Stroke in the Emergency Room: What do we need to know?

Transcription

1 Stroke in the Emergency Room: What do we need to know? Salah G. Keyrouz, MD, FAHA March 10, 2012 Stroke in the Emergency Room: What do we need to know? Disclosure: None 2 1

2 Outline Definition Introduction ti Clinical Presentation Differential diagnosis Urgent assessment in the ER Intravenous thrombolysis Post thrombolysis care 3 Definition A STROKE is an acute, non convulsive neurologic dfiit deficit 3 types: ischemic, Intracerebral hemorrhage, subarachnoid hemorrhage Diagnosis is clinical Imaging and laboratory data help differentiate the type of stroke, and confirm the diagnosis 4 2

3 5 Introduction Stroke is an emergency The non emergent approach to treating stroke is replaced by a rapid and systematic approach (time limited treatment) Early assessment + intervention start in the pre hospital setting Therefore, initial minutes hour in ED are crucial 6 3

4 Clinical Presentation History is very important (>> examination) SUDDEN weakness SUDDEN numbness/sensory deficits SUDDEN loss of ability to understand, produce speech SUDDEN dysarthria SUDDEN vision loss (monocular or binocular) SUDDEN imbalance, vertigo, dizziness 7 Clinical Presentation Pain is not a common symptom of stroke Headache more common with ICH, SAH Other pain (Chest, retro orbital, cervical) might signal underlying cause of stroke Aortic dissection, AMI, carotid/vertebral artery dissection Memory loss is not a symptom of stroke Transient Global Amnesia (TGA) 8 4

5 Clinical Presentation Localization Loss of consciousness occur in stroke when: Brainstem (ARAS) involved Extensive bihemispheric involvement Bi thalamic involvement Large ICH with tissue shifts/midline structures IVH SAH

6 Clinical Presentation Localization Language disturbances (aphasia) Dominant hemisphere cortical/immediate subcortical area Agnosia (neglect, inability to perceive sensory stimulation); Apraxia Non dominant hemisphere cortical/immediate subcortical area Anosognosia, asomatognosia

7 Clinical Presentation Localization Forced gaze deviation Away from the weak side: ipsilateral frontal, ipsilateral thalamic To the weak side: contralateral pons, contralateral thalamic Bilateral ptosis/apraxia of eyelid opening (gives the false impression of sleepiness) Non dominant hemisphere (large) 13 Clinical Presentation Localization Visual fields cut (HH, HQ) Contralateral occipital, posterior parietal, medial temporal lesion Visual loss Monocular: retina Binocular: bilateral occipital 14 7

8 Clinical Presentation Localization Diplopia (double vision) Monocular: retinal, vitreal, corneal, conversion/malingering Binocular: thalamus, midbrain, pons, cerebellar INO (MLF lesion medial midbrain, pons) Skew deviation Thalamus, cerebellum, pons Vertigo, dizziness Brainstem, cerebellum, inner ear apparatus

9 Clinical Presentation Localization Dilated, unreactive pupils Midbrain (CN III nuclei, fibers) Pinpoint pupils Pons, thalamus Midposition pupils midbrain i 17 Differential Diagnosis Stroke mimics Seizures Non convulsive Complex partial (confusion, aphasia) Post ictal state, post ictal weakness/paralysis Migraine (complicated or hemiplegic) Hypoglycemia, hyperglycemia Peripheral nerve injuries/palsies (not acute) Syncope/cardiac arrhythmias Conversion, malingering 18 9

10 Urgent assessment in the ER ABC, O 2 if needed, IV access, CBC, coags, BMP History. Particular attention to establishing last known well time Code stroke: a stroke team member at bedside in 15 min CTbrain (non contrasted): differentiate ICH, SAH and others, from IS MRI should not delay thrombolysis if indicated 19 Urgent assessment in the ER Review inclusion & exclusion criteria for thrombolysis Discuss with patient and family members EKG, CXRay, CE (should not delay thrombolysis) Aggressively treat hyper and hypoglycemia, hyperthermia 20 10

11 Urgent assessment in the ER Signs of early ischemia on CT: Loss of Gray white differentiation Loss of differentiation of cortical ribbon (insular cortex) Loss of differentiation of caudate head and surrounding white matter (IC) Unilateral dense MCA sign CT also helpful to look for complications Cerebral edema HCP Hemorrhagic conversion

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14 Urgent assessment in the ER blood pressure treatment in IS 27 Urgent assessment in the ER blood pressure treatment in IS 28 14

15 IV thrombolysis Remains the only approved acute therapy for ischemic i stroke 29 Tissue plasminogen activator Tissue plasminogen activator plasminogen plasmin plasmin plasmin Fibrin Fibrinogen 30 15

16 31 IV thrombolysis 32 16

17 33 IV thrombolysis up to 4.5h Exclusion (different than 0 to 3 hours): Age > 80y Severe stroke (NIHSS score>25 or >1/3 of MCA territory on CT or MRI) Patients on oral anticoagulants regardless of INR Previous stroke AND Diabetes 34 17

18 Implications of ECASS III AHA guidelines: IV t PA should be considered for eligible ibl patients t Not FDA approved yet (approved in Europe) Widely adopted in most stroke centers Benefit < than that seen between 0 3h Consent; adherence to inclusion/exclusion criteria Time is brain 35 IV thrombolysis IV t PA dose 0.9mg/Kg (max 90mg) 10% of dose given as bolus over 1 min 90% infusion over one hour Pharmacokinetics Half life 10 to 15 min Adverse events: Bleeding Angioedema (1 to 2% of patients on ACE ) 36 18

19 Who is eligible to receive IV t PA Clinically Clinical diagnosis of ischemic stroke causing measurable deficit Onset of symptoms < 4.5 hours prior to starting IV t PA No symptoms suggestive of subarachnoid hemorrhage (thunderclap headache, LOC) Symptoms not rapidly improving no head trauma, prior stroke in previous 3 months no history of intracerebral hemorrhage 37 Who is eligible to receive IV t PA Clinically No major surgery in previous 14 days No GI or UT hemorrhage in previous 21 days No arterial puncture at non compressible site in previous 7 days No evidence of active bleeding of major trauma on exam No seizure with post ictal neurologic deficits BPs < 185 mmhg and BPd < 110 mmhg (not requiring more than 3 doses of IV anti hypertensive to lower) 38 19

20 Who is eligible to receive IV t PA Laboratory and Imaging Head CT showing no blood (ICH, SDH, SAH, EDH) Platelets > 100,000 INR < 1.5 PTT within normal range Glucose > 50 mg/dl

21 Who is eligible to receive IV t PA Warnings High NIHSS score ( > 22) Older patients ( > 77 years) Patients with early ischemic changes on head CT however, to increase # of patients treated with t PA, and given lack of evidence for most exclusion criteria, many are relaxing criteria to t PA administration (with no increase in rate of complications) 41 IV t PA in the era of new anticoagulants Direct thrombin inhibitors (Dabigatran) Factor Xa inhibitors (Apixaban, Rivaroxaban) 42 21

22 IV t PA in the era of new anticoagulants Direct thrombin inhibitors (Dabigatran) Check thrombin time (TT). 10 min If normal (laboratory/coagulation analyzer specific; sec) proceed with IV t PA regardless of time of last dose Factor Xa inhibitors (Apixaban, Rivaroxaban) Check a prothrombin time If < upper limit of normal (laboratory/coagulation analyzer specific; 15.7 sec) proceed with IV t PA regardless of time of last dose Written consent 43 Beyond IV thrombolysis if onset > 4.5h OR patient ineligible for IV t PA OR fails to improve following IV t PA OR on new oral AC, consider other interventions IA t PA Mechanical embolectomy and thrombectomy 44 22

23 Post thrombolysis care Following t PA administration: BP check and control (ok in arm with IV) Frequent neurologic evaluation (beware new HA or one with changing characteristics) NIHSS at 24 hours No invasive procedure unless necessary No ASA, Plavix, or Aggrenox. No Lovenox or Heparin x 24 hours NPO until swallowing evaluated ±CT head at 24 hours

24 Complications following t PA Beware angioedema Treat with steroids, H1 and H2 blockers for 24h (or longer if needed) Bruising common. If severe in one place, consider Fx Mucosal bleeding is usually self limited and does not require any specific therapy Deterioration and/or new HA warrants brain CT, stopping infusion (if ongoing), type and screen If bleeding: PLTS, cryoprecipitate, FFP 47 Stroke mimics and IV t PA Risk of complications is low to non existent 48 24

25 Stroke mimics and IV t PA

26 Thank You 26