A Tale of 3 Stroke Adventures BETHANNE MCCABE, MSN, MS, CRNP, CNRN

Transcription

1 A Tale of 3 Stroke Adventures BETHANNE MCCABE, MSN, MS, CRNP, CNRN

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3 I. Carotid Dissection with L ICA/MCA Occlusion 44 year old female, no significant PMH Presented with aphasia, dysarthria and headache S/P Thrombectomy and stent placement

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5 Causes of Artery Dissection Occurs when structural integrity of the arterial wall is compromised, allowing blood to collect between layers, forming hematoma, thrombus. Causes include: Trauma, mechanical triggering events or spontaneous events (extrinsic) Physical activities: skating, tennis, basketball, volleyball, swimming, scuba diving, dancing, yoga, trampoline, roller coaster ride Other reported activities: childbirth, sexual intercourse, coughing or sneezing, neck manipulation, hyper extended neck, hyper flexed neck Underlying predispositions such as in some connective tissue abnormalities (intrinsic) Fibromuscular dysplasia, Marfan Syndrome, Ehlers-Danlos Syndrome, Autosomal dominant polycystic kidney disease, cervical artery tortuosity to name a few. (Low percentage contribute). Smoking: causes an inflammatory response to the cerebral vessels which effect the integrity

6 Artery Intima

7 Hospital Course - Acute onset of word finding difficulties and dysarthria, while working on computer in a hyper flexed position - Arrived in ED w/nihss of 2 - MRI revealed L ICA occlusion with M2 occlusion & small insular infarct - NIHSS increased to 3, outside of TPA window, NIHSS then increased to 9 Aphasia, dysarthria, headache, left Horner s syndrome, ataxia, decrease sensation in right arm - Urgently taken for angiogram revealing a L ICA skull based dissection - S/P aspiration thrombectomy and stent placement

8 Horner Syndrome w/carotid Dissection

9 Left Insular Cortex Infarction

10 Work up and Plan - CT: no acute pathology - MRI: L ICA occlusion with M2occlusion w/left insular infarct - Cerebral Angiogram: revealed L ICA skull based dissection s/p L M1 Thrombectomy with L ICA Stent - DAPT: Load 1 st with 300/600 (ASA and Plavix) for 3 6 months - Medrol dose pack for headache - Magnesium 500 mg - Atorvastatin 40 mg - PT and SLP, outpatient - Follow up in Neuro IR Clinic

11 Follow Up - CDUS prior to exam to assess stent patency - Full Neurological Examination - Continue ASA/Atorvastatin, Coenzyme Q10 for myalgia - Risk Factor Modification -- LDL goal between Patient reports ongoing decrease sensation in right arm and ptosis of left eye when or sneezing (symptoms worsen when sneezing) *****No clear cause of dissection, suspect hyper flexed for length of time*******

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13 II. Right MCA/ACA Strokes w/ bilateral ICA occlusion 40 year old female with PMH of tobacco use Presented with left side weakness Treated with DAPT and aggressive risk factor modification

14 Causes of Carotid Stenosis or Occlusion High blood pressure Tobacco use Diabetes High levels of certain fats and cholesterol Family history Age Obesity Lack of exercise

15 Hospital Course L.N 40 y/o female with PMH of tobacco (1.5PPD) use, asthma, anxiety, marijuana presented with left sided weakness. NIHSS 5 for dysarthria, Facial, LUE weakness and sensory changes CTH no hemorrhage CTA bilateral carotid occlusions MRI right frontal infarct Diagnostic Cerebral Angiogram confirms bilateral occlusions at the origin- anterior circulation supplied by ECA collaterals, filling through the posterior communicating artery

16 Carotid artery stenosis assessed by magnetic resonance angiography A magnetic resonance angiogram (MRA)shows marked narrowing and stenosis at the origin of the right internal carotid artery (arrow). Courtesy of Jonathan Kruskal, MD. Graphic Version 3.0 Uptodate Inc.

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18 Management of Carotid Disease SURGICAL Carotid Endarterectomy (CEA) surgically accessed carotid lesion (Vascular) Carotid Artery Angioplasty & Stenting (CAS) IA procedure (Neurology/NS) Standard for endovascular carotid intervention - Carotid lesion not accessible for CEA - Radiation induced stenosis - Restenosis after endarterectomy - Clinically significant cardiac, pulmonary disease Crest (symptomatic and asymptomatic) noted equivocal between CEA/CAS for both 30 day and 10 risk of stroke, MI or death). Crest 2 (ongoing now) only symptomatic carotid MEDICAL - ASA, 81 mg daily (325 load) - Plavix, 75 mg daily (300 or 600 load) - Effient (Prasugrel) (60 load), then 10 (Plavix non responders) - Dual Antiplatelet Therapy (DAPT) - Statin helps to stabilize plaque (Lipitor Atorvastatin Crestor- Rosuvastatin/Zocor-Simvastatin) - Risk Factor Modification - HTN - DM - OSA

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20 Right MCA/ACA Infarcts

21 Cerebral Vessel & Anatomy

22 Work up and Plan STROKE WORK UP MRI: R ACA/MCA territory infarcts DSA: bilateral ICA occlusion; distal RICA was reconstituted from ophthalmic artery LDL 105 Started on Atorvastatin 80 mg daily HgbA1c 5.1%, U/A negative TEE: Preserved LVF, EF 55-60%, no PFO, no thrombus D/C PLAN Fluoxetine 20 mg for motor recovery ASA 81, Plavix 75 mg daily Smoking Cessation 48 Hour Holter Monitor Inpatient Rehabilitation NIR Clinic in 2-5 weeks NIHSS of 5

23 Follow Up 7 weeks post event ASSESSMENT Completed IPR, 2 weeks NIHSS 3 for LUE drift and ataxia 48 Hour Holter No atrial fibrillation Carotid Doppler: LICA occlusion/rica 80-99% NO Stroke Symptoms Still smoking ½ pack per day LPN, not working Memory and Executive Function/Fine Motor deficit No exercise PLAN Continue ASA/Ator/Plavix for now Follow up in 4 weeks in NIR with CDUS prior Risk Factor Modification - Smoking cessation (PCP Wellbutrin) - Weight loss/diet/exercise

24 III. Dural Sinus Thrombosis 24 year old female, G1P1, uncomplicated vaginal birth with PMH of PCOS, Anxiety/depression, smoker Presented with severe headache, increased ICP Treated with AC Lovenox to Warfarin

25 What is Cerebral & Dural Sinus Thrombosis (CVT)? - Thrombosis of cerebral veins or dural sinus obstructs blood drainage leading to dysfunction, increased venous and capillary pressure resulting in disruption of the BBB. Increase in vasogenic edema Lowers cerebral perfusion pressure and CBF End result ->cytotoxic edema - Occlusion of the dural sinus resulting in decreased cerebrospinal fluid (CSF) absorption and increased ICP (more frequent in superior sagittal sinus thrombosis

26 Risk Factors &Causes of CVT - Prothrombotic conditions, either genetic or acquired (connective tissue disease, hematologic disorder) Genetic component 22% (Protein C or S deficiency, Factor V Leiden mutation, G20210 A prothrombin gene mutation, hyperhomocysteinemia) - *Oral contraceptives - *Pregnancy and the puerperium - *Malignancy - Infection (6-12%) - Head injury and mechanical precipitants (less than 10%) - Obesity when combined with female sex and use of oral contraceptives *Typically 75% female, with 65% either using oral contraceptives, hormone therapy, pregnancy or puerperium period.

27 Typically. Signs and Symptoms of CVT - Encephalopathy Multifocal signs, (delirium, cognitive dysfunction, apathy)mental status changes, stupor or coma - Focal syndrome Focal deficits, seizures (more common in CVT) or both - Intracranial hypertension syndrome Headache w/or w/out emesis, papilledema, and visual problems H/A most frequent symptom, 89%, usually the first symptom and sometimes only symptom - Cerebral edema, venous infarction, and hemorrhagic venous infarction associated with more of a severe syndrome; patients more likely to have motor deficits, aphasia and seizures

28 Hospital Course - 24 year old female, G1P1, uncomplicated vaginal birth with PMH of PCOS, Anxiety/depression, smoker presents 2 weeks after delivery with severe headache and vision changes - MRI reveals no infarct with extensive Venous Sinus Thrombosis - Thrombectomy considered - LDL 70; HgbA1C ICP monitored, seizure prophylaxis, pain management - Lovenox 150mg q12 to warfarin bridge - Hypercoagulable state work up, most likely 2 nd to postpartum state - Goal normotension

29 Signs of cerebral venous thrombosis on head CT scan Noncontrast head CT shows a hyperdense thrombosed cortical vein (arrow). (B) Noncontrast head CT shows a hyperdensity in the torcula (small arrowhead) and the straight sinus (large arrowhead), a direct sign of dural sinus thrombosis (the dense triangle sign). (C) Head CT shows non-filling of the confluent sinus after contrast injection (the empty delta sign). Uptodate Inc. Graphic Version 4.0

30 Superior sagittal sinus thrombosis on MRI T1-weighted magnetic resonance imaging discloses an isointense signal in the superior sagittal sinus (arrows), corresponding to a thrombus (A), and the corresponding absence of flow on magnetic resonance venography (B). Graphic Version 3.0 Uptodate Inc.

31 Considering the diagnosis. - New onset headache and that differ from the usual pattern - Signs and symptoms of increased ICP - Encephalopathy - Focal neuro signs and symptoms, especially those not fitting into a vascular distribution or involving multiple territories - Seizures - Present risk factors

32 Plan - Lovenox 150mg q12 to warfarin bridge - AED, Zoloft, Effexor (seizure prevention and depression) - H/A: Tylenol - F/U imaging CTV in 3 months - F/U in clinic in 3 months

33 Follow Up in 3 months WORK UP & EVALUATION -CTV reveals no evidence of occlusive dural sinus thrombosis w/ evidence of subocclusive thrombi at the sagittal sinus - Smokes 2 cigarettes per day - Reports intermittent h/a - Reports intermittent blurred vision PLAN D/C Warfarin Start ASA 81 mg daily Continue antidepressant Continue Metformin for PCOS Continue Lamictal (antiseizure) Follow up in 6 months

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