Stroke Stroke Megan Stevens MD Vascular Neurology SUDDEN Maximal at onset Lateralized weakness, lateralized numbness, vision loss (one eye or portion of field in both eyes), double vision, slurred speech, trouble producing or understanding language, severe dizziness, severe new worst headache of life Types *if patient experiences any of these symptoms, call 911 tpa 4.5h from last known well Thrombectomy now out to 24 hours last known well Time is brain" Ischemic aka infarct Cardioembolic Small vessel (lacunar strokes) Large artery. (carotid disease) Other: dissection, hyper coagulable, venous ESUS (embolic streak unknown source) aka cryptogenic Hemorrhagic aka intraparenchymal hemorrhage Need to classify? What is this? Classification guides work up which guides secondary prevention 1
Small Vessel stroke Symptoms of small vessel strokes - risk factors: HTN, DM2, HLD, OSA, smoking, alcohol - Usually less than 2cm, attributable to a perforator vessel Pure sensory Pure motor Sensorimotor Clumsy hand dysarthria Ataxic hemiparesis Treatment What is this? Aspirin Treat chronic diseases Large Vessel stroke Risk factors: HTN, HLD, DM2, smoking, alcohol, cocaine/amphetamines, vessel inflammation, estrogen Carotid disease, intracranial stenoses, vertebrobasilar disease Most common stroke type world wide 2
Treatment What is this? Symptomatic carotid stenosis> 70% on CTA or >50% on angiography, CEA or CAS (CTA 50-69% depends) Aspirin, statin, management 0f chronic diseases, avoid triggers ICAD=asa/plavix/statinX 3mo Cardioembolic (aortoembolic) stroke Treatment Risk factors: DVT, intracardiac thrombus, valvular disease including e These strokes often look wedge shaped and/or are cor If multiple strokes in multiple vascular distributions: thin Anticoagulation for Afib once out of the acute stroke setting Too risky to start right away (HEMORRHAGIC CONVERSION) Usually wait 5days-3weeks depending Other options LAA closure, PFO closure, DAPT for atheroma WORK UP Extended work up MRI brain or Head CT CTA H/N vs MRA H/N vs carotid US Echocardiogram +/- bubble A1c, Lipid panel Telemetry OUTPT: 30 day cardiac monitor (if you think AFIB) OUTPT: sleep study (screen for OSA) esr/crp (if you think GCA/ vasculitis) Hypercoag panel (clotting Hx, young stroke) TEE (LAA clot/valves, young stroke, bad TTE windows) LP (inflammation/infection) Conventional Angio 3
Bleeds: HTN-ive Trauma or SAH, SDH, EDH = Neurosurgery Non traumatic Intraparenchymal focus here ICH score, associated with 30 day mortality Older age, infratentorial, IVH, bigger than 30cc s, low GCS do worse Same locations as lacunar strokes ( subcortical white matter, deep gray nuclear, pons, cerebellum) SBP usually 170 or higher Intraventricular extension Amyloid Lobar bleeds Cortical microbleeds on GRE/T2* Anticoagulation contrainidicated ever after Venous Infarct/Hemorrhage Only bleed you ANTICOAGULATE Metastatic disease Gray white junction Look for primary tumor CT c/a/p 4
AVM Bleed Work Up CTA Head (often also shows cerebral veins) Diagnostic on cerebral angio Screen BP MRI w/wo (tumors/amyloid) UDS +/- angio, MRV, CT c/a/p, LP, echo (endocarditis) Bleed Treatment SAY yes TO THERAPY Reverse anticoagulation Stop antiplatelets SBP goal less than 140 +/- NSGY for hematoma evacuation/ EVD, decompressive craniectomy If needed restart AC/antiplatelet again in 1-3 months MUCH easier to get good therapy plan BEFORE discharge harder to get insurance to cover IPR after d/c Studies shows IPR helps maximize recovery potential Recovery timeline Some recovery occurs in hours to days Most recovery over ensuing weeks and months Motor recovery: 90% at 90days Language: out to a year and beyond Bleed recovery- window for potential recovery large maybe year or more Who recovers maximally? Young Healthy (no medical comorbidities) Smaller strokes Those who have early improvement 5
Follow up after the hospital Ensure there is an anti platelet or anticoagulation plan Statin? Therapy? Sleep study? Depression!!!!! Post stroke issues Depression/anxiety Spasticity Poor sleep Central Pain Headache Memory issues Depression/Anxiety Spasticity Really common post-stroke Stroke causes chemical changes that SSRIs can help restore SSRIs help more that just mood- also thinking and motor recovery (FLAME trial) Baclofen, tizanidine, methocarbamol Sometimes gabapentin helps Botox injections Sleep Central Pain Sleep apnea very common in stroke patients When untreated increase stroke and heart disease risk When untreated contributes to attention, memory issues and headaches Refer to sleep medicine Occurs in days to months after a stroke affecting sensation pathways Often burning/tingling or deep difficult to localize pain Gabapentin, lyrica, cymbalta, venlafaxine Some may need referral to pain management 6
Headache Memory issues Acute phase of bleeds narcotics ok Gabapentin can be helpful in acute phase (watch sedation) rescue as well as prophylactic Depakote can be rescue as well as prophylactic SNRI s, topamax, verapamil prophylactic Rescue: APAP, midrin, benadryl/compazine CAN T use triptans after stroke Very common May get better in recovery phase, though many have some residual issues Multifactorial: mood disorder, sleep disorder, delirium, stroke deficit Treat sleep, mood disorders, treat thyroid and vitamin deficiencies ( thiamine, folate, B12, vitamin D)get exercise May do trial of anticholinesterase inhibitors if persistent issue after 6mo to year after stroke 7