stroke john p. connolly md medical director, resp care lodi memorial hospital assoc clin prof...
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STROKE John P. Connolly MD
Medical Director, Resp Care
Lodi Memorial Hospital
Assoc Clin Prof Medicine
UC Davis
STROKE Acute brain disorder of vascular origin accompanied by
neurological dysfunction that persists for longer than 24 hours…
Stroke 1990
One death every 4 seconds in the US…
Circulation 2013
TIA
Less than 24 hours
“clinical reversibility”
1/3 of TIAs are associated with cerebral infarction
TIME IS BRAIN TISSUE
Each minute of cerebral infarction results in destruction of 1.9 million neurons and 7.5 miles of myelinated nerves…
Stroke 2006
CLASSIFICATION
Ischemic Stroke 87%
80% thrombotic
20% embolic
Hemorrhagic Stroke 13%
97% intracerebral
3% subdural
INITIAL EVALUATION
Clinical diagnosis
most are unilateral/ no LOC
if coma –> hemorrhagic CVA
brainstem CVA
non-convulsive seizure
Left hemispheric damage -> aphasia
disturbance in comprehension/formation of language
receptive
expressive
global
contralateral weakness – can be due to seizure
hemiparesis can result from hepatic encephalopathy or sepsis
Suspected CVA
30% will have another condition
Seizures
Sepsis
Metabolic encephalopathies
Space occupying lesions
…..in that order
NIH Stroke Scale…NIHSS
11 different aspects of performance with a number from 0 to 3 or 4
Total score 0 to 41
>22=poor prognosis
<10=unlikely to be CVA
IMAGING
CT…reliable for intracranial hemorrhage
close to 100% sensitive
not sensitive for ischemic CVA…especially early
MRI…diffusion weighted
hyperdense regions of ischemia
can detect ischemia after 5-10 minutes
time consuming….cooperation issues
ECHO…echocardiography can identify source of cerebral emboli
identify patent foramen ovale
THROMOLYTIC THERAPY
Selection criteria
inclusion
exclusion
relative exclusion
Time limit recently expanded to 4-5 hours
Balance against 6-7% incidence of cerebral hemorrhage with lytic Rx
Time of stroke onset can be difficult to pinpoint
HBP as an exclusion…>185S/>110D
labetalol, nicardipine, nitroprusside
THROMBOLYSIS
As early as possible
rtPA 0.9 mg/kg up to 90 mg
10% in 1-2 minutes/ remained over 60 minutes
No anticoagulant or antiplatelet agent for 24 hours
Then only SQ heparin for DVT prophylaxis
and
ASA 325 given 24-48 hours after CVA then 81 mg a day
OTHER THERAPY
Oxygen…if O2 is ok then no benefit
toxic oxygen metabolites promote cerebral vasoconstriction
only if sat < 94%
BP Control…HBP in 60-65% of CVAs
usually corrects in 48-72 hours
correction only id >220S/>120D or acute MI
labetalol, nicardipine, nitroprusside(can increase ICP)
Fever Control…fever in 30%
can be infection or due to tissue necrosis
intracranial blood
fever harmful to brain tissue
GUIDELINES REVIEWED
AHA/ASA Guidelines for the early management of patients with acute ischemic stroke Stroke 2013 44: 870-947
AHA/ASA Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack Stroke 2014 45: 2160-2236
AHA/ASA Palliative and end of life care in stroke Stroke 2014 45: 1887-1916
Early Management of CVA
“5 suddens”….weakness, speech, visual loss, headache, dizziness
“FAST”…face, arm, speech, time
http://mmcneuro.files.wordpress.com/2013/01/stroke.gif
EMS
Prehospital Stroke Screen
LA prehospital Stroke Screen
Cincinnati Prehospital Stroke Scale
Stroke Center Transport
Primary Stroke Center
Comprehensive Stroke Center/neuro critical care
Emergency time…eval and begin fibrinolytic rx <60 min of ED arrival
NECT or MRI < 45 minutes
assess BG but no delay for ECG, CXR, troponin
General Support
Correct hypoxemia ?supplemental O2
Supine position
Cardiac Monitoring
BP control
Intubation for unconsciousness or bulbar dysfunction
Correct hypovolemia and hypoglycemia 140-180
Temperature < 38 degrees
rtPA {Alteplase}
With normal or early ischemic change on imaging
If frank hypodensity >1/3 MCA no rtPA
Unclear use…mild deficits
improving CVA symptoms
surgery< 3 months
recent MI
Maybe harmful in pts on dabigatran, apixaban, rivaroxiban
Other lytics…not recommended (streptokinase) or investigational
rtPA
0.9 mg/kg up to 90 mg IV within 3 hours
Door to needle < 60 minutes
Can treat 3-4.5 hours with more exclusions
With BP control <185/110
Complications…angioedema, bleeding
Management Decisions
Endovascular interventions
inter-arterial rtPA…no FDA approval
mechanical thrombectomy
emergency angioplasty and stenting
Anticoagulation
within 24 hours of rtPA…not recommended
ASA 24 hours later ok
glycoprotein 2b/3a inhibitors not recommended
abciximab,eptifibatide, tirofiban
Management Decisions
Volume expansion, vasodilators, induced hypertension…no
Albumin, hemodilution…no
Some use of vasopressors to support BP
Neuroprotective agents
statins…should be continued, ? Started
hypothermia…not proven
transcranial infrared laser…no
hyperbaric oxygen….only for air embolism
drugs…EtOH, Magnesium, Caffeine…not established
General Care
Specialized Stroke Units
Infection therapy/DVT prophylaxis
Swallow eval before po intake
Early mobilization
No benefit to specialized nutritional therapy or prophylactic antibiotics
Surgical intervention…emergent CEA not established
Treatment of Complications
Brain edema/Increased ICP…peaks 3-4 days after CVA
restriction free water
avoid excess glucose
minimize hypoxemia and hypercarbia
treat hyperthermia
elevate HOB 20-30 degrees
avoid antihypertensive agents causing cerebral vasodilation
Treatment of increased ICP
hyperventilation, hypertonic saline, osmotic diuretics
Interventricular CSF drainage
Steroids not recommended
decompressive surgery…effective…decisions based on volume of tissue infarcted and midline shift
Treatment of Complications
Hemorrhagic transformation
within 24 hours of rtPA
most fatal hemorrhages within 12 hours
optimal management debated
?cryoprecipitate
? tranexamic acid
Seizures….standard anti-epileptic therapy
prophylactic anticonvulsants not indicated
Acute hydrocephalus
placement of ventricular drain
Palliative Care
Secondary Prevention of CVA
Control of Risk Factors
Intervention for vascular obstruction
Antithrombotic therapy for cardioembolic stroke
Antiplatelet therapy for noncardioembolic stroke
Special circumstances
Risk Factor Control
HBP…risk for CVA rises directly with BP>115 syst
No benefit to systolic <120
BP Rx if >140/90 several days post CVA
lacunar infarct – goal<130 syst
Lipids…statin to LDL-C <100
DM…screen all CVA patients with HgbA1C
Risk Factor Control
Obesity…BMI< 30 usefulness of weight loss uncertain for secondary prevention
Risk for CVA rises above BMI 20
Metabolic Syndrome…overweight, trig, low HDL-C, high BP, high BG
….20% of adults over 20
Physical Inactivity … 40 minutes 3-4x a week
….supervision by PT or Rehab after CVA
Nutrition…over or under, routine supplements not helpful
vitamins not helpful, Mediterranean diet possibly helpful
Risk Factor Control
OSA…very high incidence…sleep studies
Cigarettes…strong risk for 1st CVA
second hand smoke increases risk
EtOH…light to moderate decreases 1st ischemic CVA risk
increased risk of hemorrhagic CVA with any EtOH
heavy EtOH increases risk for both types
Extracranial Carotid / VertebrobasilarDisease
CEA for > 70% stenosis
Not recommended for < 50%
Carotid Angioplasty and stent vs. CEA
Older patients…CEA better
Younger…equivalent
Optimal Medical Therapy
Vertebrobasilar…medical therapy, BP lowering, lipid control
Stenting vs VB endarterectomy considered
Intracranial Disease and Cardioembolic Disease
Atherosclerosis…>50% ASA> warfarin
BP control and high Intensity statin therapy
>70% add clopidogrel for 90 days
Cardioembolism…Afib is main risk
warfarin, apixaban, dabigatran, for nonvalvular afib
rivaroxaban also reasonable
anticoagulation and antiplatelet Rx if CAD
Cardiac Disease
Acute MI/LV Thrombus…VKA for 3 months
or apixaban dabigatran rivaroxaban
Cardiomyopathy…LVAD…VKA
EF< 35% anticoagulation and antiplatelet
Valvular Heart Dz…MV Disease plus Afib…VKA
MV Disease without Afib…consider VKA
CVA/TIA on VKA…add ASA
Prosthetic Heart Valves…Mechanical AV/MV….VKA plus ASA 81
Bioprosthetic…ASA
if CVA …add VK
Non-cardioembolic CVA/ Aortic Arch/ ICH
Antiplatelet agents
ASA and dipyridamole or clopidogrel
?Add VKA….unclear importance
Aortic Arch Atheroma
antiplatelet therapy and statin
VKA or surgery not recommended
Arterial Dissection
??surgery …Antiplatelet therapy or anticoagulation considered
ICH…controversy…high risk of bleed…antiplatelet therapy
restart anticoagulation > 1 week
Other risks
PFO
Hyperhomocystinemia
Thrombophilia
Antiphospholipid antibodies
HbSS
Venous sinus thrombosis
Pregnancy risks
LMWH or UFH every 12 hours
or heparin until the 13th week followed by VKA
Palliative/End of Life Care
2010…130,000 CVA deaths/ >5% of all deaths
50% in hospital
35% SNFs
15% home/other
20% of CVAs to SNF
30% of CVAs permanently disabled
Grief/ Pain/ Non-pain Issues
Anticipatory and acute grief
Complicated grief/depression…1-2 months later
more severe if acute loss
Pain…central post stroke pain….1-12%
hemiplegic shoulder pain
post-CVA spasticity
Non-pain…fatigue, incontinence, seizures, sexual dysfunction, sleep disordered breathing, depression, anxiety/delirium, emotional lability
Palliative Care/ Prognosis & Decision Making
“what is a good outcome”
Aspects of recovery most important to patient and family
Decision making…Surrogate Decision Makers
Cultural and Religious preferences
Bereavement Services Available
Preference Sensitive Decisions…DNR/DNI
Swallowing Care
Decompressive Craniectomy, etc.
Access to Palliative Care
Interdisciplinary
Collaborative/patient centered communication
Services available
Peace and dignity
Access…any CVA affecting daily functioning or reducing life expectancy
Goals of care…communication, best available science, acknowledge uncertainty, changes in preferences over time
A final Word…Paul Marino MD (2014)
Number of Strokes each year in US 700,000
Number of Ischemic Strokes (88%) 616,000
Number of Stroke Patients receiving lytic therapy 12,320
Number of pts who benefit from lytic Rx (1 in 9) 1,369
Percent of strokes that benefit from lytic RX 0.2%