Andrew Barreto, MD MS Associate Professor of Neurology Stroke Neurologist UTHealth. May 23, 2018

Transcription

1 Andrew Barreto, MD MS Associate Professor of Neurology Stroke Neurologist UTHealth May 23, 2018

2 Disclosure No personal financial relationships with any company.

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4 Presentation Outline Definitions, signs & symptoms, risk factors Types & causes of stroke Treatments Exciting brand-new information Prevention Future

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6 Stroke Quick Facts 3 rd 4 th 5 th leading cause of death in USA 800,000 strokes per year 1 stroke every 40 seconds in US 5/sec in world 164,000 deaths from stroke/year #1 cause of disability in adults Time is Critical, TIME IS BRAIN

7 What is a stroke? Damage to the brain caused by problems in the arteries or veins of the head and neck - Interruption of normal blood flow to the brain - Rupture and bleeding of a vessel

8 Signs & Symptoms

9 Sudden onset of: weakness or numbness of the face, arm or leg, especially on one side of the body confusion, trouble speaking or understanding trouble seeing in one or both eyes trouble walking, dizziness, loss of balance or coordination severe headache with no known cause (especially bleeding strokes)

10 Transient Ischemic Attacks (TIAs) Warning stroke which can precede a major stroke mini stroke Blood flow to the brain is reduced for a short time Symptoms are temporary & identical to those of stroke Duration of symptoms ~ minutes A person with a TIA is 9.5 times more likely to have a stroke

11 Aphasia a language disorder

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14 Stroke Risk Factors Modifiable Hypertension Heart disease Smoking Elevated Cholesterol Diabetes Carotid atherosclerosis Alcohol Drugs of abuse Hormones post-menopausal Non-modifiable Age Sex (M > F) Race AA > Hispanic > White Prior Stroke Family History

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16 Stroke Types Ischemic Blocked blood vessels 75-80% Hemorrhagic Burst or leaking blood vessels 15-20%

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18 Ischemic Stroke Blocked blood flow Without blood flow & oxygen, nerve cells start to die in minutes 2 million neurons per min TIME IS BRAIN infarction ischemic penumbra

19 #1 cause - Atherosclerosis

20 Cholesterol build-up (plaques) in arteries Critical 99% narrowing of carotid artery

21 Location Location Location

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23 Hemorrhagic Stroke (non-trauma) Occurs when a weakened blood vessel ruptures Hypertension Aneurysms Ballooning of a weakened artery Subarachnoid Hemorrhage Arteriovenous Malformations Cluster of abnormal blood vessels Clots in the veins of brain hemorrhage

24 57 year old man with sudden onset headache & right sided paralysis 6 hours later 15cc 50cc

25 Brainstem Strokes Can be rapidly deadly Whole body paralysis Breathing Swallowing Locked-In syndrome

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27 Emergent Treatment Hemorrhagic Stroke Blood pressure, Blood pressure, Blood pressure Blood products/medications to reverse blood thinners Surgery Secure aneurysm Remove certain types/locations of blood Ischemic Stroke tpa Endovascular

28 Telemedicine: Remote Vascular Neurologist Obtains history & stroke severity score Reviews web-uploaded CT scan Orders tpa for eligible patients

29 UT-Houston Mobile Stroke Unit Diagnostic Equipment Portable CT scanner Point-of-care laboratory system Teleradiology & Teleneurology connection

30 Ischemic Stroke Acute therapy - tpa Intravenous medication Busts open clots Must be given within 4.5 hours of symptom onset or last seen normal Disabling symptoms No recent surgeries; history of hemorrhagic stroke; brain tumor Odds of excellent outcome Time to tpa start - minutes

31 tpa the Clotbuster medication for Stroke Of 100 patients that receive tpa: BENEFIT RISK

32 Acute Therapy Endovascular Therapy Devices - Stentrievers

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34 Imaging Selection used to find patients most likely to benefit from opening the artery 1. Inject dye into arm & capture many pictures of the brain over ~40 seconds 2. Automated software creates images used to guide treatment 3. Choose patients with small core of brain already dead and large area of tissue at risk Salvageable brain

35 CONVERSLY - Large core stroke - unlikely to benefit with reperfusion - may actually harm

36 68 year old man Heart disease, high BP & cholesterol Sudden onset of left sided paralysis - NIH Stroke Scale score = 12 - tpa started quickly 1.5 hours from onset - onboard the mobile stroke unit - Artery opened 2.6 hours from stroke onset Clot length reduced 80% 20mm 5mm Stentreiver Discharged home at 48 hours with NIHSS=1

37 Big strokes can swell and be deadly Baseline 24 hours Historically, mortality 80% 48 hours

38 Surgical removal of skull prevents swelling into the brain Bone is white on CAT scan Skull removed

39 Impact of Specialized Stroke Hospitals 61,685 consecutive Finnish stroke patients receiving care in: 1) PSC - Primary Stroke Center 2) CSC - Comprehensive Stroke Center 3) General Hospital RESULTS PSC treated patients: 11% less likely to die 11% less likely to be institutional care 16% more likely to be at home at 1-year * even better for CSC Stroke. 2010;41:1102-7

40 Admit patients to Hospital Stroke Units Greater survival 14% reduced odds of death Greater return to home & regaining independence 18% reduced odds of death or dependence (disability) Stroke 1997;28: Stroke 2008; 39:

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42 I ve had a stroke, how do I prevent a second? It Depends. Hemorrhagic Stroke Aggressive Blood Pressure control Surgery or coil aneurysm, abnormal blood vessels Surgically remove tumor Ischemic Stroke.what was the cause? Stop smoking Medications are key Blood thinners - Strong (Afib) = Coumadin/warfarin, Xarelto, Eliquis, Pradaxa - Not so strong (non-afib) = Aspirin, Plavix Cholesterol lowering (statins) = atorvastatin (Lipitor), Crestor, etc. Blood Pressure lowering Surgery or Stenting of carotid artery plaque Closure of small hole in heart (PFO Patent Foramen Ovale)

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44 Pre-Hospital Recognition of Stroke & 911 Activation At the patient: Skype / Facetime In the field Ultra-fast delivery of tpa stroke ambulances Strategic delivery of patients to stroke centers Geography ideal placement of comprehensive stroke hospitals

45 In the Emergency Department Amplify tpa with combination blood thinners Ultrasound Amplified tpa at any hospital Broader patient range of endovascular therapy Currently only 1-3% of patients qualify

46 In Stroke Rehab Devices that can stimulate brain during therapy Transcranial Magnetic Stimulation (TMS) Physical Occupational Speech Other Investigational Devices

47 THANK YOU VERY MUCH FOR YOUR ATTENTION