Ucm_463250.pdf

Linda Bayless, APRN-C, ACNP, FNP, CNRN

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OBJECTIVES

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Identify signs and symptoms of possible stroke. 2. Education regarding stroke statistics. 3. Identify mechanisms of stroke and stroke mimics. 4. Learn modifiable and non-modifiable risks for stroke. 5. Learn basic treatment of all stroke types and TIAs. Understand etiology of subarachnoid hemorrhages and treatment modalities.

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F.A.S.T.

FACE Ask person to smile. Warning sign: one side moves different than the other

ARMS Ask person to raise both arms. Warning: one arm does not move or there is a drift in one

SPEECH Ask per to repeat a simple sentence. Warning: unable to speak or slurred speech

TIME Find out when the last observed well time is.

Over 80% have abnormality in at least one area. 4

Cincinnati, 2007

INTRODUCTION TO STROKE

Term “stroke” originated in 16th century. Thought to be a “stroke of God’s Hand”.

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Rapidly evolving, sudden onset, non-epileptic neurologic deficit. .

Cerebrovascular accident (CVA)- not used today. Correct term is Ischemic or Hemorrhagic Stroke.

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American Heart Association, Heart Disease and Stroke Statistics, 2011 5

STROKE STATISTICS

795,000 per year > 136,000 deaths

7 million survivors alive today Annual cost of stroke $53.6 billion Mean lifetime cost per patient $140,048.

One in 6 patients die within 30 days American Heart Association. Heart Disease and Stroke Statistics—2011 6

NON-MODIFIABLE RISK FACTORS

AGE About 10% occur in 18-50 year olds.

HEREDITARY RACE (Increased incidence in African Americans and Asians) Gender Prior Stroke, TIA, or Heart Attack

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RISK FACTORS PRIMARY STOKE PREVENTION MODIFIABLE:

Hypertension Cigarette Smoking Diabetes Mellitus Carotid Artery Disease Peripheral Artery Disease

Atrial Fibrillation Heart failure, CAD Sickle Cell Disease High Cholesterol Poor Diet Physical Inactivity Obesity 8

UNDERSTANDING STROKE-LESS DOCUMENTED RISKS

Geographic location: Strokes more common in SE United States. “Stroke Belt”

Socioeconomic Factors: Some evidence stroke is more prevalent in low-income people compared to more affluent.

Alcohol Abuse: Recommend no more than 2 drinks per day in men and 1 drink for women. (Can lead to multiple medical complications).

Drug Abuse: Cocaine, methamphetamines and heroine.

Stroke Association, Together to End Stroke. 2012 9

ESTIMATED PACE OF NEURONAL LOSS IN LARGE VESSEL STROKE

Neurons Lost

Accelerated Aging

1.2 billion

36 years

Per Hour

120 million

3.6 years

Per Minute

1.9 million

3.1 wk

32,000

8.7 hrs

Per Stroke

Per Second

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Stroke 2006;37:263

MEET YOUR NEXT STROKE VICTIM…

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RECOGNIZING STROKE SYMPTOMS

Numbness of face, arm, leg Confusion, difficulty speaking or understanding Visual changes in one or both eyes Ataxia, loss of balance or coordination Severe headache

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PRE-HOSPITAL STROKE CHECKLIST

• LAST KNOWN WELL! • Stroke Symptoms • Blood Pressure • Blood Glucose • Past Medical History • Medication List

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IMMEDIATE DIAGNOSTIC STUDIES

All Patients NIHSS Blood Glucose Blood Pressure CT Scan Head (non-contrast) CBC INR

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Selected Patients Hepatic function tests Toxicology screen Blood ETOH level Serum HCG CXR EEG

STROKE ASSESSMENT TOOLS

Canadian Neurologic Scale Four Score Glascow Coma Scale Neurologic Assessment Cincinnati Stroke Scale NIH Stroke Scale Journal of Neuroscience Nursing, 46:2, 2014. 16

NIHSS

National Institutes of Health Stroke Scale: Developed in 1983 as a research tool to measure severity of ischemic stroke. Allows examiner to rank focal neurological deficits often overlooked by other scales. Composed of 11 items using a 0 to 4 point score. First used by nurses in 2009 to structure communication between providers. Higher score correlates with severity of neurological deficits.

Brott et al., 1989 17

Acute Focal Neurological Deficit

Migraine Seizure Multiple Sclerosis Radiculopathy

Stroke Acute Ischemic Stroke (82-85%)

Large vessel disease (35%) Small vessel disease (25%) Cardio-embolic (15-20%)

Hemorrhagic Stroke (9-13%)

Cryptogenic (5-7%) CVT 18

ICH IVH

SAH (3-5%)

AVM (1%)

STROKE TYPES

15% Intracerebral Hemorrhage (ICH)

87% Ischemic Stroke (IS)

3% Subarachnoid Hemorrhage (SAH)

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VASCULAR ANATOMY/TERRITORY

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ARTERIAL WALL

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LEFT OR RIGHT BRAIN DOMINANCE

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COMMON PATTERNS OF NEUROLOGICAL IMPAIRMENTS

• Left Hemisphere

• Right Hemisphere

Aphasia (? Handed-ness)

Left hemiparesis / hemisensory

Right hemiparesis / hemisensory

Left sided spatial neglect

Right hemianopia

Right gaze preference

Left gaze preference

Brain Stem

Subcortical (Lacunar) • • • • •

• • • • •

Pure hemiparesis Pure hemi-sensory Dysarthria clumsy hand Ataxic hemiparesis No abnormalities of cognition, language, or vision

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Motor / sensory in all 4 limbs Crossed findings (face/arm-leg) Nystagmus Ataxia Dysarthria / Dysphagia

EFFECTS OF STROKE

Right Brain: Paralysis on left side of body. Visual problems. Memory Loss.

Brain Stem: Can effect both sides of body. Concern for “locked in” state.

Left Brain: Paralysis on right side of body. Speech/Language Problems* Slow, cautious behavior. Memory Loss.

Occipital: Vision problems. Cerebellum: Coordination, balance issues.

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ISCHEMIC STROKE

Embolic

Thrombotic

Blood clot or plaque forms in the body and travels through the blood stream to the brain. Maximal at onset, MCA most commonly involved, may be associated with seizures.

Fatty deposits develop in the lining of the blood vessel wall which narrows the blood vessel. Stuttering or progressive course. Sensitive to BP fluctuations.

(Cardiac sources, artery-to-artery embolism, systemic veins). .

(Progressive or Sudden Closure of Vessel Lumen: atherosclerosis, fibromuscular dysplasia, arteritis, vasospasm, arterial dissection, hypercoagulable states).

Handbook Neurocritical Care, 2011.

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MENINGES

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BASIC ANATOMY

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MENINGEAL LAYERS

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MORE ANATOMY

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INTRACRANIAL LARGE ARTERY STENOSIS

High prevalence in African Americans, Asians, Hispanics Annual risk of stroke 7%25% Under studied Lack of proven therapy 33

CAROTID STENOSIS

85,000 strokes per year 20% of all ischemic stroke 26% risk of stroke in 2 years CEA reduces risk 4%/year? Carotid Angioplasty ?

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ATRIAL FIBRILLATION

70,000 strokes per year 15% of ischemic stroke Annual risk 5%-25% Warfarin effective

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UGLY

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LACUNAR DISEASE Overall good prognosis Classic clinical syndromes Rx Antiplatelet agents

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RIGHT MIDDLE CEREBRAL ARTERY INFARCTION

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STROKE TREATMENT… THE PAST!

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OPEN THE ARTERY FAST!

What Options??? 46

Tissue Plasminogen Activator for Acute Ischemic Stroke. The National Institute of Neurological Disorders; Stroke rt-PA Stroke Study Group.

Only “ FDA Approved” Treatment” AHA/ASA Class 1 Recommendation, Level of Evidence A Since 1996, Activase has been used to treat > 220,000 acute ischemic stroke patients in the United States 47

NINDS T-PA

Five year study by the National Institute of Neurological Disorders (NINDS): Found that some stroke patients within 3 hours onset – Received IV t-PAWere at least 30% more likely to recover with little or no disability after three months!

NIH Publication No. 10-4872, 2010 48

CONTRAINDICATIONS: IV T-PA Beyond 3 hours from symptom onset, up to 4.5 hours in specific situations. Time of onset cannot be determined reliably. Diagnosis not established by physician with expertise in this area. NIHSS rapid improvement. INR >1.7 CT scan not assessed by physicians with expertise in this area.

Head CT : Early Changes in > 1/3 MCA Territory

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RADIOLOGIC EVIDENCE OF ISCHEMIC STROKE

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ENDOVASCULAR INTERVENTION

1. First Generation: Intra-arterial t-PA, Merci Stent retriever (Concentric) 2. 2nd Generation: (Penumbra) Suction 3. 3rd Generation: “Stent on a Stick”, (Trevo), Penumbra 5MAX ACE

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CONCENTRIC CLOT RETRIEVAL DEVICE

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MERCI

Typically used up to 6 hours Posterior strokes can even extend to 24 hours. 53

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PENUMBRA

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TREVO

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SOLITAIRE

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CLOT RETRIEVALS RETRIEVED

62 year-old Male ICA Occlusion History: Atrial Fibrillation

82 year-old Female MCA Occlusion History: Atrial Fibrillation Failed IV t-PA

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32 year-old Male Basilar Occlusion

HUGE CLOT

59 APM0115/A/2312, 2005-12

“TICI”

The original Thrombolysis in Cerebral Infarction Scale: Designed to aid in the objective description of angiographic results., standardized data, and assist in outcome prediction. Proposed by Higashi et al., 2003.

American Journal of Neuroradiology, 2013. 60

TICI

Varyiing definitions of TICI grades in literature. •Grade 0: No flow/canalization, complete occlusion, no reperfusion. •Grade 1: <20% recanaliztion, limited to no perfusion, minimal flow without significant flow distal to occlusion. •Grade 2: Partial recanalization, incomplete reperfusion, Near-normal flow with flow distal to the occlusion, but not filling distal branches normally. •Grade 2a: Perfusion<50% of MCA, partial filling of entire vascular territory. •Grade 2b: Partial reperfusion, >/= 50-99% of expected territory, complete filling but is slow. •Grade 2c: Near complete perdusion withour clearly visible thrombus but delay in contrast run-off. •Grade 3: Full perfusion, normal flow, partial recanalization with >50% reperfusion. AJNR, 2013, 34:1792-1797. 61

SECONDARY STROKE PREVENTION

Get with the Guidelines!

American Heart and Stroke Association. Provides hospitals with a Web based Management tool. Guides decision making, real time benchmarking capabilities, and other performance improvements toward the goal of enhancing patient outcomes and saving lives.

Get with the Guidelines Stroke, 2013 62

HYPERTENSION

HTN is the most common condition seen in primary care: leading to MI, stroke, renal failure, and death if not appropriately controlled.

JAMA. 2013.284427 63

ANTITHROMBOTICS

•IV t-PA within 180 minutes of last known well. •Antithrombotics by end of hospital day 2. •Anticoagulation for AFIb/Flutter prior to discharge.

Get with the Guidelines, 2013. 64

CIGARETTE SMOKE Doubles the risk of ischemic stroke Clearly associated with a 2 to 4 fold risk for hemorrhagic stroke. Can clearly interact with oral contraceptives in increasing stroke risks for young women.

Ischaemic stroke and combined oral contraceptives: results of an international, multicentre, casecontrol study: WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone 65 Contraception. Lancet. 1996;348:498–505.

DYSLIPIDEMIA

In general, increased levels of total cholesterol are associated with stroke. High LDL levels is a risk factor for ischemic stroke Recommend Atorvastatin 80 mg daily (LDL < 100) Patients with known CAD and hypertensive patients at high risk should be treated with lifestyle measures and a statin.

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DIABETES

Tight control of hypertension with ACEI or ARB treatment reduces stroke risk in diabetics. (BP <120/80 mm Hg) Glucose <100 mg/dL Glycemic control reduces microvascular complications but is not as potent at stroke prevention. Statin treatment of diabetic patients substantially decreases their risk of first stroke.

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TRANSIENT ISCHEMIC ATTACK

“brief episode of neurological dysfunction caused by focal disturbance of brain or retinal ischemia, with a clinical symptom typically lasting less than 24 hours, typically less than 1 hour, without evidence of ischemia” TIA is caused by a clot; the only difference between stroke and TIA is that with TIA the blockage is temporary (transient). Most last less than five minutes, with average duration one minute.

Circulation 2006;113:409-449

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200,000-500,000 Americans with TIAs / year 15% of Strokes with history of TIAs

5% stroke in 2 days 8.6% in 1 week 12% in 30 days 10% in 90 days

29% in 6 months 69

TIA WORKUP -Hospitalization -At least a CT head -Labs and EKG -Consider MRI/MRA -Carotid / Vertebral A. Dopplers -2D Echocardiogram w/bubble -Aspirin 325mg /day OR PLAVIX -Anticoagulation in A-fib -Consider CEA carotid grade 70-99% stenosis ?angioplasty -Target BP < 120/70 -Cholesterol<200 and LDL < 100 -Alcohol: Limit to 1 drink / day -Smoking: Cessation -Diabetes: Tight control (<124mg/dl) -Exercise: 3 time per week -Harmful to continue OCP/HRT 70

ICH ICH results from bleeding of a vessel directly into the brain substance.

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ICH SECONDARY TO HTN

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TYPES AND LOCATION OF ICH

- Hypertensive ICH - putamen - thalamus - pons - cerebellum

- Lobar Hemorrhage - Vascular malformation -Iatrogenic -Tumors -Trauma 73

SUBARACHNOID HEMORRHAGE

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PRESENTATION

Severe headache of sudden onset ("thunderclap headache") accompanied by loss of consciousness

"worst headache of my life.“ Neck stiffness, photophobia, and low back pain

Nausea and vomiting seizure at onset (10-25%) An estimated 10-15% of patients with pre-ruptured symptoms: headache (48%), dizziness (10%), orbital pain (7%), diplopia (4%), and visual loss (4%). The premonitory symptoms may represent small leaks ("sentinel bleed") or expansion of the aneurysm. Approximately 30-40% of patients are at rest at the time of SAH. Physical or emotional strain, defecation, coitus, and head trauma contribute to varying degrees in the remaining 60-70% of cases. 75

SUBARACHNOID HEMORRHAGE

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SUBARACHNOID HEMORRHAGE

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SUBDURAL HEMATOMA

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INTRACEREBRAL HEMORRHAGE WITH EDEMA

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EPIDURAL HEMATOMA

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FEVER AND FUNCTIONAL OUTCOME

THE COPENHAGEN STUDY

390 consecutive acute stroke patients Classified on admission as hypothermic, euthermic, or hyperthermic (>37.5) Positive correlation to initial severity, infarct size, mortality, and functional outcome For every 1°C rise, 2.2 fold increase in poor outcome (CI 1.4-3.5) Lancet. 1996;347:422–425 82

DECOMPRESSIVE HEMICRANIECTOMY

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Temperature and Neurologic Injury Fever

Hypothermia

Accelerates Injury

Preserves Tissue 37° 36°

41°

Clinical Goal:

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39°

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38°

Tissue Preservation

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40°

37°

1o C rise in temperature on admission correlated with a 15 84 mm increase in infarct diameter

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HYPOTHERMIC TREATMENT

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ALSIUS COOLING CATHETER

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EMS HYPOTHERMIC SYSTEM!

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SURGICAL CLIPPING ANEURYSM

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CLIP LIGATION

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Endovascular Coiling for aSAH

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PENUMBRA COIL

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ONYX

Onyx is a liquid polymer approved by FDA to treat brain aneurysms. Majority patients go home next day. Cameo Trial (Europe), demonstrated Onyx as safe as coil embolization in thus safer than surgery. Goal: Seal the aneurysm shut.

Medical News and Health Information, 2009. 94

THANK YOU!

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