stroke, etc. 082808

Dallas Presbyterian HospitalInternal Medicine Resident LectureAugust 28, 2008Samir Shah, MDNeurology Consultants of DallasSTROKE, SUBARACHNOID HEMORRHAGE AND HYPOTHERMIA FOR CARDIAC ARREST-Andy Rekito

Quick Stroke Facts - 2008FACT: About 780,000 Americans suffer a new or recurrent stroke each year. That means, on average, a stroke occurs every 40 seconds.

FACT: Stroke kills nearly 150,000 people each year. Thats about 1 of every 16 deaths. It remains the #3 cause of death behind heart disease and cancer. An American dies of a stroke every 3 minutes.

FACT: Americans will pay about $63 billion in 2007 for stroke related medical costs and disability.American Heart Association. Heart Disease and Stroke Statistics 2008 Update. Dallas, Tex.: American Heart Association; 2008.

Prevalence of Stroke by Age and SexNHANES: 1999-2002Source: CDC/NCHS and NHLBI.FACT: Prevalence of stroke in the US is 5.7 million people (2004). 15-30% of stroke victims are permanently disabled.

Chart1

0.40.34

1.10.8

1.22.1

3.13

6.66.3

1211.5

`

Men

Women

Ages

Percent of Population

HYPPRSEX

1976-801988-941999-001976-801988-94

Non-Hispanic White Men45.025.628.9Non-Hispanic White Men34.225.2OLD!

Non-Hispanic White Women33.719.724.7Non-Hispanic White Women25.920.5

Non-Hispanic Black Men50.736.538.0Non-Hispanic Black Men44.836.7

Non-Hispanic Black Women51.136.441.0Non-Hispanic Black Women46.736.6

Mexican Men25.625.930.6Mexican-American Men31.024.2

Mexican Women22.522.325.0Mexican-American Women31.422.4

Age-Adjusted Prevalence Trends for High Blood Pressure in Americans, Ages 2074 by Race/Ethnicity, Sex and SurveyAge-Adjusted Prevalence Trends for High Blood Pressure, Ages 2074 by Race/Ethnicity, Sex and Survey

NHANES II, III & IV: 1976-80, 1988-94 and 1999-2000United States: 197680 and 1988-94

1988-94

MenWomen

Non-Hispanic Whites25.220.5

Non-Hispanic Blacks36.736.6

Hispanics24.222.4

Estimated Age-Adjusted(2000) Prevalence for High Blood Pressure in Adults Ages 20-74 By Sex and Race

United States: 1988-94

MenWomenMenWomen

20-348.110.6WRONG!20-349.80.0

35-4414.329.535-4417.116.0

45-5429.144.345-5432.330.5

55-6443.058.055-6444.153.0

65-7454.965.265-7459.970.3

75+59.071.375+68.884.1

Prevalence of High Blood Pressure in Americans Age 20 and Over by Age and SexPrevalence of High Blood Pressure in Americans Age 20 and Over by Age and Sex

United States: 1999-2000NHANES IV: 1999-2000

MenWomen

20-3411.15.8

35-4421.318.1

45-5434.134.0

55-6446.655.5

65-7460.974.0

75+69.283.4

Prevalence of High Blood Pressure in Americans Age 20 and Over by Age and Sex

NHANES: 1999-2002

&A

Page &P

HYPPRSEX

000

000

Non-Hispanic Whites

Non-Hispanic Blacks

Hispanics


HYPREV

00

00

00

00

00

00

1976-80

1988-94


HYPAWARE

00

00

00

00

00

00

Men

Women

Ages


strokeprev

00

00

00

00

00

00

Men

Women

Ages


INCHA

000

000

000

000

000

000

1976-80

1988-94

1999-00


FHSrisk

00

00

00

00

00

00

Men

Women

Ages


MenWomen

1960-6241.334.9

1971-7443.935.8

1976-8045.135.8

1988-9426.421.5

Estimated Age-Adjusted (2000 Standard) Prevalence for High Blood Pressure, Ages 2074 by Sex and Survey

United States: 196062, 197174, 197680, to 198894

&A

Page &P

0000

0000

1960-62

1971-74

1976-80

1988-94


1976-801988-941991-94

On Medication, Controlled102818-3940-5960+

On Medication, Uncontrolled2126Awareness51.873.369.8

Not on Medication2017Treatment27.762.962.7

Unaware4929Control, Treated51.966.443.7

Awareness Treatment and Control Rates for High Blood PressureControl, All Hypertensives14.441.627.4

United States: 1976-80 and 1988-94

Extent of Awareness, Treatment and Control of High Blood Pressure by Age

NHANES IV: 1999-2000

1976-801988-911991-94

Awareness51.073.068.4

Treatment31.055.053.6Non-Hispanic WhitesNon-Hispanic BlacksMexican Americans

Control10.029.027.4

Awareness69.573.957.8

Treatment60.163.040.3

High Blood Pressure* Awareness, Treatment and Control RatesControl, Treated55.644.644.0

United States: 1976-94Control, All Hypertensives33.428.117.7

Extent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity

NHANES IV: 1999-2000

&A

Page &P

00

00

00

00

&A

Page &P

1976-80

1988-94

Percent of People With High Blood Pressure

000

000

000

1976-80

1988-91

1991-94

Percent of People With HBP

51.873.369.8

27.762.962.7

51.966.443.7

14.441.627.4

18-39

40-59

60+


69.573.957.8

60.16340.3

55.644.644

33.428.117.7

Non-Hispanic Whites

Non-Hispanic Blacks

Mexican Americans


Stroke Prevalence NHANES 1999-2002

AgesMenWomen

20-340.40.3

35-441.10.8

45-541.22.1

55-643.13.0

65-746.66.3

75+12.011.5

Prevalence of Stroke by Age and Sex

NHANES: 1999-2002

&A

Page &P

`

Men

Women

Ages


MenWomen

29-4434,00010,000

45-64250,00088,000

65+410,000372,000

Annual Number of Americans Having Diagnosed Heart Attack by Age and Sex

ARIC: 1987 - 2000

&A

Page &P

00

00

00

Men

Women

Ages

New and Recurrent Attacks in Thousands

MenWomen

A55MenWomen

B138A2.61.1

C2520B4.02.0

D3727C5.43.5

D8.46.3

Estimated 10-Year CHD Risk in 55 Year-Old AdultsE14.819.1

According to Levels of Various Risk Factors - Framingham Heart StudyF22.427.0

Framingham Heart Study

Estimated 10 Year Stroke Risk in 55 Year Old Adults

According to Levels of Various Risk Factors

Framingham Heart Study

ABCD

Blood Pressure120/80140/90140/90140/90

Cholesterol200240240240

HDL-C50504040

DiabetesNoNoYesYesABCDEF

CigarettesNoNoNoYesBlood Pressure*95-105138-148138-148138-148138-148138-148

DiabetesNoNoYesYesYesYes

Source: PWF Wilson, et al., "Prediction of Coronary Heart Disease Using Risk Factor Categories",Cigarette SmokingNoNoNoYesYesYes

Circulation 97:1837-47, 1998.Prior AFNoNoNoNoYesYes

Prior CVDNoNoNoNoNoYes

* - Closest ranges for women are : 95-104 and 115-124.

&A

Page &P

00

00

00

00

Men

Women

Estimated 10-Year Rate (%)

00

00

00

00

00

00

Men

Women


Definitions So Were All on the Same PageAn established and universally accepted definition for stroke by the World Health Organization is "acute neurologic dysfunction of vascular origin . . . with symptoms and signs corresponding to the involvement of focal areas of the brain."

Stroke. 1989 Oct;20(10):1407-31.

BEFOREStroke has also been described as the rapid onset of neurological deficits that persist for at least 24 hours and are caused either by intracerebral or subarachnoid hemorrhage or by partial or complete blockage of a blood vessel supplying or draining a part of the brain, leading to the infarction of brain tissue. A stroke is distinguished from a transient ischemic attack (TIA) by the fact that neurological deficits in TIAs clear spontaneously within 24 hours.

NOWClinical, experimental, and imaging data have shown that the 24-hour criterion is inaccurate in suggesting an absence of brain injury and often results in uncertainty on the part of patients and practitioners alike about what to do when a TIA occurs. In short, the 24-hour definition of TIA is outdated, confusing, and potentially misleading

NEW DEFINITIONa TIA is a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction. The corollary is that persistent clinical signs or characteristic imaging abnormalities define infarction that is, stroke (N Engl J Med 2002;347:1713-1716).

THEREFORE

The development of symptoms of acute brain ischemia constitutes a medical emergency and transient symptoms do not exclude the possibility of associated brain infarction.

TIME=BRAIN

Now, lets talk about how we evaluate and manage stroke.We will focus on ischemic stroke

Consult for a 68 year-old man that has new right-sided weakness and is talking funny. It started a few hours ago.

What Else Could It Be?Stroke MimicsAbcessSubdural and Epidural HematomasTumorsGiant aneurysmsVascular malformations (AVMs)Hypertensive EncephalopathyEncephalitis/cerebritisSeizure/Todds paralysisMigraineMetabolic-Hypoglycemia/HyperglycemiaCerebral venous thrombosisPsychogenicDeficit from previous stroke made worse by general medical condition

When presented with acute onset neurological dysfunction, stroke should always be on your differential and one of the first goals in the evaluation is differentiating hemorrhagic stroke from ischemic stroke

All patients, with few exceptions should undergo STAT cranial imaging. In other words, GET A NON-CONTRAST HEAD CT (MRI if available STAT).Quickly Narrow the Differential With Imaging

What Else to Ask for Over the Phone?ALL stroke patients should get immediate

CBC with plateletsBedside glucosePTT, PT (INR)Chem 7 (Chem 10)EKG, continuous cardiac monitoringIV access, 0.9% NS (no glucose)NPO?Troponin

Whats the Cardiac Workup for?Not infrequently, patients with acute cerebral ischemia have concomitant acute myocardial ischemia

In addition cardiac evaluation helps determine etiology of the cerebral event

Several small studies have shown that patients with TIA and stroke have a high prevalence of asymptomatic CHD. These studies suggest that 20% to 40% of stroke patients may have abnormal tests for silent cardiac ischemia.

2% to 5% of patients with acute ischemic stroke have fatal cardiac-related events in the short term after stroke.

Circulation. 2003;108:1278.

Other Acute StudiesUrine pregnancy testUrine toxicologyHypercoagulable screenCXRType and Screen

What are the risk factors for ischemic stroke?

Risk Factors for Ischemic StrokeRisks that can be controlled or treated

High Blood PressureSmokingDiabetes MellitusPrior TIA Atrial FibrillationOther Heart DiseaseCarotid Artery Disease or atherosclerosis in another arterial bedCertain blood disordersSickle Cell DiseaseHypercholesteremiaPhysical Inactivity, ObesityExcessive alcoholIllicit drugsHRTRisks that cannot change

AgePrior stroke or MIGenderHeredity/Ethnicity

Estimated 10-Year Stroke Risk in 55-Year-Old Adults According to Levels of Various Risk Factors - Framingham Heart StudyABCDEFSystolic BP95-105130-148130-148130-148130-148130-148DiabetesNoNoYesYesYesYesCigarettesNoNoNoYesYesYesPrior Atrial Fib.NoNoNoNoYes YesPrior CVDNoNoNoNoNoYesSource: Stroke 1991;22:312-318.

Chart2

2.61.1

42

5.43.5

8.46.3

14.819.1

22.427

Men

Women


Sheet1

CVDCVD2001 CVD total mortalityLCD BLACK M/F, 2001LCD AM. INDIAN M/F, 2001AgesMenWomenMenWomenNHES IIINHANES INHANES III

MalesFemales145,908141,80125-442.02.8A2.61.1Non-Hispanic WhitesNon-Hispanic BlacksMexican AmericansWhite Males163163155% of Men using PA to lose weight% of Men meeting PA guidelines% of Women using PA to lose weight% of Women meeting PA guidelinesNumber of TransplantsEST. COST OF CV DISEASES 2004

1979500469MALESFEMALESMALESFEMALES45-546.75.5B4.02.0Black Males171165166Whites66.522.863.520.1196823

80510490Coronary Heart Disease54502,18954CVD+cong.A33.5CVD+cong.A40.1D of H/St.A24.4D of H/St.A25.455-6413.18.4C5.43.5Awareness69.573.957.8White Females170166163Blacks70.122.662.816.9197010Heart Disease238.6

81500484Stroke18163,53818CancerB22.4CancerB20.8CancerB17.1CancerB19.165-7417.711.1D8.46.3Treatment60.163.040.3Black Females172174168Hispanics63.817.152.714.3197522Coronary Heart Disease133.2

82495484Congestive Heart Failure652,8286AccidentsC5.9DiabetesF5.1Acc.C14.0Acc.C8.275+18.616.1E14.819.1Control, Treated55.644.644.0Others68.423.063.520.6198057Stroke53.6

83498494High Blood Pressure546,7655Assault(Homicide)D4.6Nephritis, etc.G2.9C. Liver D.D4.8DiabetesE6.7F22.427.0Control, All Hypertensives33.428.117.7Trends in Mean Total Blood Cholesterol Among Adolescents Ages 12-17 by Sex and Race and Survey1985719Hypertensive Disease55.5

84491493Diseases of the Arteries439,4044HIV(Aids)E3.7AccidentsC2.8DiabetesE4.3C. Lower res.D.F4.1Prevalence of Coronary Heart Disease by Age and SexNHES III, NHANES I, NHANES III: 1966-70, 1971-74 and 1988-94Leisure-time Physical Activity (PA) Patterns Among Overweight Adults by Race/Ethnicity and Sex19902,107Congestive Heart Failure28.8

85491498Rheumatic Fever/Rheumatic Heart Disease0.43,4890.4NHANES III: 1988-94Estimated 10 Year Stroke Risk in 55 Year Old AdultsBRFSS: 199819952,363Total CVD*368.4

86481498Congenital Cardiovascular Defects0.44,1090.4Leading Causes of Death for Black or African American Males and FemalesLeading Causes of Death for American Indian/Alaska Native Males and FemlaesAccording to Levels of Various Risk FactorsExtent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity20002,199

87475499Other13118,78613United States: 2001United States: 2001Framingham Heart StudyNHANES IV: 1999-200020022,154Estimated Direct and Indirect Costs (in Billions of Dollars) of Cardiovascular Diseases and Stroke

88476504100.8931,108100.0United States: 2004

89456486Trend in Heart Transplants

90448478Percentage Breakdown of Deaths From Cardiovascular DiseasesUnitedStates: 1968-2002

91447479United States:2001

92444479

93457500

94452498

95455505

96453506

97450503

98446504

99446513

00439507Non-Hispanic WhitesNon-Hispanic BlacksMexican Americans

01432499YearMalesFemales12% of high school students who participated in vigorous or moderate physical physical activity in past 7 daysMen5.47.68.1

70779597Whites76.644.218.2Women4.79.511.4

Cardiovascular Disease Mortality Trends for Males and FemalesMales71851628Blacks26.724.116.4Non-Hispanic White MalesNon-Hispanic White FemalesNon-Hispanic Black MalesNon-Hispanic Black FemalesHispanic MalesHispanic FemalesMalesFemales

United States: 1979-2001Males72935693ABCDEFCHF PREVALENCEMexican Americans34.317.317.5Vigorous73.759.872.447.868.852.4Non-Hispanic Whites12.45.3Prevalence of Age-Adjusted (2000) Physician-Diagnosed Diabetes in Americans Age 20 and Older by Sex and Race/Ethnicity

73982725Blood Pressure*95-105138-148138-148138-148138-148138-148MalesFemalesModerate29.824.723.716.525.918.5Non-Hispanic Blacks17.514.6NHANES III: 1988-94 NHANES III

741030756DiabetesNoNoYesYesYesYes20-240.10.1Prevalence of Current Smoking for Men Ages 18-24 by Education and Race/EthnicityHispanics21.38.8

751043789Cigarette SmokingNoNoNoYesYesYes25-340.10.1NHANES III: 1988-94Prevalence of Students in Grades 9-12 Who Participated in Sufficient Vigorousu.s. 1979-00

Prevalence of CVD, U.S. 1988-94 NHANES III761087843Prior AFNoNoNoNoYesYes35-440.70.5or Moderate Physical Activity During the Past 7 Days by Race/Ethnicity and SexPercentage of Overweight Among Students in Grades 9-12 by Sex and Race/EthnicityCatheterizationsOpen-HeartBypassPTCAEndarterectomyPacemakers

771111852Prior CVDNoNoNoNoNoYes45-541.81.3United States: 2001United States: 200119792991721145442

AgeMalesFemales78111084455-646.23.4803501971375544

20-245.54.6791014724* - Closest ranges for women are : 95-104 and 115-124.65-746.86.6814162221597326

25-3410.44.280104973775+9.89.7824732401708231

35-4417.413.6811095765MenWomen835122601919525

45-5434.228.982116084120-349.80.0Prevalence of Congestive Heart Failure by Age and Sex8457627820210339

55-6451.048.183122985235-4417.116.0NHANES III: 1988-948569030823010740

65-7465.265.284104484045-5432.330.5867863702848332

75+70.779.085120584655-6444.153.0878794093321568189

86125088965-7459.970.38894445735321170120

Females87126890175+68.884.18999846836824370107

Prevalence of Cardiovascular Diseases in Americans Age 20 and Older by Age and SexFemales8812208309010465013922666897

NHANES III :1988-94MenWomen891174819Prevalence of High Blood Pressure in Americans Age 20 and Over by Age and Sex91105751840730367121

DR FOR WOMEN, CV AND CANCER 2001A55901151795United States: 1999-200092108459046836791113

LCD HISPANIC M/F, 2001B138911146806WhitesBlacksMexican Americans93107860648536989123

White FemalesBlack Females63,31747,082C252092124788612

Annual Probability(%) Stroke Vascular DeathCerebrovascular FeaturesEstimates of Vascular Event Rates for Persons With Various Features of Atherothrombotic Cerebrovascular Disease Stroke. 1997;28:1507-1517.

General elderly male population0.6 -------Asymptomatic carotid disease1.33.4Transient monocular blindness2.23.5Transient ischemic attack3.72.3Minor stroke6.13.2Major stroke9.03.5Symptomatic carotid stenosis >70%152.0

Risk Factors for Intracerebral and Subarachnoid Hemorrhage

++ indicates strong evidence; +, moderate positive evidence; ?, equivocal evidence; , moderate inverse evidence; and 0, no relation.

ICH SAHStroke. 1997;28:1507-1517.

Age+++Women-+Race/ethnicity++Hypertension+++Cigarette smoking?++Heavy use of alcohol++?Anticoagulation++?Amyloid angiopathy++0Hypocholesterolemia?0Oral Contraceptives0?

What Else Will You Ask?Exact time of onset or last time the patient was last seen at baselineHistory of seizures? Any seizure activity prior to onset of symptomsMigraine headachesTrauma or neck injury in the preceding daysRecent illnessesVomiting, change in level of consciousnessAllergies MedicationsAssociated symptoms (?chest pain)

What to Do on Exam?ABCs firstVital Signs: especially notice BP and dont forget weightCardiac, vascular, extremity examinationDirected and focused exam based on history - NIHSS

NIH Stroke Scale focuses on 5 major areas

Level of consciousnessVisual functionMotor functionSensation and neglectCerebellar function

NIHSS is easily performed, reliable and valid. It is strongly associated with outcome with and without thrombolytics, and can predict those patients likely to develop hemorrhagic complications from thrombolytic use.

www.ferne.org

Goal of History and Physical Is to Localize Lesion and Its Vascular SupplyKnowing the location of the lesion and its vascular supply allow you to begin to speculate on the underlying pathophysiology as different stroke mechanisms characteristically affect certain cerebral vessels.

Blood Supply of the BrainAnterior Circulation: Two ICAs which divide into ACA and MCA. Each ICA supplies roughly two fifths of the brain by volume.

Posterior Circulation: Two Vertebrals which join to form the Basilar which then forms PCAs. The posterior circulation supplies roughly one fifth of the brain.

Source: Loyola University Neurovascular Tutorial

Four Divisions of the Vertebral Artery

Stroke MechanismsCan simplify stroke mechanisms or etiologies into 5 categories

ISCHEMIAThrombosis (60%)Embolism (20%)Decreased Systemic PerfusionHEMORRHAGEIntracerebral Hemorrhage (12%)Subarachnoid Hemorrhage (8%)

Common Stroke MechanismsThe Seventh ACCP Conference on Antithrombotic and Thrombolytic TherapySTROKE

Ischemic StrokePrimary HemorrhageIntraparenchymalSubarachnoidAtherosclerotic Cerebrovascular Disease(Large Artery)HypoperfusionArteriogenic EmboliPenetrating Artery Disease(Lacunes)Cardiogenic Embolism

Cryptogenic StrokeOther, Unusual Causes

Prothrombotic StatesDissectionsArteritisMigraine/vasospasmDrug AbuseMany MoreAtrial FibrillationValve DiseaseVentricular ThrombiMany Others15%85%20%25%20%30%5%

You are done thinking of stroke mechanisms and you are almost at the ER when you get paged by the doctor that the patient has a blood pressure that is sky high at 182/102 and that he is going to give him some oral clonidine to take care of it.

What should you tell her?

Cerebral Autoregulation:It may not be workingDO NOT TREAT BP IN ACUTE ISCHEMIC STROKE UNLESS BP>200-220/100-120

The patients daughter is at the bedside. She tells you that her dad had some right sided weakness yesterday that resolved in 25 minutes and thats why she brought him in. She says his new symptoms on the right started in the hospital just 45 minutes ago. She says he has some kind of heart problem but hasnt been taking any of his medications. Shes not sure what he was taking and is worried about his talking.

The Patient Encounter

You examine the patient and with your excellent neurological skills quickly realize that his talking funny is actually an expressive aphasia and that he has a right facial droop, a left gaze preference, 2/5 right arm weakness and 4/5 right leg weakness.

All the labs you wanted are unrevealing, and the EKG shows evidence of LVH, but otherwise ok. The nurse tells you that the monitor went off a little while ago for a rapid, irregular heart rate.

You are astute enough to realize that this guy is in the usual 3 hour window for acute stroke therapy and decide to go look at the CT scan.

Now what?

Hyperdense MCA Sign

Insular Ribbon SignLoss of Gray-White Junction

The New England Journal of MedicineCopyright, 1995, by the Massachusetts Medical Society

Volume 333 DECEMBER 14, 1995 Number 24TISSUE PLASMINOGEN ACTIVATOR FOR ACUTE ISCHEMIC STROKETHE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE rt-PA STROKE STUDY GROUP*IV t-PA FDA approved for use in acute ischemic stroke < 3 hours from onset in 1996. As compared with patients given placebo, patients treated with t-PA were at least 30 percent more likely to have minimal or no disability at three months on the assessment scales.

The Use of IV t-PAEligibility

Age 18 or olderClinical diagnosis of ischemic stroke causing a measurable neurological deficitTime of symptom onset well established to be less than 180 minutes before treatment would begin

Contraindications

Evidence of intracranial hemorrhage on pretreatment CTClinical presentation suggestive of SAH, even with normal CTActive internal bleedingKnown bleeding diathesis, including but not limited to:Platelet count < 100,000/mm3Patient has received heparin within 48 hours and has an elevated aTT (greater than upper limit of normal for laboratory)Current use of oral anticoagulants or recent use with an elevated prothrombin time > 15 secondsWithin 3 months any intracranial surgery, serious head trauma, or previous strokeOn repeated measurements, systolic blood pressure greater than 185 mmHg or diastolic blood pressure greater than 110 mmHg at the time treatment is to begin, and the patient requires aggressive treatment to reduce blood pressure to within these limitsHistory of intracranial hemorrhageKnown AVM or aneurysm

Warnings

Only minor or rapidly improving stroke symptomsHistory of GI or Urinary tract hemorrhage within 21 daysRecent arterial puncture at a noncompressible siteRecent lumbar punctureAbnormal blood glucose (400 mg/dL)Post myocardial infarction pericarditisPatient was observed to have a seizure at the same time the onset of stroke symptoms were observed

Other relative contraindications (not NINDS)Bacterial endocarditis or CNS lesion likely to hemorrhage after t-PASignificant trauma within 3 monthsCPR with chest compressions within past 10 days Major surgery within past 14 days, minor surgery within past 10 days Pregnant (up to 10 days postpartum) or nursing woman Life expectancy < 1 year from other causes Peritoneal dialysis or hemodialysis

What to Tell the FamilyAfter you determine your patients eligibility based on NINDS criteria, you go and talk with the daughter about the risks and benefits

What are the risks?Bleeding and its complications (6% vs

Copyright 1999 American Heart AssociationGrotta, J. C. Stroke 1999;30:1722-1728Distribution of outcomes on NIH Stroke Scale (NIHSS) (top), Barthel index (middle), and Rankin scale (bottom) in parts 1 and 2 combined of the NINDS rtPA Stroke Study

You write to administer t-PA at 0.9mg/kg (max 90mg) infused over 60 minutes with 10% of the dose administered as a bolus over 1 minute. You ensure that BPs have been consistently less than 185/110 prior to administration. You also make sure that no other antithrombotics or anticoagulants will be given in the next 24 hours and write for a Head CT in 24 hours. You also write orders for ICU admission as you know the patient will need close BP monitoring over the next 24 hours per NINDS protocol to maintain BP

Lets Get SeriousOnly a small fraction of ischemic strokes (likely 1-3%) are treated with IV t-PA, mostly because patients arrive to medical attention after the 3 hour time window. At places without 24 hour neurointerventional capability, what do we do for a stroke acutely when the patient is not eligible for IV t-PA?

This CT has a clear hypodensity. This patient is not eligible for IV-tPA given days duration of symptoms. In patients that do not receive thrombolysis: In the acute period, all ischemic stroke patients should receive 160-325mg of ASA within 48hours of onset. (some may advocate acute anticoagulation for certain stroke subtypes).Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

Copyright 2000 American Heart AssociationChen, Z. et al. Stroke 2000;31:1240-1249Absolute effects in CAST and IST of early use of aspirin in 40 000 randomized patients with suspected acute ischemic strokeFor every 1000 acute strokes treated with ASA, 7 fewer early recurrent ischemic strokes were observed and 13 fewer patients will be dead or dependent at 6 months at the expense of two or more ICHs.

All stroke patients should be admitted to the hospital for observation, diagnostic evaluation, and determination of treatment for secondary stroke prevention. All patients should be admitted to a stroke unit or when not available to a cardiac monitored bed with staffing to perform frequent neurological checks.

As already discussed, thrombolysis patients need ICU care. Admit the Patient

Where would you admit this patient?

How about this patient?

Lets say the patients symptoms resolved by the time you got there and he now feels fine and wants to go home

TIAs carry a substantial short term risk of stroke, hospitalization for cardiovascular events, and death. Of 1,707 TIA patients evaluated in an emergency department of a large health care plan, 180 patients or 10 percent developed stroke within 90 days. 91 patients or 5 percent did so within 2 days. Predictors of stroke: more than 60 years of age, DM, focal symptoms of weakness or speech impairment, and TIA lasting longer than 10 minutes (JAMA 2000;284:2901-6).PATIENT IS AT HIGH RISK AND NEEDS TO BE ADMITTED

Evaluation During AdmissionLabs: LFTs, fasting lipid profile and glucose, QID bedside glucose and SSI. Consider Hypercoagulable workup, ESR, ANA, hsCRP, HbA1c, homocysteine, LPImaging: All patients should have MRI imaging of brain and vascular imaging of head and neck. Consider TCD, PET, SPECT or other study based on clinical findingsEchocardiogram: all patient should have echo TTE when h/o of CAD or abnormal EKG or lacunar event. All others TEE (more sensitive and cost effective in evaluation of stroke. Ann Intern Med. 1997 Nov 1;127(9):775-87.)Rehabilitation evaluationBedside or formal swallow evaluationMedications: Home medications except BP meds. Restart or add after patient stable for >48hrs. Again, in general do not treat BP unless >220/120 in the acute phaseDVT and GI prophylaxis if indicated

Hospital Initiation of Secondary PreventionAll patients receive statin with goal LDL

Antithrombotic / Anticoagulant TherapyIn patients who have experienced a noncardioembolic stroke or TIA, we recommend treatment with an anti-platelet agent. Aspirin at a dose of 50 to 325mg qd; the combination of aspirin, 25mg and extended-release dipyridamole, 200mg bid; or clopidogrel, 75mg qd, are all acceptable options for initial therapy

No good evidence on what to do if patient already on therapy

In patients with Afib who have suffered a recent stroke or TIA, we recommend long-term oral anticoagulation, INR range 2-3

?Best treatment in cryptogenic stroke, PFO, aortic disease, post-MI

?Use of IV Heparin in certain situationsbrain goal PTT of 45-65

Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

Copyright restrictions may apply.Kidwell, C. S. et al. JAMA 2004;292:1823-1830.Acute Intraparenchymal Hematoma Imaged With Computed Tomography and With Magnetic Resonance Imaging

The Ischemic PenumbraApproximated by PWI-DWI MRI Mismatch and used to help guide interventional acute stroke therapies

IA t-PA within 6 hours of stroke onset in anterior circulation and 24+ hours in posterior circulation

Mechanical Clot removal within 8+ hours of ischemic stroke (MERCI) Stroke. 2005;36:1432.

Subarachnoid HemorrhageCauses:Aneurysm (80% of non-traumatic cases)TraumaVascular MalformationsTumorsInfectionVenous Thrombosis

Subarachnoid Hemorrhage(Aneurysmal)Demographics:Mean age = 55 yearsWomen 1.6X > MenBlacks > WhitesAverage Case Fatality Rate > 50%

Subarachnoid Hemorrhage(Aneurysmal)Risk Factors:SmokingHypertensionCocaine UseHeavy alcohol useFirst degree relatives with SAH

Subarachnoid HemorrhageClinical Features:Sudden severe headache (thunderclap headache)NauseaVomitingNeck PainPhotophobiaLoss of consciousness

Retinal hemorrhages (subhyaloid hemorrhage)MeningismusLocalizing neurological signs

Subarachnoid HemorrhageDiagnostic Evaluation:Head CTSensitivity > 90% in first 24 hoursSensitivity drops to 50% at 1 weekLumbar PunctureFinding to look for is xanthochromia (12 hours to develop)

Subarachnoid HemorrhageTreatment:Blood PressureLow before aneurysm securedHigh after aneurysm securedTreat hyperglycemia and hyperthermiaDVT prophylaxis (Heparin after aneurysm secured)Nimodipine 60mg PO q 4 hours X 21 daysSecure aneurysmNeurosurgical ClippingEndovascular Coiling (favored in ISAT)

Subarachnoid HemorrhageComplications:Rebleeding (7%)Vasospasm (46%) Highest incidence 3-12 days after SAHScreen with TCDTreat with Hypervolemia and Induced HypertensionAngiographyHydrocephalus (20%)EVDPermanent ShuntSeizures (30%)Antiepileptics for 1 week to 1 month

Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32C to 34C for 12 to 24 hours when the initial rhythm was ventricular fibrillation (VF).

HYPOTHERMIASuch cooling may also be beneficial for other rhythms or in-hospital cardiac arrest. Circulation. 2003;108:118

***

stroke, etc. 082808

Documents