Management of Acute Ischemic Stroke. Learning Objec=ves. What is a Stroke? Jen Simpson Neurohospitalist

Transcription

1 Management of Acute Ischemic Stroke Jen Simpson Neurohospitalist Learning Objec=ves Iden=fy signs/symptoms of stroke Recognize pa=ents who may be eligible for treatment of acute stroke What is a Stroke? Fixed focal neurological deficit ajributable to arterial or venous territory, typically las=ng longer than 24 hours with evidence of acute infarc=on. So what s a TIA? a brief episode of neurological dysfunc=on caused by focal brain or re=nal ischemia, with clinical symptoms typically las=ng less than one hour, and without evidence of acute infarc=on

2 65 year old man with right face/ arm/leg weakness Resolved on the way in to the hospital Lasted about 50 minutes No prior symptoms Now completely neurologically intact Why should I care about TIA? Common problem Incidence: ~200,000 to 500,000 per year Prevalence 2.3%, or 5 million people Sequela of disease STROKE! 3-10% at 2 days 9-17% at 90 days Other CV disease 43% combined risk of stroke, MI or vascular death over 10 years Heart Diseases and Stroke Sta=s=cs 2011 Update: A report from the American Heart Associa=on. Circula=on Published online Dec 15, 2010.

3 ABCD 2 Is admission required? TIA Clinics are revolu=onizing TIA treatment! Mul=ple studies show that they are just as effec=ve as admission if done quickly! Two Aces EXPRESS Study SOS- TIA And others Clinics are cost effec=ve and have no reduc=on of tpa u=liza=on!

4 MRI in TIA vs Stroke 2 pa=ents, both with right sided weakness 65 year old man presents with right sided weakness star=ng an hour ago History of hypertension, hyperlipidemia, and smoking Right face and arm weakness, leg is normal. No sensory problems No gaze devia=on No aphasia NIHSS=5 What is the best way to determine =me of onset?

5 CTOH and CTA NORMAL! Iden=fy Door to Treatment Times 3 Hour Window Exclusions Age <18 Heparin within last 48 hours AND Minor/isolated symptoms or elevated PTT spontaneously clearing Oral an=coag w/inr >1.7 or PT >15 Seizure at onset Plts <100,000 Other stroke/serious head trauma in Glucose <50 or >400 last 3 months Lacta=ng/suspected to be pregnant Major surgery or serious head trauma Clinical presenta=on c/w acute MI or in last 14 days post- MI pericardi=s Known history of ICH Ac=ve bleeding or acute tramua (fx) Sustained SBP >185 or DBP >110 on exam Aggressive treatment required to Hypodensity >1/3 of cerebral lower BP hemisphere Symptoms sugges=ve of SAH even if Intracranial neoplasm, AVM, NCHCT is nega=ve aneurysm GI or GU hemorrhage in last 21 days Arterial puncture at noncompressible site

6 4 ½ Hour Window Exclusion Age <18 or >80 NIHSS >25 Previous stroke and diabetes Oral an=coagulant use Minor surgery/severe trauma in past 3 months How effec=ve is tpa? You ve given tpa, and the nurse wants to know about neurochecks. How ouen? Every 15 minutes for the first 2 hours Every 30 minutes for the next 6 hours Every 1 hour for 16 hours Anything else you want to watch closely? Goal BP: 180/105 What if it is higher than goal?? Labetalol 10 mg IV, can redose about every minutes Hydralazine 10 mg IV Nicardipine drip

7 Other than bleeding, what are some adverse effects to tpa? Oro- lingual angioedema Nausea What are other post- stroke measures?? Swallow screen: Every pa=ent MUST have one DVT prophylaxis When? Rehab If they don t need it you must say that the pa=ent was evaluated for rehabilita=on services and was not warranted due to. OMG, my pa=ent got worse, and has a big bleed on CT. Can you reverse tpa? What is the half life? Is that reassuring? What should your next few orders be? STOP THE DRUG Type & Screen (if not already done) Cryo FFP Neurosurgery consult

8 Anterior Circula=on ACA Occlusion MCA occlusion: Posterior Circula=on PCA occlusion: Vertebro- basilar occlusion: COMMON STROKE PATTERNS Contralateral hemiparesis: Leg weakness > Arm Contralateral sensory loss: Leg>arm Confusion, personality changes Contralateral hemiparesis: Arm and face weakness >Leg Contralateral sensory loss: Arm/face>leg Aphasia (usually leu brain) Spa=al neglect (usually right brain) Homonymous hemianopia on opposite side of the infarct Gaze devia=on towards side of stroke Homonymous hemianopia on opposite side of the infarct Contralateral sensory loss Possible aphasia Disconjugate gaze (uncommon) ataxia, ver=go, diplopia, dysarthria, hiccups, nausea, vomi=ng disconjugate gaze crossed signs decreased LOC A 65 year old man admijed with CHF exacerba=on with new leu sided weakness Woke up with symptoms Inability to move leu arm, or leg. Facial droop present. Sensory loss on leu and field cut NIHSS=15

9 What do you want to know? Perfusion Scan Cerebral Blood Volume Mean Transit Time

10 What else can I do? What else can I do? MERCI Penumbra Solitaire Other Possibili=es

11 First IV tpa vs IA therapy RCTs IMS III Efficacy of combina=on treatment SYNTHESIS Expansion IV TPA vs IA therapy (no IV) head to head MR RESCUE Penumbral imaging for pa=ent selec=on up to 8 hours 31 Each trial has limita=ons Time to procedure start is clearly a factor As is the device used New devices not evaluated in these studies