Cerebrovascular Disease

Wednesday AM lecture series

Mitch Deshazer

Focus on the basics

• Stroke: ischemic, hemorrhagic

• Subarachnoid hemorrhage

Stroke guidelines in 1 slide

1. Clinical diagnosis

2. Yell “Please page a Brain Attack to room X”

3. Resume coffee drinking while watching the fun.

What the Brain Attack team does, as per 2008 guidelines

1. Clinical diagnosis

2. NIH stroke scale

3. CT/MRI to confirm dx and determine type of stroke (level 1A recc), CT just as good as MRI

Then things diverge a bit

• Ischemic stroke:

– Supportive care: airway/breathing, fever control*, BP control if SBP over 180 for tPA, 220 otherwise*; (safe to restart outpt HTN meds in 24 hrs; CHHIPS study), euglycemia.

– Go quick quick to tPA.

IA tPA? What about with mechanical lysis added on?

Time to treatment: >6 but <24 hours

Stuff that doesn’t work

• Heparin/ASA*

• Hemodilution

• Vasodialators

• Induced hypertension if pt hypotensive

• Combinations of thrombolytics↓

• “neuroprotective” agents—see next slide

Neuroprotective drugs?

Complications

No data on prophylactic anticonvulsants

In ischemic stroke

The bleedy kind

To Do list- intracerebral bleed• Image head

• Check for and correct coagulopathy (prothrombin complex concentrates or FFP, but NOT fVII)

• Take blood pressure down to SBP 140s*

• Fix hypoglycemia, not sure what to do with hyperglycemia; fix fever#, DVT SQ heparin ok after day 1-4 if no bleeding

• I guess we should call neurosurgery

The other level 1A recommendation(clinical seizures only)

Prophylaxis changes the frequency, but no evidence that seizures change

outcomes

All data about ICH, etc from TBI literature

Within TBI literature, ICP monitors define 3 patient populations

1) Normal ICP

2) Abnormal ICP that responds to treatment; type of treatment appears unimportant

3) Abnormal ICP that doesn’t respond to treatment

Data for ICP monitor in hemorrhagic stroke

What about the ventricles?

*

What about surgery?

The ICH score is determined by adding the score from each component as follows:

1) Glasgow Coma Scale (GCS) score 3 to 4 (= 2 points); GCS 5 to 12 (= 1 point) and GCS 13 to 15 (= 0 points)

2) ICH volume ≥30 cm3 (= 1 point), ICH volume <30 cm3 (= 0 points)3) Intraventricular extension of hemorrhage present (= 1 point); absent (=

0 points)4) Infratentorial origin yes (= 1 point); no (= 0 points)5) Age ≥80 (= 1 point); <80 (= 0 points)

Thirty-day mortality rates increased steadily with ICH score; mortality rates for ICH scores of 1, 2, 3, 4, and 5 were 13, 26, 72, 97, and 100 percent, respectively. No patient with an ICH score of 0 died, and none had a score of 6 in the cohort

Prognosis

Subarachnoid Hemorrhage

Clinical Presentation “Worst headache of my life”--80% Sentinel bleed—10% AMS, vomiting, seizures, stiff neck, focal

deficits Diagnosis: CT scan, if negative LP

If positive, then either CTA, MRA, or angiography to spot the lesion

Hunt & Hess grading scale

Asymptomatic, mild headache, slight nuchal rigidity--1 Moderate to severe headache, nuchal rigidity , no neurologic

deficit other than cranial nerve pals--2 Drowsiness / confusion, mild focal neurologic deficit--3 Stupor, moderate-severe hemiparesis--4 Coma, decerebrate posturing--5

Vasospasm

General Concepts in management

Establish baseline TCD to watch for vasospasm DVT with SCD until after coil/clip, then SQ hep Get rid of all blood thinners Nimodipine, baby. HyperNa done frequently but without data Fluctuations in BP thought to cause rebleed, so keep it

even. Absolute value unclear. Fix hypoxia, hypo- or hyperglycemia, pH

Stuff that doesn’t work

Antfibrinolytic therapy—stops bleeding but causes more ischemic strokes

Hypothermia

Hemodilution, Hypertension, hypervolemia (triple H therapy)

Stuff that might work

Infusion of urokinase into CSF to prevent vasospasm

Statins to prevent vasospasm

Magnesium sulfate to prevent vasospasm

Unclear how to prevent rebleed