11/27/2017 COMPLEX AND HARD TO DIAGNOSE STROKES. No Relevant Financial Disclosures Sub-Investigator

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1 COMPLEX AND HARD TO DIAGNOSE STROKES Michelle Lee Kearney, ACNP-BC NP, Stroke Program St Thomas Health Nashville, TN DISCLOSURE No Relevant Financial Disclosures Sub-Investigator Stroke-AF Trial (Medtronic) RESPECT-ESUS (Boehringer Ingelheim) OBJECTIVES Identify the signs and symptoms of a posterior circulation stroke Apply the best work-up for hard-to-diagnose strokes Implement appropriate treatments for posterior circulation strokes Suggest evidence-based changes to improve the diagnosis of posterior circulation strokes 1

2 POSTERIOR CIRCULATION STROKES CONFOUNDING AND MIMICKER Annually in the US: 2.6 million ED visits for dizziness or vertigo Dizziness and stroke: missed 35% Are nearly 3x more likely than anterior circulation strokes to be missed >20% of Posterior Strokes missed in the ED Causes: emboli, atherosclerosis & stenosis, small vessel disease, and arterial dissection. Occlusion of the large vessels in this area has a mortality risk of 85% Kerber et al., Stroke, 2006; Nouh, Remke, & Ruland, 2014 ; Pawlukiewicz, 2017,Tarnutzer, et al., 2011 COMMON SYMPTOMS Dizziness Diplopia Dysarthria Dysphagia Dysphonia Dysmetria/Dystaxia Dysthesia Drop Attacks (DFO) Altered mental status Tongue Deviation Tinnitus Nausea Vomiting Vertigo Facial numbness Perioral numbness Nystagmus Headache Cross symptoms Unilateral or bilateral sensory loss Unilateral or bilateral hemiparesis Quadraperesis Balance POSTERIOR STROKES OCCUR WITHIN THE AREAS SUPPLIED BY THE VERTEBRAL/BASILAR ARTERY SYSTEM Strokes occurring within the vascular territory supplied by the vertebrobasilar arterial system The posterior arteries supply the inferior temporal and occipital lobes of the left cerebral hemisphere and the right hemisphere. The Cranial Nerves Exit Via the brainstem 2

3 Motor or sensory loss in all 4 limbs Crossed signs (CN vs. body) Nystagmus BRAINSTEM Ataxia Dysarthria Dysphagia Respiration Living LET US PRACTICE 62 YO FEMALE SUDDEN ONSET OF NAUSEA, VOMITING AND DYSPNEA; I MAY HAVE PASSED OUT DDX? MI? Aortic Issue? W/U: 12-lead EKG, CXR, Telemetry 20 minutes? Continued Questioning: -Reports orthostatic dizziness -She received a new antihypertensive last week DDX? Arrhythmia? Hypotension? Any other questions you want to ask? Enough to warrant a CT scan? Neuman-Toker, Stroke DIZZINESS PLUS Symptom Altered mental status Loss of Consciousness Headache Neck pain Chest/Back Pain Abdominal Back Pain Dyspnea Palpitations Blood/Fluid Loss New/recent medication use Fever, Chills Abnormal Glucose Possible Diagnoses Worst to Bad Stroke, Seizure, Encephalitis;ETOH, Illicit drugs SAH, Stroke, ACS, Aortic Dissection, PE, Seizure, Syncope, Arrhythmia, Hypovolemia SAH, Stroke; Dissection; meningitis; high or low ICP; migraine; [Vertebral artery] dissection ACS; Aortic dissection Aortic dissection;ruptured ectopic pregnancy PE; Pneumonia; Anemia Arrhythmia; Vasovagal syncope; Panic Disorder Hypovolemia; Anemia Medication side effects or toxicity Systemic infection; Encephalitis; Meningitis DKA, Symptomatic hypoglycemia Eid, Dastan, & Heckmann, 2015 Neurol Clin 3

4 THOROUGHLY INVESTIGATE 27 yoon pain meds, h/o MVC 3 days ago. Woke up dizzy. Dizzy PLUS AMS PLUS new medications A little nauseated, ate breakfast, stayed dizzy, then drowsy. Wife worried that he took to many pills DDX: Posterior Circulation Stroke Overdose Vertebral artery dissection A Person with Posterior Circulation Stroke Will: USUALLY present with more than one finding RARELY has an isolated symptom of PC ischemia CASE STUDY 60 year old male Tobacco, alcohol, DM, HTN, chronic Afib on Rivaroxaban and a beta blocker for rate control Symptoms began: 1530 Headache, Nausea, Vomiting, Dizziness OSH at 1630 AF on arrival with RVR Immediate treatment of his AF, rate control with Diltiazem hydrochloride drip 2145-Stopped speaking, Right hemiparesis Telemedicine consult-wife declines tpa 2215-Begins posturing like a seizure No longer protecting airway-intubated They call the helicopter 2330-Arrival to the CSC Believe symptoms began about 1530 URGENT CTA ON ARRIVAL EARLY ISCHEMIA 4

5 INITIAL MRI REPEAT MRI 2 DAYS Assessment: NO reflexes PERIPHERAL OR CENTRAL? Condensed from Nouh, Remke, & Ruland, Frontiers in Neurology CEREBELLAR, BRAINSTEM, CRANIAL NERVE DEFICITS WHAT IS THE BEST EXAM? LAMS (Arm, Grip, Facial Droop) Cincinnati (Facial Droop, Arm, Speech) FAST-ED (Face, Arm Speech, Eye Deviation, Denial/Neglect) RACE (Face, Arm, Leg, Head/Eye Deviation, Aphasia, Agnosia/Neglect) BE FAST Balance + Eyes + FAST NIHSS Ataxia Visual deficits Gaze Arch et al. Stoke,

6 STROKE IMAGING NCCT Not for all dizziness cases Bad News: Poor resolution in the posterior fossa due to bone and beam artifact 12% false negatives CTA/Perfusion Many CTA/P will not give you an accurate penumbra in the posterior fossa Thrombus? Dissection? MRI Can miss a small posterior fossa stroke but it s better than CT Often too late for treatment DELAYING THERAPY IS DENYING THERAPY 50% of the patients show up inside of the treatment windows..but if missed: No tpa No Mechanical Thrombectomy Worse 90- day clinical outcomes Increased LOS SNF instead of IPR Discharge differences Missed GDT Antiplatelet agents within 48 hours No Statin on discharge Missed metrics Arch et al. Stroke, 2016; Saver et al. JAMA; 2013 CASE STUDY 2 72 year old man PMH: Psoriasis, Psoriatic Arthritis, IDDM, Hypothyroidism, DVT on Warfarin Woke with a right occipital HEADACHE; Hypoglycemia 2330 Nausea/Vomiting Diplopia INR 3.0 To hospital via family O x 3, diplopia, disconjugate gaze, dysarthric, abnormal gait, headache, nausea, vomiting, DIZZINESS 6

7 RIGHT CEREBELLAR HEMORRHAGE Intubated Transferred from the Spoke hospital Warfarin reversal BP orders for 160 (not 140 per our protocol) Temporary corticosteroid treatments CEREBELLAR HEMORRHAGE 9-10% OF ALL ICH USUALLY IN PATIENTS > 50 YEARS OLD Urgent craniectomy DVT confirmed by venous doppler Hematology consult: Aspirin on POD #5 Re-evaluation for Oral Anticoagulant in 30 days with MRI Discharged to inpatient rehab Neuro ataxic deficits remained with some improvement in diplopia Inpatient rehab was recommended. EARLY RECOGNITION=EARLY INTERVENTION= BEST RECOVERY CHANCE The Romberg test Stand, eyes closed; assess for sway/fall Central: sway eyes open and closed The Dix-Hallpike maneuver Turn head rapidly, lie back quickly Unreliable to determine central vs peripheral HINTS: Head Impulse Central: Eyes fixed on the target w/ rapid head movement Nystagmus Central: vertical, directional-changing horizontal Test of Skew Central: Vertical misalignment of eyes; cover one eye Newman-Toker& Edlow, 2015 How about just walk your patient? Step-wise approach If any of these are positive, stop exam Sit with dizziness in bed? Sit on side of the bed with dizziness? Stand on side of the bed with dizziness? Ambulate with dizziness? Mullin, & Erpenbeck,

8 POSSIBLE HELP FROM THE EHR FAST TO BE FAST Aroor, Singh, & Goldstein, 2017 WHAT IF IT ISN T A STROKE 512 patients received tpa On f/u imaging, 21% did not show an infarct Median NIHSS 7 on admit, 0 at discharge No symptomatic ICH Neurology 2010 study Independent at discharge (median LOS 3 days) Most frequent mimics: Seizure, conversion, migraine Giving IV tpawithin the 3 hour window to a suspected stroke is safe even if there is no stroke Chernyshev, et al., Neurology IN SUMMARY: KEY POINTS Symptoms of PC stroke are confounding and are wrought with mimics PC strokes affect cranial nerves, the brainstem, the cerebellum, the occipital & temporal lobes PC Hemorrhages = Emergent Surgical Considerations Overall a PC stroke has worse 90-day outcomes Not noticed or treated early Early Recognition = Early Treatment Ataxia testing HINTS testing BE FAST (add to your EHR!!) Beware of the Deadly D s : Dysarthria, Dysphagia, Dystaxia, Diplopia Dizziness PLUS another symptom (ataxia, nausea, headache) warrants more work-up Predict a central lesion 8

9 QUESTIONS/COMMENTS? MICHELLE KEARNEY NASHVILLE, TN REFERENCES Arch, A. E., Weisman, D. C., Coca, S., Nystrom, K. V., Wira, C. R., & Schindler, J. L. (2016). Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services. Stroke, 47(3), Aroor, S., Singh, R., & Goldstein, L. B. (2017). BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of StrokesMissed Using the FAST Mnemonic. Stroke, 48(2), Chernyshev, O. Y., Martin-Schild, S., Albright, K. C., Barreto, A., Misra, V., Acosta, I., Savitz, S. I. (2010). Safety of tpa in stroke mimics and neuroimagingnegative cerebral ischemia. Neurology, 74(17), Eid, E., Dastan, S., & Heckmann, J. G. (2015). Acute dizziness in rural practice: Proposal of a diagnostic procedure. Journal of Neurosciences in Rural Practice, 6(2), Hwang, D. Y., Silva, G. S., Furie, K. L., & Greer, D. M. (2012). Comparative Sensitivity of Computed Tomography vs. Magnetic Resonance Imaging for Detecting Acute Posterior Fossa Infarct. The Journal of Emergency Medicine, 42(5), Kerber KA, Brown DL, LisabethLD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke. 2006;37: Mullin, Michael, & Erpenbeck, P. (2017, August). Improving the Assessment of Acute Posterior Strokes. Presented at the AANN Advances in Stroke Care Conference, Chicago, IL. Retrieved from Newman-TokerDE, Cannon LM, StofferahnME, Rothman RE, Hsieh YH, Zee DS. Imprecision in patient reports of dizziness symptom quality: a crosssectional study conducted in an acute care setting. Mayo Clin Proc 2007;82: Nouh, A., Remke, J., & Ruland, S. (2014). Ischemic Posterior Circulation Stroke: A Review of Anatomy, Clinical Presentations, Diagnosis, and Current Management. Frontiers in Neurology, 5. Saver, J., Fonarow, E., Smith, E., Reeves,, M., Grau-Sepulveda, M., Pan, W., et al. (2013). Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA, 309(23), Pawlukiewicz, A. (2017, March 15). Posterior Circulation Strokes and Dizziness: Pearls and Pitfalls. Retrieved November 20, 2017, from 9