when stroke strikes, strike the stroke. by mikhail serebrennik, md dept. of radiology, trinity...
TRANSCRIPT
When stroke strikes, strike the stroke.
By Mikhail Serebrennik, MDDept. of Radiology, Trinity Health
What is stroke?
• An act of hitting a small dimpled white ball with an iron club
• A high-voltage discharge of atmospheric electricity
• What this presenter almost had when he found out he wasn’t going to sleep in today
Correct terminology• The word “stroke” is imprecise• Ischemic infarction – death of tissue due to interruption of
blood supply– Can be arterial, venous or due to hypotension/hypoxia– Distinction is important for workup and treatment– Arterial: atherosclerosis, vasculitis, embolus, spasm– Venous: dehydration, blood disorders (hypercoagulable state,
polycythemia), infection (meningitis)– Hypotension/hypoxia: cardiac arrest, blood loss, drowning
• Intracerebral hemorrhage– HTN, amyloid angiopathy, trauma, coagulopathy, AVM
• Extraaxial hemorrhage is not included in this discussion
Signs and SymptomsWatch for these signs and symptoms if you think you or someone else may be having a stroke. Note when signs and symptoms begin, because the length of time they have been present may guide treatment decisions.
• Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination.
• Trouble with speaking and understanding. You may experience confusion. You may slur your words or be unable to find the right words to explain what is happening to you (aphasia). Try to repeat a simple sentence. If you can't, you may be having a stroke.
• Paralysis or numbness on one side of your body or face. You may develop sudden numbness, weakness or paralysis on one side of your body. Try to raise both your arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your mouth may droop when you try to smile.
• Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision, or you may see double.
• Headache. A sudden, severe "bolt out of the blue" headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke.
Ref: Mayo Clinic website
Diagnostic tests
• History and physical examination; question witnesses. Cheap and effective but not enough to guide modern therapy. Look for what is missing!
• CT scan: very good for quick evaluation for hemorrhage. May not pick up very recent onset infarctions.
• MRI: sensitive to even hyper-acute infarctions (DWI) and very small hemorrhages (GRE/T2*). Can also do MRA head and neck while patient is in the magnet. Expensive, taxes time and resources.
But who cares?
Infarcted tissue is dead and cannot be saved, right?
But who cares?
Infarcted tissue is dead and cannot be saved, right?
Yes, but…
More about infarctions
ischemia
It’s all about the penumbrapen·um·branoun \pə-ˈnəm-brə\plural pen·um·brae or pen·um·brasDefinition of PENUMBRA
1 a : a space of partial illumination (as in an eclipse) between the perfect shadow on all sides and the full light b : a shaded region surrounding the dark central portion of a sunspot
2: a surrounding or adjoining region in which something exists in a lesser degree : fringe
Restricted diffusion = dead brain1. Interruption of blood supply2. Membrane failure (No ATP –
breakdown of Na-K pump – Na stays in cells – cells suck in water and undergo cytotoxic edema)
3. Cells swell up, intercellular space shrinks
4. Water molecules cannot move and5. They return signal to receiver
Diffusion-perfusion mismatch
Radiologyassistant.nl
What goes on in the affected brain
Pay attention to detail, document, communicate
• Time is brain• Early diagnosis is key• Keep your mind, eyes and hands on the
patient• Take notes and compare them with prior
notes to find subtle changes• Communicate with the treating physician!
Case 1
89 y.o. male with syncope
Case 1
MRI performed, DWI
Case 1
US carotid
Society of Radiologists in Ultrasound 2003 Consensus Panel Gray-Scale and Doppler US Criteria for
Diagnosis of ICA Stenosis
Case 1
10 days laterBefore stent
Case 1
After stent
Case 1
Afterstent US
How is the brain perfused?
http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case4/CerebralCirc.htm
How is the brain perfused?
http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case4/CerebralCirc.htm
Where is perfusion the weakest?
http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case4/CerebralCirc.htm
At the watershed zones.
http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case4/CerebralCirc.htm
Case 2
52 y.o. male, agonal respirations
Case 2Acute or chronic?
Case 2
Case 2
Case 2CT cannot always tell acuity. Use DWI and ADC mapping
Case 2T2 and FLAIR do not differentiate between acute and chronic
Now go back and check the ADC map again…
Case 2
5 days later…
Case 2
Understand tissue at risk!
Case 3
84 yo maleAMS, confusion
Case 3
Case 3
Case 3
Case 3
Case 3 – 10 days later…
Case 4 – 36 y.o. female
Case 4
Case 4
Case 4
Case 4
Not much on the CT, but…
Case 4
Case 4
OK, maybesomething onDWI/ADC…
Anything on MRA?
Case 4
Case 4
Case 4
Case 4 – two weeks later…
Case 4 – two weeks later…
Case 4 – two weeks later…
Is there anything?
Case 4 – two weeks later…
Yes.
Case 4 – two weeks later…
There is.
Case 4 – two weeks later…By the way…Did you see this?
Case 4 – But why is this happening?
Ahh, I see…
Case 4 – 2 more days…
Case 4 – another 6 days.
Case 4 – diagnosis?
?
Case 4Wallenberg’s syndrome is a neurological condition caused by a stroke in the vertebral or posterior inferior cerebellar artery of the brain stem. Symptoms include difficulties with swallowing, hoarseness, dizziness, nausea and vomiting, rapid involuntary movements of the eyes (nystagmus), and problems with balance and gait coordination. Some individuals will experience a lack of pain and temperature sensation on only one side of the face, or a pattern of symptoms on opposite sides of the body – such as paralysis or numbness in the right side of the face, with weak or numb limbs on the left side. Uncontrollable hiccups may also occur, and some individuals will lose their sense of taste on one side of the tongue, while preserving taste sensations on the other side. Some people with Wallenberg’s syndrome report that the world seems to be tilted in an unsettling way, which makes it difficult to keep their balance when they walk.
