Stroke: Evaluation and Treatment

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Stroke Evaluation and Treatment

• John B. Terry, M.D.
• Medical Director, Neurocritical Care
• Via Christi Regional Medical Center

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Stroke-in-Evolution

• Emergency
• Heterogenous group of etiologies
• Increasing number and complexity of treatment
  options

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Stroke Definition

• A syndrome characterized by acute onset of a
  neurologic deficit that persists for at least 24
  hours, reflects focal involvement of the central
  nervous system, and is the result of a
  disturbance of the cerebral circulation.

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Stroke Definitions

• Transient Ischemic Attack (TIA)
• Reversible Ischemic Neurologic Deficit (RIND)
• Stroke in Evolution (Progressive Stroke)
• Completed Stroke

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Stroke Epidemiology

• gt 700,000 new or recurrent strokes occur per year
• Accounts for gt 50 of all hospitalizations for
  acute neurologic disease
• 4 million Americans are living with neurologic
  deficits due to stroke
• Leading cause of serious, long-term disability
• Risk and mortality increase with age
• Third leading cause of death in the U.S. second
  leading cause worldwide

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Stroke Subtypes
Lacunar 19
Thromboembolic 6
SAH 13
Cardioembolic 14
Hemorrhagic 26
Ischemic 71
ICH 13
Unknown 32
Other 3
Data from NINCDS Stroke Data Bank Foulkes et
al. Stroke. 198819547.
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Stroke Risk Factors

• Tobacco use
• High blood pressure
• Previous TIA or Stroke
• Diabetes mellitus
• Atrial fibrillation
• Family history of stroke or heart attack
• hyperlipidemia

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Stroke Risk Factors

• Cardiac structural conditions
• Cholesterol
• Serum homocysteine
• Sedentary lifestyle
• Gender
• Age
• heavy alcohol use
• oral contraceptives

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From NIH, 1996
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From Wolf PA, et al, Stroke 22312, 1991
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Stroke Symptoms Signs

• Symptoms suggest the cause of the lesion and its
  location
• Signs accurately identify the location of the
  lesion (cortex, brainstem, or spinal cord left
  or right side anterior or posterior circulation)
• Neuroimaging confirms the location and excludes
  other disorders which might produce similar signs
  and symptoms.

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• MCA distributes to the lateral surface of the
  hemisphere
• ACA distributes to the medial frontal and
  parietal lobes
• PCA distributes to the medial occipital and
  temporal lobes

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Arteries of Brain Inferior View
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Anterior Circulation

• Internal carotid artery and its branches
• anterior middle cerebral arteries (ACA MCA)
• anterior choroidal artery
• lenticulostriate branches of MCA
• Supplies much of cerebral hemispheres and
  adjacent subcortical white matter

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Clinicoanatomical Correlates

• Anterior Cerebral Artery
• Parasagital cerebral cortex motor sensory
  cortex related to contralateral leg, bladder
  inhibitory micturation center
• Paralysis and sensory loss contralateral leg
  uninhibited bladder

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Clinicoanatomical Correlates

• Middle Cerebral Artery
• Superior div. contralateral hemiparesis
• with relative sparing of the leg, contra-
• lateral hemisensory loss Brocas
• aphasia
• Inferior div. homonymous hemianopsia,
• impaired cortical sensory function, ano-
• sognosia, apraxia, Wernickes aphasia

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Clinicoanatomical Correlates

• Middle Cerebral Artery
• Superior div. motor sensory cortex
• for face, arm, hand Brocas area
• Inferior div. visual radiations, macular
• vision Wernickes area
• Lenticulostriate vessels basal ganglia,
• genu posterior limb internal capsule

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Clinicoanatomical Correlates

• Middle Cerebral Artery
• Lenticulostriate vessels dense hemi-
• paresis affecting arm/leg/face equally

22
Clinicoanatomical Correlates

• Internal Carotid Artery
• Signs and symptoms similar to MCA stroke
• Transient monocular blindness (amaurosis fugax)

23
Posterior Circulation

• Vertebral artery, basilar artery their
  branches
• posterior inferior cerebellar artery (PICA)
• posterior cerebral artery its thalamoperforate
  and thalamogeniculate branches

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Clinicoanatomical Correlates

• Posterior Cerebral Artery
• Occipital cerebral cortex, medial temporal lobes,
  thalamus, rostral midbrain
• Homonymous hemianopsia, cortical blindness,
  impaired recent memory, anomic aphasia, alexia
  without agraphia, visual agnosia (eg.,
  prosopagnosia)

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Clinicoanatomical Correlates

• Basilar Artery
• Occipital medial temporal lobes, medial
  thalamus, posterior limb internal capsule,
  brainstem, cerebellum
• Bilateral neurologic signs, cranial nerve
  cerebellar signs, diplopia, vertigo, crossed
  motor sensory signs, hemi- or quadraplegia,
  ataxia, dysarthria, LOC

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Clinicoanatomical Correlates

• Lacunar Stroke
• Atherosclerosis with fibrinoid necrosis
  lipohyalinosis of small penetrating arteries
• (internal capsule, thalamus, pons)
• Occurs in setting of longstanding hypertension or
  diabetes mellitus

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Clinicoanatomical Correlates

• Lacunar Stroke
• Multiple syndromes including
• Pure motor hemiparesis
• Pure hemisensory loss
• Ataxic hemiparesis
• Dysarthria-Clumsy Hand Syndrome

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Stroke Management Algorithm
Acute Evaluation
CT scan
Recanalization Strategy
Operative Intervention
Acute Support
Acute Support
Definitive Evaluation
Definitive Evaluation
Secondary Prevention
Secondary Prevention
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Pre-Hospital Care

• Recognition of symptoms
• Weakness or numbness on one side of the body
• Speech difficulties
• Visual difficulties
• Balance problems
• Sudden severe headache
• Loss of consciousness
• Emergency requiring a prompt response
• Rapid Transport to hospital

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After Arrival at Hospital

• Prompt examination
• CT scan
• Determination of etiology of symptoms
• Admission
• Pharmacologic treatment
• Diagnostic tests
• Physical therapy and swallowing evaluation
• Definitive stroke prevention and rehabilitation
  strategy

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Stroke Differential Diagnosis

• hypoglycemia
• tumor
• abcess
• syncope
• seizure

• trauma
• classic migraine
• multiple sclerosis
• Bells palsy
• conversion reaction

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CT Scan
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Immediate Treatment Options

• Thrombolysis (tPA)
• Aspirin
• Antiplatelet agents
• Fluids
• Blood Thinner (heparin)
• Future options

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Barnett HJM, Buchan AM, JAMA, 283(23), June 21,
2000
35
Stroke Treatment

• risk factor modification
• antiplatelet agents
• aspirin
• ticlopidine
• clopidogrel
• dipyridamole
• anticoagulants
• Heparin
• Coumadin
• LMWH

• carotid endarterectomy
• extracranial-intracranial bypass
• thrombolytics
• tissue plasminogen activator
• streptokinase
• glutamate antagonist

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Neurovascular Evaluation

• Cardiogenic emboli
• Large arterial process
• embolic
• thrombotic
• Penetrating vessel process
• Hematologic process

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Stroke Evaluation

• History
• Onset and course
• Associated symptoms (seizure, headache)
• Predisposing risk factors

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Stroke Evaluation

• Physical Examination
• Blood pressure (both arms) pulse
• Ophthalmoscopic exam for retinal emboli
• Carotid or ocular bruits
• Cardiac murmur or dysrhythmia
• Temporal artery tenderness
• Neuro Exam (may be normal after TIA)

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Stroke Evaluation

• Routine laboratory tests
• CBC w/ diff
• Multichemistry profile including glucose
• Lipid profile
• Protime, PTT, ESR, VDRL
• Routine Urinalysis

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Stroke Evaluation

• Other Clinical Studies
• ECG CXR
• CT or MRI
• Echocardiogram (transthoracic vs. TEE)
• Carotid Transcranial Doppler
• Continuous ECG monitoring (eg., Holter)
• Cerebral arteriogram
• Lumbar Puncture
• EEG

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Stroke PreventionEchocardiographic Evaluation of
Stroke

• Documentation of Cardiac Embolism
• Introduction of TEE
• Increased Proportion of Cardiogenic Embolism1
• Additional Findings
• Aortic Arch Atheroma
• Patent Foramen Ovale
• Coronary Screening2

1. Gomez CR, Tulyapronchote R, Malkoff MD, Malik
MM, et al. J Stroke Cerebrovasc Dis 1994.
4(3)169-173 2. Thakur AC, Voros S, Nanda NC,
Gomez CR, et al Echocardiography 1999.
16(2)159-166
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Stroke Evaluation

• Special Laboratory Studies
• Serum viscosity
• antithrombin III, protein C S
• lupus anticoagulant, anticardiolipins
• Homocysteine, Factor V mutation
• Sickle cell prep
• ANA
• Coagulation factor analysis

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MRI Scan
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Cerebrovascular Doppler
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Neurovascular Evaluation
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Stroke Etiology (vascular)

• Atherosclerosis
• Fibromuscular dysplasia
• Carotid or vertebral artery dissection
• Lacunar stroke
• Drug abuse
• Venous sinus thrombosis
• Complicated migraine

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Stroke Etiology (vascular)-continued-

• Inflammatory disorders
• temporal arteritis
• systemic lupus erythematosus
• syphilitic arteritis
• AIDS
• granulomatous angiitis
• polyarteritis nodosa
• Herpes zoster

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Stroke Etiology (cardiac)

• mural thrombus
• rheumatic heart disease
• dysrhythmias (esp. atrial fibrillation)
• endocarditis
• bacterial
• marrantic

• mitral valve prolapse (?)
• paradoxical embolus
• patent foramen ovale
• atrial septal defect
• left atrial myxoma
• prosthetic heart valve

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Stroke Etiology (hematologic)

• Thrombocytosis (platelets gt1,000,000/uL)
• Polycythemia (hematocrit gt50-60)
• Leukocytosis (WBCgt150,000/uL)
• Sickle Cell Disease
• Hypercoagulable states

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Hypercoagulable States

• hyperviscosity syndrome
• pregnancy postpartum
• estrogen therapy
• postoperative
• cancer

• antiphospholipid antibody syndrome
• protein C or S deficiency
• antithrombin III deficiency
• Factor V Leiden mutation

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Prevention of Future Stroke

• Antiplatelet agents
• Coumadin
• Mechanical procedures (ie, Carotid Endarterectomy)

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Secondary PreventionMedical Treatments
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Stroke PreventionAspirin Dosing and Its Efficacy
50 100 50
Low Dose
300 75 300
Medium Dose
Algra, van Gijn
Johnson
900 1500 650 1500
High Dose
Dose (mg/day)
-30
-25
-15
-10
-5
0
5
10
-20
RRR () 95 CI
Endpoint stroke, MI, or vascular death.
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Stroke PreventionFatal or Nonfatal Stroke in
CAPRIE
6
Aspirin
Event Rate per Year
5
3.61
4
Clopidogrel
Cumulative Event Rate ()
3
2.91
2
1
P 0.0082
0
6
9
12
15
18
21
24
27
30
33
36
3
Months of Follow-Up
Based on post hoc analysis of individual
outcome events (N 19,185). 1 Data on file,
Sanofi Pharmaceuticals, Inc. 2 Gent M.
Circulation. 199796(suppl)I-467. Abstract 2608.
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ESPS-2 Results RRR for All Strokes
36.8 P lt 0.001
40
30
18.9 P 0.009
16.5 P 0.036
RRR vs Placebo ()
20
10
0
ASA
ER-DP
ASA/ER-DP
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Stroke PreventionCardiogenic Brain Embolism
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Stroke PreventionWarfarin on LV Dysfunction
50.0
No Warfarin Users (n 5652) Warfarin Users (n
861)
W -
40.0
W
24 RRR P 0.0006
30.0
All-Cause Mortality ()
20.0
10.0
0.0
0
500
1000
1500
2000
Follow-up Time (Days)
Al-Khadra AS. SOLVD Study J Am Coll Cardiol.
199831749753.
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Effect of Simvastatin on Stroke/TIA in
the Scandinavian Simvastatin Survival Study (4S)
6
5
Placebo
28 Risk Reduction p 0.033
4
Percentage of Patients with Stroke/TIA
3
2
Simvastatin
1
0
1
2
3
4
5
6
0
Years
The majority of study population were on
antihypertensive medications or aspirin at
baseline. Patients were started on 20mg daily and
titrated to 40mg (37) if Total-C was over 200
mg/dL. Mean Changes in LDL-C and Total-C were
-35 and -25, respectively.
Pederson TR, et al Am J. Cardiol 199881333-335.
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Discharge Disposition - FY 98 - FY 99
Home/Self Care
Another Type Facility
(Rehab/Psych)
Expired
10/97-03/98 (n177)
Skill Nursing Facility
04/98-09/98 (n138)
(Nursing Home)
10/98-03/99 (n150)
Home Health Care
04/99-09/99 (n117)
Intermediate Care Facility
(Assisted Living)
Another Hospital
Against Med Advise
0
20
40
60
80
100
120
Number of Patients
DRG 014 Non-Hemorrhagic - Stroke Service Only -
Not Type "T" (23 Hr Admits)
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Intracranial Hemorrhage

• The brain is a highly vascular organ
• It receives 20 of the cardiac output
• Prone to hemorrhage
• Fixed volume contraints of the skull result in
  unique consequences
• These consequences are the cause for concern and
  uneasiness of many physicians

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Intracranial Hemorrhage

• Categorized based on location
• Intraparenchymal
• Subarachnoid
• Subdural
• Epidural
• Similar clinical presentations
• Easily diagnosed by CT scan
• Treatments differ

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Intracranial Hemorrhage

• The brain is surrounded by multiple tissue layers
• Many areas of the brain are supplied by
  perforator arteries
• Berry aneurisms occur most frequently in the
  circle of Willis

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Intracranial Hemorrhage

• Intraparenchymal Hemorrhage

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Intracranial Hemorrhage

• Intraparenchymal Hemorrhage
• Charcot-Bouchard aneurism

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Intracranial Hemorrhage

• Intraparenchymal Hemorrhage
• Charcot-Bouchard aneurism
• Hypertensive hemorrhage Spontaneous hemorrhage

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Intracranial Hemorrhage

• Intraparenchymal Hemorrhage
• Charcot-Bouchard aneurism
• Hypertensive hemorrhage Spontaneous hemorrhage
• Occur in Basal ganglia, thalamus, pons,
  cerebellum

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Intracranial Hemorrhage

• Intraparenchymal Hemorrhage
• Charcot-Bouchard aneurism
• Hypertensive hemorrhage Spontaneous hemorrhage
• Occur in Basal ganglia, thalamus, pons,
  cerebellum
• Controvery exists regarding best treatment

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Intracranial Hemorrhage

• Subarachnoid Hemorrhage

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Intracranial Hemorrhage

• Subarachnoid Hemorrhage
• Most blood is present in the basal cisterns

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Intracranial Hemorrhage

• Subarachnoid Hemorrhage
• Most blood is present in the basal cisterns
• Results from rupture of a berry aneurism

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Intracranial Hemorrhage

• Subarachnoid Hemorrhage
• Most blood is present in the basal cisterns
• Results from rupture of a berry aneurism
• Occur most commonly in the anterior circulation

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Intracranial Hemorrhage

• Subarachnoid Hemorrhage
• Most blood is present in the basal cisterns
• Results from rupture of a berry aneurism
• Occur most commonly in the anterior circulation
• Has significant early and late complications

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Intracranial Hemorrhage

• Subarachnoid Hemorrhage
• Most blood is present in the basal cisterns
• Results from rupture of a berry aneurism
• Occur most commonly in the anterior circulation
• Has significant early and late complications
• Treatment is prevention of complications

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Intracranial Hemorrhage

• Subdural Hemorrhage

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Intracranial Hemorrhage

• Subdural Hemorrhage
• Felt to be associated with venous bleeding

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Intracranial Hemorrhage

• Subdural Hemorrhage
• Felt to be associated with venous bleeding
• May be associated with trauma

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Intracranial Hemorrhage

• Subdural Hemorrhage
• Felt to be associated with venous bleeding
• May be associated with trauma
• Subjacent brain often traumatized

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Intracranial Hemorrhage

• Subdural Hemorrhage
• Felt to be associated with venous bleeding
• May be associated with trauma
• Subjacent brain often traumatized
• Treatment is surgical drainage

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Intracranial Hemorrhage

• Epidural Hemorrhage
• Arterial bleeding

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Intracranial Hemorrhage

• Epidural Hemorrhage
• Arterial bleeding
• May be associated with a lucid period followed by
  rapid deterioration
• Often associated with trauma and skull fracture
• Treatment is surgical drainage

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Intracranial Hemorrhage

• Future Challenges
• To develop systems to provide rapid evaluation
  and treatment of these lesions
• To develop innovation in treatments
• Maximize potential for recovery

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Case 1

• 52 y/o found confused in car by the side of the
  road on 3/14/01.
• Arrived in ER approximately 1800
• Intubated, sedated secondary to vomiting
• Right hemiparesis
• Bilateral upgoing toes
• Fluctuating level of consciousness

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Case 1

• Last seen normal at 1715
• CT scan showed no evidence of stroke or
  hemorrhage
• Received tPA at 1958.

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MRA 3/17/01
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MRI 3/17/01
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Discharge 3/27/01
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Head CT 5/11/01
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Clinic 5/10/01
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Case 2

• History
• 53 y/o female presenting with one week of
  headache and confusion and bilateral thalamic
  lesions.
• Exam
• Obtunded
• Reacted to pain with flexion

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Initial MRI
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Post Biopsy CT
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MRV
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Final CT
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Cerebrovascular Disorder

• .

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Cerebrovascular Disorder

• References
• -Neurosonology by CH Tegeler et al Mosby 1995
• -Principles of Neurology by RD Adams and M.
  Victor,5th edition ,1993
• -AHA Guideline of management of unruptured
  intracranial aneurysm.Stroke 312742-2750.2000
• -AHA Guideline Surgery in intracerebral
  hemorrhage.Stroke .312511-2516,2000

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Cerebrovascular Disorder

• References
• AHA GuidelineTheinopyridines VS ASA to prevent
  Stroke and Vascular disease.Stroke
  31311779-1784,2000
• AHA Guideline Atrial Fibrillation. Stroke
  32803-808,2001
• AHA GuidelineGuideline for TIA management Stroke
  30 2502-2511,1999
• AHA GuidelineCarotid Endarterectomy for
  asymptomatic stenosisStroke 29554-562,1998

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Cerebrovascular Disorder

• References
• AHA Guideline Comparison of angioplasty VS
  endarterectomy for symptomatic carotid artery
  disease, Stroke 311439-1443,2000
• AHA GuidelineCalcium antagonists, Stroke
  32570-576,2001- Meta analysis of 29 trials
  -Dont help in acute stroke
• AHA Guideline Intravenous Unfractionated Heparin
  is not helpful in acute stroke Stroke
  32579,2001

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Cerebrovascular Disorder

• References
• CAST Study and IST study ( 40,000 patients) ASA
  at the dose of160 mg and 300 mg as an acute
  treatment prevents early recurrence of stroke.The
  benefit is about 1

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Cerebrovascular Disorder

• Intracerebral Hemorrhage
• Cerebral Ischemia
• Stroke Classification Investigations
• Major Vascular anatomy
• Treatment

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Cerebrovascular Disorder

• Intracerebral hemorrhage
• Epidural hematoma
• Subdural hematoma
• Subarachnoid hemorrhage
• Intraparenchymal hemorrhage
• Intraventricular hemorrhage

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Cerebrovascular Disorder

• Epidural hematoma
• -Associated with head injury
• -Bleeding from arterial blood middle meningeal
  artery
• -Bleeeding between the dura mater and skull
• -Lucid interval may be described
• -Radiographically- lens shape blood /skull x-rays
  fracture across the middle meningeal artery
  groove
• -Treatment surgical evacuation
• -Good prognosis if intervene early

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Cerebrovascular Disorder

• Subdural hematoma
• Acute subdural hematoma
• Chronic subdural hematoma

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Cerebrovascular Disorder

• Acute subdural hematoma
• -Almost always associated with head injury
• -Bleed between arachnoid and dura mater
• -Almost always associated parenchymal
  injury-hemorrhagic contusion
• -Prognosis is not so good because of associated
  with parenchymal injury
• -Radiographically showed blood covering along
  concavity of the brain

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Cerebrovascular Disorder

• Chronic subdural hematoma
• -May or may not associated with head injury
• -Specific patient population-old
  age,alcoholic,demented and coagulopathic patient
• -Non specific symptoms- headache , partial or
  generalize seizure,mental status
  change,asymptomatic
• -Bleeding from the venous blood bridging vein

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Cerebrovascular Disorder

• Chronic subdural hematoma
• -Prognosis is not the best- probably due to
  underlying condition
• -Treatment surgical ,if symptomatic

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Cerebrovascular Disorder

• Subarachnoid hemorrhage
• a)Post traumatic subarachnoid hemorrhage
• b)Aneursysmal subarachnoid hemorrhage
• c)Subarachnoid hemorrhage from AVM
• Need to know AHA guideline for incidental
  aneurysm

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Cerebrovascular Disorder

• Post traumatic subarachnoid hemorrhage
• a) History is very important-accident happen
  before headache
• b) Specific locations- frontal/temporal( due to
  the brain slide on the rough part of the skull)
  and occipital( due to contre coup)
• c) Occasionally associated with hemorrhagic
  contusion of of the temporal/frontal lobe
• d) No specific treatment
• e) If in doubt get an angiogram to R/O aneurysm

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Cerebrovascular Disorder

• Aneurysmal subarachnoid hemorrhage
• Hunt and Hess Scale
• Grade I-Asymptomatic or slight headache and stiff
  neck
• Grade II- Mod- severe headache and stiff neck
  without focal neurological finding
• Grade III- Drowsiness,Confusion, with mild
  neurological deficit
• Grade IV- Stupor/semicoma,decerebrate rigidity
• Grade V- Deep Coma and decerebrate rigidity

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Cerebrovascular Disorder

• Aneurysmal subarachnoid hemorrhage
• -Need to know Hunt Hess scale clinical scale
  estimated the clinical outcome
• -Need to know Fishers scale radiographic scale
  predict the risk of symptomatic vasospasm
• -Aneurysm usually arise around circle of Willis
• -Need 4 vessels cerebral angiogram with cross
  compression because of 20-25 of patient with
  SAH has more than one aneurysm and need to
  evaluate the adequacy of collateral circulation
  if need to sacrifice the ICA

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Cerebrovascular Disorder

• Aneurysmal subarachnoid hemorrhage
• Treatment of aneurysm is to exclude aneurysm from
  the circulation-clipping or coiling
• Pre- op BP control,Pain control, laxative and
  Nimodipine
• Post op- Watch for neurological changes- could
  be due to
• 1) Vasospasm 2) hydrocephalus 3) Other ongoing
  medical conditions and 4) less likely rebleeding

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Cerebrovascular Disorder

• Aneurysmal subarachnoid hemorrhage
• Vasospasm- usually started around day 5 after
  hemorrhage
• -Monitor by TCD- high velocity of MCA and MCA/ICA
  ratiogt3
• -Treatment of vasospasm HHH therapy-hypertensive
  ,hemodiluation and hyperdynamic
• -If intractable intraarterial papaverine or
  angioplasty or Pentobarbital coma

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Cerebrovascular Disorder

• Aneurysmal subarachnoid hemorrhage
• -Radiographic and symptomatic vasospasm
• -Nimodipine study The incidence of vasospasm are
  the same in both groups,but the clinical outcome
  in Nimodipine group is better. Believe that
  Nimodipine work at smaller vessels or the
  cellular level to prevent the ischemic cascade

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Cerebrovascular Disorder

• Unruptured aneurysm seen incidentally
• What to do ?/ What to do ?
• Data from ISUIA( international study for
  unruptured intracranial aneurysm)
• Rate of rupture chiefly depends on size( lt10mm
  0.005 / year,gt10mm 1 /year,gt25 mm- 6 for
  the first year)
• Locations- Posterior circulation have greater
  rate of rupture
• MRA is useful as a screening test up to 93
  sensitivity compared with cerebral angiogram

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Cerebrovascular Disorder

• Unruptured aneurysm seen incidentally
• What to do ?/ What to do ?
• Cerebral angiogram come with neurological
  morbidity 0.5
• Special group of patient warrant screening-
  Coarctation of Aorta,Polycystic Kidney,Type IV
  Ehlers-Danlos syndrome and familial intracranial
  aneurysm syndrome
• Symptomatic unruptured aneurysm ( eg 3rd palsy)
  have more risk than truly unruptured aneurysm

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Cerebrovascular Disorder

• Unruptured/ Ruptured aneurysm
• What to do ?/ What to do ?- AHA recommendation
• -Treatment of small incidental intracavernous
  aneurysm is not generally indicated.Large ones
  should be individualized
• -Symptomatic intradural aneurysm should be
  considered for treatment with urgency
• All remaining aneursym of patient with prior SAH
  should be considered for treatment
• Treatment of small incidental aneurysm without
  prior SAH are not advised

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Cerebrovascular Disorder

• Unruptured/ Ruptured aneurysm
• What to do ?/ What to do ?- AHA recommendation
• -Treatment is recommend for gt 10 mm in size
• Need to consider the patient age and coexisting
  medical problems as well as life span rate of
  rupture per year and calculate the necessity of
  treatment

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Cerebrovascular Disorder

• Intracerebral hemorrhage
• -Hypertensive Hemorrhage- 4 common locations
• 1)Basal ganglion Caudate/Putaminal be careful
  A-com aneurysm pointing backward
• 2) Thalamus 3) Pontine and 4) Cerebellar
  Hemorrhage
• Need to know Charcot Bouchard aneurysm- in the
  matching section

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Cerebrovascular Disorder

• Intracerebral hemorrhage
• -Non hypertensive Peripheral located
• a) Age ? old consider amyloid angiopathy
  /Congophillic angiopathy- presented with
  recurrent lobar hemorrhage and dementia.The most
  common location of hemorrhage is parietal lobe.
  Finding under polarized microscope- Birefringent
  crystral

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Cerebrovascular Disorder

• Intracerebral hemorrhage
• -Non hypertensive Peripheral located
• Age ? old another consideration is bleeding in
  metastatic tumor
• Metastatic tumor likely to go to brain
  early-Thyroid ,Lungs ,Breast,Renal cell carcinoma
  ,testicular,Choriocarcinoma ,melanoma and Colon
  plus GBM( which is primary brain tumor) these
  types of tumor can manifest by bleeding in the
  brain

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Cerebrovascular Disorder

• Intracerebral hemorrhage
• To remember - Paired organ mets to the brain
  early
• Use ovary( which is paired organ link to
  Choriocarcionoma)
• If one wants to remember paired organ Colon
  Melanoma GBM

129
Cerebrovascular Disorder

• -Intracerebral hemorrhage non hypertensive/non-
  lobar,doesnt look like tumor and patient is not
  old
• 1)Vasculitis underlying connective tissue
  disease
• 2)Venous sinus thrombosis- post partum /severe
  dehydration
• 3)Drug abuse-Needle track-Cocaine or Heroin
• 4)Endocarditis Mycotic aneurysm Fever and
  cardiac murmer
• 5)Teenager- Diet Pill-Amphetamine/Phenyl
  Propranolamine

130
Cerebrovascular Disorder

• Isolated intraventricular hemorrhage-not common
• -Vascular anomaly- AVM or aneurysm
• -Hypertensive hemorrhage that rupture in
  ventricular system with minimal blood in the
  parenchyma
• -Coagulopathy

131
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• -Need to know the etiology of stroke
• -The treatment plan tailor according to etiology
  and need to be addressed accordingly
• -Need to evaluate the whole vascular system, if
  possible

132
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• Carotid ultrasound and TCD
• MRI and MRA both intracranially and
  extracranially
• Transesophageal Echocardiogram
• CT angiogram

133
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• Carotid Ultrasound
• Screening test usually give the range of
  stenosis,use velocity as to predict stenosis
• B-Mode is use to identify anatomy and plaque
  characteristic
• Color doppler help locate the location to sample
  the velocity
• d) Use to follow the carotid non- invasively

134
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• Carotid Ultrasound
• Pitfall
• Accelerating flow without stenosis-Anemia,hyperthy
  roidism,Aortic insufficiency ,old patient with
  tortuousity
• Difficult or impossible to differentiate between
  preocclusion and occlusion-unless Power Doppler
  is used.

135
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• Trancranial Doppler
• Use Continuous wave doppler to evaluate the
  velocity of the 1st order of intracranial vessels
• 10-15 of the studies are technically limited
  due to skull thickness and displacement from
  normal location
• Other use including monitoring vasospasm and
  evaluate the need to do blood exchange in sickle
  cell disease

136
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• Trancranial Doppler
• Viewing Vessels according to the window
• Transtemporal distal ICA, MCA-M1 portion, ACA
  and PCA- P1 portion
• Transorbital- distal ICA,Carotid siphon,Opthalmic
  artery
• Foramen Magnum- vertebral arteries and basilar
  artery

137
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• 2-D echocardiogram
• -Limited sensitivity
• -Cant evaluate aortic arch ,which is one of the
  independent risk factor
• - Inadequate sensitivity as a complete evaluation

138
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• Tranesophageal echocardiogram
• -Much superior sensitivity
• -Taking advantage of the anatomy of the esophagus
  lies just behind the left side of the heart and
  much closer in location,therefore increase
  ultrasound resolution
• -Capable to evaluate aortic arch plaque and LAA
• -Not invasive/or expensive as we thought
• -2 cases of endocarditis being missed by 2-D
  echocardiogram
• -Role of TEE of asymptomatic CAD

139
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• MRI
• -Evaluated infarcted area esp brain stem .
• -Evaluated brain parenchyma at risk
• -DWI showed the acute infarction earlier than T2
  and FLAIR
• -R/O any surprised lesion

140
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• MRA
• -Need to evaluate both extracranial and
  intracranial vessels
• -Intracranial stenosis is another new entity of
  risk factor
• Limitationn of MR
• Severe claustophobic
• Metallic fragment in head and neck area
• Recent stenting either heart or head
• Pacemaker and AICD

141
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• CT angiography
• Recent new technology
• Use Iodine dye
• Small slice of the of each portion of the vessels

142
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143
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• CT angiography
• Limitation
• Uncooperative patient
• Dye allergy
• Time consuming of radiologist
• Renal dysfunction

144
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• Cerebral angiogram
• -Gold standard test
• -Able to evaluate both intracranial and
  extracranialvessels
• -Give the anatomical data
• -Associated with small risk-stroke,groin hematoma
  etc
• -Can discover ostial vertebral artery stenosis-
  potential risk of stroke

145
Cerebrovascular Disorder

• Evaluation of Ischemic stroke
• Newly identified / less common risk factors of
  stroke
• -Lupus anticoagulant? Anticardiolipin antibody
  syndrome
• -Protein C/S deficiency
• -Factor V Leiden Mutation- Activated protein C
  resistance
• -Heterozygote form of Hyperhomocysteine-
  methionine loading test
• -Vasculitis process- either primary or secondary
  angiitis

146
Cerebrovascular Disorder

• Treatment of stroke
• Acute treatment
• a) Thrombolysis- t PA intravenously
• 2 landmark studies- NINNDS and ECASS
• Intraarterial with various medications /time
  windows- have not been demonstrate successful(
  doesnt mean they dont work)
• Total more than 17 studies- 2 intraarterial and
  15 intravenous
• consisted total of 5144 Patients

147
Cerebrovascular Disorder

• Treatment of stroke
• Acute treatment
• Neuroprotective agents- attack various locations
  of of ischemic cascades-free radical scarvenger,
  glutamate antagonist esp NMDA receptor ,Na and Ca
  channel blockers,ICAM
• - Up to 47 studies showed no
  benefit-doesnt mean they dont work though

148
Cerebrovascular Disorder

• Treatment of stroke
• Primary stroke prevention- the only well known
  data is AF
• SPAF I-compared placebo and anticoagulation(
  either ASA or coumadin)
• The study terminated prior to complete enrollment
  because of the placebo group got to end point
  sooner
• The data suggest that patient with AF required
  some type of anticoagulation
• This study also identified 3 more risk factors
  associated with AF including diastolic
  hypertension,poor LV function and remote history
  of thromboembolism( more than 3 months)

149
Cerebrovascular Disorder

• Treatment of stroke- Primary stroke prevention in
  AF
• SPAF II- compared the efficacy of ASA and
  coumadin at different age group( less than and
  more than 75 YO)
• This study showed coumadin is slightly more
  effective than ASA in younger age group- but this
  group of patient has low risk any way
• In older age group, coumadin is much more
  effective than ASA in term of preventing ischemic
  stroke but after adding the risk of ICH make the
  beneficial effect marginal.

150
Cerebrovascular Disorder

• Treatment of stroke- Primary stroke prevention in
  AF
• SPAF III- comparing the efficacy of fixed dose
  coumadin plus ASA to against adjusted dose of
  coumadin to keep INR in the good range
• The study was terminated early by safety
  committee because the fixed dose of coumadin plus
  ASA group reach the primary end point more often
  and faster.

151
Cerebrovascular Disorder

• Treatment of stroke- Secondary stroke prevention
  in AF
• The study that worth mentioned is EAFT-European
  atrial fibrillation trial
• The randomization was pretty much similar to SPAF
  study but the mean age is older and INR level was
  higher.
• The result of the study is the similar to SPAF
  suggest that coumadin is better than ASA
• The risk of intracerebral bleeding in coumadin
  group is higher and almost eliminate the
  beneficial effect of prevention from coumadin

152
Cerebrovascular Disorder

• Treatment of stroke- Meta-analysis of
  antiplatelet drug trialist comparing various
  doses of ASA and various different entering
  criteria and end-points
• The meta-analysis showed that ASA reduce the risk
  of recurrent stroke approximately 25 comparing
  with placebo

153
Cerebrovascular Disorder

• Carotid stenosis 2 Major worth mentioned studies
• NASCET North American symptomatic carotid
  endartectomy trial- Secondary prevention
• ACAS Asymptomatic Carotid Artery Study-Primary
  prevention

154
Cerebrovascular Disorder

• NASCET study
• -Symptomatic patient- either TIA or non-
  disabling stroke
• -Comparing best medical treatment and CEA best
  medical treatment
• -Relatively low risk patient
• -Strict angiographic criteria-not ultrasound nor
  MRA
• -No tandem lesion/R/O cardioembolic source
• -Best surgeons in the world with very low
  morbidity and mortality

155
Cerebrovascular Disorder

• NASCET study
• Less than 50 stenosis Best medical treatment
• More than 70 stenosis Surgery with best
  medical treatment is better
• In between, medical and surgical treatment
  medical treatment are equally good.
• Subgroup analysis Women do poorer than men,
  left carotid do poorer than right carotid
• Overall the absolute risk reduction is around 25
  over 24 months period

156
NASCETIpsilateral Stroke (18 Months)
157
Cerebrovascular Disorder

• ACAS study
• -Asymptomatic carotid stenosis
• -Very low risk patient
• -Over all risk of ipsilateral stroke in the 60
  stenosis around 11 over 60 months
• -Overall the surgical risk around 5 on the day
  of surgery