CEREBRO VASCULAR S MICHAEL OPONG-KUSI, DO MBA MORTON CLINIC, TULSA, OK, USA 8/9/2012 1
Cerebrovascular Accident Third Leading cause of deaths (USA) 750,000 strokes in USA per year. 150,000 deaths in USA per year Statistics for Ghana??? 8/9/2012 2
TRANSIENT ISCHEMIC ATTACKS TIA: focal neurological deficit with abrupt onset resolves within 24 hours. Up to 50% will show acute infarction on MRI. If symptoms persists > 1 hr 14% will resolve in 24hours. 8/9/2012 3
TRANSIENT ISCHEMIC ATTACKS Carotid distribution TIA resolves within 14 minutes. Vertebral artery distribution TIA resolves within 8 minutes. 8/9/2012 4
TRANSIENT ISCHEMIC ATTACK TIA precursor for ischemic stroke Cardio embolic disease stroke Lacuna stroke Hemorrhagic stroke TIA proceed to CVA @ 10% in 3 mo @ 13% in 1 yr @ 30% in 5 yrs 8/9/2012 5
TRANSIENT ISCHEMIC ATTACK Differential diagnosis: Aortic dissection Drugs Venous thrombosis Paroxysmal arrhythmias Complicated migraines Arterial vasculitis Todd s paralysis 8/9/2012 6
TRANSIENT ISCHEMIC ATTACK Todd s Paralysis Transient hemi paresis in post ictal period after a grand mal seizure. Can last half hour to 36 hours. 8/9/2012 7
TRANSIENT ISCHEMIC ATTACK Evaluation: Clinical history!! Determine carotid vs. vertebral history per exam CT of head without contrast to rule out hemorrhage. Carotid duplex ultrasound Cerebral arterial angiography or MRI 8/9/2012 8
TRANSIENT ISCHEMIC ATTACK Therapy: Ischemic etiology Platelet agent Statin agent Modification of risk factors 8/9/2012 9
TRANSIENT ISCHEMIC ATTACK Therapy: Aspirin first drug of choice 81mg to 325mg po q daily 18% risk reduction by cyclooxygenase inhibition. Clopidogrel (plavix) 75mg po q daily blocks platelet ADP inhibition. Dipyridamole 200 mg BID 8/9/2012 10
TRANSIENT ISCHEMIC ATTACK Cardio embolic etiology: Atrial fibrillation multiple stroke sites, Mitral stenosis, mechanical valves, recent MI, tumor, estrogen BCPs Therapy IV heparin and initiate warfarin therapy to attain INR 2-3 8/9/2012 11
TRANSIENT ISCHEMIC ATTACK Endarterectomy If >70 stenosis is documented by carotid imaging studies and pt. symptomatic Endarterectomy is beneficial. Symptomatic patients with <50% stenosis no surgical benefit over medical therapy Surgical mortality <6% in experienced centers. 8/9/2012 12
85% Ischemic Stroke Thrombolic or embolic; cardiac to artery or artery to artery. 15% Hemorrhagic stroke Intracerebral, subarachnoid, subdural or epidural 8/9/2012 13
Lacuna CVA 20% of all CVA 80% present as completed defect 20% present in hours or days. Etiology Thrombosis of penetrating branches cerebral arteries. Major risk factor Hypertension, dyslipidemia 8/9/2012 14
Embolic etiology Sudden onset of symptoms No loss of consciousness Accurate documentation of time of onset key in determining thrombolytic therapy. 8/9/2012 15
Internal Carotid Artery Ipsilateral monocular blindness. Contralateral weakness Contralateral sensory loss 8/9/2012 16
Anterior Cerebral Artery Contralateral weakness Contralateral sensory loss Deficit leg > arm and face Personality changes. 8/9/2012 17
Posterior Circulation Cortical blindness Ataxia Ipsilateral cranial nerve defect Diplopia Dysarthria (aphasia) Altered level of consciousness. 8/9/2012 18
Hemorrhagic stroke: Sudden onset of severe headaches (the worst headache of my life!) Loss of consciousness imply brain stem involvement. 8/9/2012 19
Onset of stroke at young age AV malformation Cerebral aneurysm Endocarditis Vasculitis Traumatic carotid disease Hypercuagable state Drugs 8/9/2012 20
Onset of stroke at young age Hypercouagulable states Test at least 2 months post stroke No wafarin at least 2 weeks Protein C & S, Leiden Factor V, antiphospholipid antibody syndrome Lupus anticoagulant 8/9/2012 21
Evaluation: Transesophageal echo (TEE) Invaluable in evaluating atrial septal defects, patent foramen ovale, cardiac clot, valvular disease, endocarditis. Aortic arch atheroma 8/9/2012 22
Evaluation: History, History, History!!! Stat CT of the head WITHOUT CONTRAST media (contrast will obliterate intracranial bleed.) CT may be normal for 6-24 hours post ischemic stroke! CT may miss posterior fossa defects. 8/9/2012 23
Evaluation: MRI head scan indicates: Early defects Vertebral basilar CVA Occlusion of venous sinus Small infarctions MRI does not show bleeding well 8/9/2012 24
MRI angiography Overestimates degree of vascular stenosis Less helpful in the carotid siphon or middle cerebral artery Gold Standard 8/9/2012 25
Primary Risk Factors: Hypertension Smoking Diabetes Milletus Hyperlipidemia Physical Inactivity Obesity / oral contraceptives Advanced age. 8/9/2012 26
Medical Therapy Aspirin 50-325 mg daily first choice! Reduces relative risk by 18% Decreases acute mortality and recurrent CVA in thrombotic strokes Clopidogrel (Plavix) 75 mg daily Alternative to aspirin less GI bleeding symptoms than aspirin. 8/9/2012 27
Medical Therapy Antiplatelet agents Dipyridamole 200mg + Aspirin 25mg BID Heparin Use in stroke in evolution 12mic gm/kg/hr 8/9/2012 28
Medical Therapy Stat CT of the head to exclude bleed. If stroke large by clinical exam and by CT hold heparin for one week Low risk for recurrent bleed. 8/9/2012 29
Medical Therapy Cardioembolic stroke If endocarditis on native valves do not give heparin. If endocarditis on mechanical valves wait 72 hours and repeat head CT if no bleed start heparin. 8/9/2012 30
Medical Therapy Intravenous thrombolysis r-tpa (approved drug for thrombolysis) Inclusion Criteria Age > 18 yrs ; Treatment within 3 hours of CVA Head CT does not show bleed Neurological defect not too big Keep BP<185/110 8/9/2012 31
Medical Therapy Intravenous thrombolysis Exclusion Criteria Small CVA CT scan show bleed Hx. Recent CVA, surgery or trauma Uncontrolled HTN, DM, coagulation defects. 8/9/2012 32
Medical Therapy Intravenous thrombolysis Results 10 fold increase in symptomatic intracerebral hemorrhage 30% decrease in disability @ 3 months No change in mortality in 1 year 8/9/2012 33
Surgical therapy Angioplasty and stent therapy Problems with artery dissection, distal embolization,re-stenosis, 8/9/2012 34
Complications of Stroke Seizures Follow Glucose and Na levels. Diazepam, phenytoin Cerebyx (very expensive!!) 8/9/2012 35
Complications of Stroke SIADH Syndrome Low serum Na+ with high urine Na+ Decreased mental status 8/9/2012 36
Complications of Stroke Cerebral Edema Maximal day 3-5 persist for 10 days Intubate and hyperventilate pco2 to 35 Mannitol Surgical decompression CNS drainage Steroids no benefits except tumor related 8/9/2012 37
Complications of Stroke Hypertension Ischemic Stroke treat if BP> 210/120 Avoid ischemia for 10 days Hemorrhagic stroke Acute bleed maintain SBP 140-160 to prevent further bleeding 8/9/2012 38
Complications of Stroke DO NOT FORGET THE COMMOM COMPLICATIONS! Pneumonia, UTI, Pulmonary emboli, DVT prophylaxis, Sepsis, treat other co morbidities! 8/9/2012 39
CASE PRESENTATIONS 45 Year old male presented to the ER with difficulty speaking when he woke in the morning. He could not move his right leg and arm. He has otherwise been healthy 8/9/2012 40