Cerebrovascular Disease

Cerebrovascular Disease
Wednesday AM lecture
Mitch Deshazer
Focus on the basics
• Stroke: ischemic, hemorrhagic
• Subarachnoid hemorrhage
Stroke guidelines in 1 slide
1. Clinical diagnosis
2. Yell “Please page a Brain Attack to room X”
3. Resume coffee drinking while watching the
What the Brain Attack team does,
as per 2008 guidelines
1. Clinical diagnosis
2. NIH stroke scale
3. CT/MRI to confirm dx and determine type of
stroke (level 1A recc), CT just as good as MRI
Then things diverge a bit
• Ischemic stroke:
– Supportive care: airway/breathing, fever control*,
BP control if SBP over 180 for tPA, 220 otherwise*;
(safe to restart outpt HTN meds in 24 hrs; CHHIPS
study), euglycemia.
– Go quick quick to tPA.
IA tPA? What about with mechanical lysis
added on?
Time to treatment: >6 but <24 hours
Stuff that doesn’t work
• Heparin/ASA*
• Hemodilution
• Vasodialators
• Induced hypertension if pt hypotensive
• Combinations of thrombolytics↓
• “neuroprotective” agents—see next slide
Neuroprotective drugs?
No data on prophylactic anticonvulsants
In ischemic stroke
The bleedy kind
To Do list- intracerebral bleed
• Image head
• Check for and correct coagulopathy (prothrombin complex concentrates or
FFP, but NOT fVII)
• Take blood pressure down to SBP 140s*
• Fix hypoglycemia, not sure what to do with hyperglycemia; fix fever#, DVT
SQ heparin ok after day 1-4 if no bleeding
• I guess we should call neurosurgery
The other level 1A recommendation
(clinical seizures only)
Prophylaxis changes the frequency,
but no evidence that seizures change
All data about ICH, etc from TBI literature
Within TBI literature, ICP monitors
define 3 patient populations
1) Normal ICP
2) Abnormal ICP that responds to treatment;
type of treatment appears unimportant
3) Abnormal ICP that doesn’t respond to treatment
Data for ICP monitor in
hemorrhagic stroke
What about the ventricles?
What about surgery?
The ICH score is determined by adding the score from each component as
1) Glasgow Coma Scale (GCS) score 3 to 4 (= 2 points); GCS 5 to 12 (= 1
point) and GCS 13 to 15 (= 0 points)
2) ICH volume ≥30 cm3 (= 1 point), ICH volume <30 cm3 (= 0 points)
3) Intraventricular extension of hemorrhage present (= 1 point); absent (=
0 points)
4) Infratentorial origin yes (= 1 point); no (= 0 points)
5) Age ≥80 (= 1 point); <80 (= 0 points)
Thirty-day mortality rates increased steadily with ICH score; mortality rates
for ICH scores of 1, 2, 3, 4, and 5 were 13, 26, 72, 97, and 100 percent,
respectively. No patient with an ICH score of 0 died, and none had a
score of 6 in the cohort
Clinical Presentation
“Worst headache of my life”--80%
Sentinel bleed—10%
AMS, vomiting, seizures, stiff neck, focal
Diagnosis: CT scan, if negative LP
If positive, then either CTA, MRA, or angiography to spot
the lesion
Hunt & Hess grading scale
Asymptomatic, mild headache, slight nuchal rigidity--1
Moderate to severe headache, nuchal rigidity , no neurologic
deficit other than cranial nerve pals--2
Drowsiness / confusion, mild focal neurologic deficit--3
Stupor, moderate-severe hemiparesis--4
Coma, decerebrate posturing--5
General Concepts in management
Establish baseline TCD to watch for vasospasm
DVT with SCD until after coil/clip, then SQ hep
Get rid of all blood thinners
Nimodipine, baby.
HyperNa done frequently but without data
Fluctuations in BP thought to cause rebleed, so keep it
even. Absolute value unclear.
Fix hypoxia, hypo- or hyperglycemia, pH
Stuff that doesn’t work
Antfibrinolytic therapy—stops bleeding but causes more
ischemic strokes
Hemodilution, Hypertension, hypervolemia (triple H
Stuff that might work
Infusion of urokinase into CSF to prevent
Statins to prevent vasospasm
Magnesium sulfate to prevent vasospasm
Unclear how to prevent rebleed