9 million stroke survivors today
#1 cause of nursing home admission
and leading cause of adult disability
Definition
• Sudden neurologic deficit, occurring
without warning
• Leads to paralysis, speech & language
problems, loss of sensation and mobility,
vision loss
• Due to an area of brain deprived of blood
or that has bleeding in it
• It is not usually associated with pain or
headache
Questions
• What is Stroke?
• What causes Stroke?
• Can Stroke be treated?
Stroke Risk Factors
• Increasing age
• Race
• Gender
– Males > females,
except 35-44 &
>85 y/o
– More females die
• Family History of
Stroke/TIA
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Hypertension
Heart disease
Atrial fibrillation
Diabetes
High cholesterol
Carotid stenosis
Cigarette smoking
Obesity
Non-modifiable Risk Factors
• Increasing age
– >55 yrs
– Risk doubles every additional 10 years
Brown RD, Whisnant JP, Sicks RD, O'Fallon WM, Wiebers DO. Stroke. 1996;27:373-380.
Modifiable Risk Factors
• Hypertension
– RR=4 (≥160/95)
• Atrial fibrillation
– 1% annual risk in <65yrs with no HTN, DM, TIA/CVA
– 24% strokes >80yrs are from AF
• Wolf PA, Abbott RD, Kannel WB. Stroke. 1991;22:983-988.
• Carotid stenosis
– 1-2% annual risk (asymptomatic)
• Bogousslavsky J, Despland PA, Regli F. Neurology. 1986;36:861-863.
– 2.3% perioperative risk
• Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.
JAMA. 1995;273:1421-1428.
– 4.5% perioperative risk
• McCrory DC, Goldstein LB, Samsa GP, Oddone EZ, Landsman PB, Moore WS,
Matchar DB. Stroke. 1993;24:1285-1291.
“The Essential Role of Neurologists
in Treating and Preventing Stroke”
• Accuracy of diagnosis
– “Early Access to a Neurologist Reduces the
Rate of Stroke Misdiagnosis in Young Adults”
– “Diagnosis of Transient Ischemic Attack Varies
by Neurologist”
• Use of appropriate treatments
– “Image Guided Patient Selection and Its
Impact on Outcome: Results of the Penumbra
Imaging Collaborative Study (PICS)”
– “Acute Ischemic Stroke Treatment with
Mechanical Embolectomy Has
Doubled in the US from
2008 to 2010”
Diagnosis of Acute Stroke
• CLINICAL EXAM
• Appropriate brain imaging
– CT, CTA, CTV, CTP
– MRI, MRA, MRV, MRP
• Appropriate lab testing
– Blood glucose
– Coagulation profile
Questions
• What is Stroke?
• What causes Stroke?
• Can Stroke be treated?
Treatment of Acute Stroke
• TPA = tissue plasminogen activator
– AKA, the “clot-buster”
• 1995: NINDS rt-PA Stroke Study
– 2-part, randomized, double-blinded,
placebo-controlled, clinical trial
– N Engl J Med 1995; 333:1581-1588
• 1996: FDA approval for TPA use in Acute
Ischemic Stroke (≤3hrs after onset)
Stroke. 2010; 41:
2381-2390.
Treatment of Acute Stroke
• 2008: ECASS-III
– IV rt-PA vs placebo at 3-4.5hrs post-stroke
– Primary outcome = mRS 0-1 at 90 days
– Alteplase = 52.4% (2.4% sICH)
– Placebo = 45.2% (0.2% sICH)
– Additional exclusion criteria
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Age > 80yrs
Combination of prior stroke + diabetes
Use of warfarin (regardless of INR)
NIHSS score > 25
Hacke, et al. N Engl J Med. 2008; 359: 1317-1329.
Mechanical Thromboembolectomy
Mechanical Thromboembolectomy
• MERCI Retriever (Concentric Medical, Inc)
– MERCI 1 = 43% recanalization; 0% sICH
• Gobin, et al. Stroke. 2004; 35: 2848-2854.
– MERCI trial = 46% recanalization; 7.8% sICH
• Smith, et al. Stroke. 2005; 36: 1432-1438.
– Multi-MERCI = 57.3% recanalization; 9.8% sICH
• Smith, et al. Stroke. 2008; 39: 1205-1212.
• Penumbra System (Penumbra Inc)
– Penumbra 1 = 100% recanalization; 10% sICH
• Bose, et al. AJNR. 2008; 29: 1409-1413.
– Pivotal Stroke trial = 81.6% recanalization; 11.2% sICH
• Sit, et al. Stroke. 2009; 40: 2761-2768.
– POST trial = 87% recanalization;
• Tarr, et al. J NeuroIntervent Surg. 2010; 2: 341-344.
Mechanical Thromboembolectomy
• Solitaire FR device (Covidien)
– Self-expanding, re-deployable stent
– SWIFT trial
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Solitaire FR vs Merci Retriever
60.7% vs 24.1% recanalization, without sICH
Better functional outcome & mortality rates
Saver, et al.
66yo woman with
large Left MCA
territory infarction
Decompressive
Craniectomy
Vahedi, et al. The Lancet Neurology. 2007. 6: 215-222.
Take Home Message: Stroke…
• Is a Neurologic Emergency
• Has many risk factors
• Is best assessed and managed by
trained neuroscience personnel
• Can and should be treated
• Requires a multidisciplinary approach
Case: Stroke Systems of Care
• 65yo man with paralysis & language
deficit
• NOT a candidate for TPA
• Emergent cerebral angiogram
• Unable to pass catheter
• Emergent Carotid surgery
• Back to cerebral angiogram
• Intracranial thrombolysis