Less Appreciated Stroke Emergencies Where We Can Get Tripped Up

1
Less Appreciated Stroke EmergenciesWhere We Can
Get Tripped Up

• June 8, 2009
• Eric Smith, MD, MPH
• Assistant Professor of Neurology
• Departments of Clinical Neurosciences, Radiology
  and Community Health Science
• University of Calgary

2
Disclosure
I do not have an affiliation (financial or
otherwise) with any commercial organization that
may have a direct or indirect connection to the
content of my presentation.
3
Objectives

• Review less common cerebrovascular emergencies
• Tips on diagnosis and early management
• Case-based format

4
Case 1

• 66 year woman
• PMH HTN, hypercholesterolemia, gout
• Smoker
• Nausea, vomiting, dizziness for 16 hours

5
Case 1 Exam

• BP 160/70, pulse 90, nauseated
• Abdomen soft, non-tender
• Right-beating horizontal jerk nystagmus on right
  gaze
• Questionable dysmetria with right hand

6
Differential

• Cerebellar infarct
• Cerebellar hemorrhage
• Acute vestibular dysfunction
• Gastroenteritis

7
(No Transcript)
8
Day 0
Day 1
9
Suboccipital Craniectomy with External
Ventriculostomy Drain
10
Pearls

• Risk of swelling after cerebellar infarct
• Importance of neuro exam in patients with nausea
  and vomiting
• Central vs. peripheral nystagmus

11
Swelling and Herniation After Cerebellar
Infarction

• May complicate 10-20 of acute cerebellar
  infarcts
• Occurs median 2-3 days after stroke onset
• Causes symptoms by
• Acute hydrocephalus drowsiness, impaired upgaze
• Upward herniation drowsiness, impaired upgaze
• Brainstem compression hemiparesis, lateral gaze
  palsies, facial weakness
• Optimal patient selection for surgery, and timing
  for surgery, is controversial
• Need to consider intervention before irreversible
  deterioration
• For hydrocephalus only, some advocate external
  ventriculostomy drain without decompressive
  craniectomy

12
Neuro Exam in Nausea and Vomiting

• Limb signs (ataxia, dysmetria, dysdiadochokinesia)
  may be absent with midline (vermian) cerebellar
  lesions
• Check for truncal and gait ataxia
• Check for nystagmus

13
Central vs. Peripheral Nystagmus

• Features of central nystagmus
• Non-fatiguing
• No latency on Dix-Hallpike
• Pure torsional
• Vertical nystagmus in primary position
• Asymmetric nystagmus between 2 eyes
• Changes direction in different positions of gaze
  (i.e. violates Alexanders law)
• Problem absence of the above features does not
  exclude central cause

14
Case 2

• 55 year woman
• PMH smoker, recently started buproprion,
  hypercholesterolemia
• Went on trip to Mexico, while in Mexico had
  thunderclap-onset headache 2 wks PTA
• Then recurrent daily headaches

15
Case 2 cont

• 7 days PTA visited ER with headache
• BP high (180/90)
• Head CT normal
• Treated with over the counter analgesics
• Started ramipril

16
Differential

• Subarachnoid hemorrhage
• Migraine
• Hypertensive encephalopathy
• Intracerebral hemorrhage

17
Case 2 Presentation

• Presents to our ED with continued headache and
  new numbness right leg, right foot drop
• BP 160/90, P 88, appears uncomfortable
• No meningismus
• Decreased sensation to touch in right lower leg
• Right ankle dorsiflexion 4/5

18
Differential?

• Subarachnoid hemorrhage
• Intracerebral hemorrhage
• Ischemic stroke
• Arterial dissection
• Migraine
• Vasospasm

19
CT-Angiogram
20
MRI DWI
21
Differential
Reversible Vasoconstriction Syndrome
Vs Vasculitis
22
Reversible Cerebral Vasoconstriction Syndrome
(Call-Fleming)

• Prolonged but reversible cerebral
  vasoconstriction with acute-onset, severe
  recurrent headaches
• Typically 20-50 years
• Femalemale 21

23
RCVS Proposed Criteria

• Multifocal (2 arteries) segmental (2 segments
  in at least 1 artery) narrowing
• Severe acute headaches
• Normal CSF
• Reversibility of arterial narrowing by 12 weeks

Calabrese LH, Dodick DW, Schwedt TJ, Singhal AB.
Narrative review reversible cerebral
vasoconstriction syndromes. Ann Intern Med.
200714634-44
24
RCVS Pathophysiology

• Essentially unknown, probably multiple causes
• Triggers include
• Pregnancy
• Eclampsia and pre-eclampsia
• SSRIs
• Triptans
• Catecholaminergic drugs or catecholamine-secreting
  tumors
• Head trauma, neurosurgical procedures

25
RCVS Clinical Features

• Severe headache (sole feature in 75)
• Nausea (57), vomiting (38), photophobia (30)
• Acute hypertension (33)
• Transient neurological deficits (16)
• Intracerebral hemorrhage (6) (at presentation)
• Ischemic stroke (4) (usually delayed 1-2 weeks)
• Cortical subarachnoid hemorrhage (22)

From Ducros, A., M. Boukobza, et al. (2007). "The
clinical and radiological spectrum of reversible
cerebral vasoconstriction syndrome. A prospective
series of 67 patients." Brain 130(Pt 12)
3091-101.
26
RCVS Treatment

• Stop all vasoactive medications
• No triptans!
• In cases without neurological symptoms, no
  further treatment may be needed
• Nimodipine and courses of steroids have been given

27
Case 2. Clinical Course

• LP normal
• Serum work up for vasculitis normal
• Progression to right hemiparesis
• Treated with nimodipine, steroids,
  cyclophosphamide
• Brain biopsy showed no vascular or perivascular
  inflammation

28
(No Transcript)
29
Day 0
Day 5
Day 18
30
When to Suspect RCVS

• Thunderclap headache with recurrent headaches,
  and normal CT and LP
• Aggravation of headaches with use of triptans
• Thunderclap headache with neurological signs and
  symptoms

31
Case 3

• 55 year man
• Smoker
• Right temporal headache radiating to right
  posterior neck
• Episode of sweating, mild dysarthria
• Exam normal

32
Differential?

• Migraine
• Transient ischemic attack
• Arterial dissection

33
(No Transcript)
34
Arterial Dissection

• Common cause of stroke/TIA in young
• Usually spontaneous, sometimes with identifiable
  trigger (cough, vomiting, sexual intercourse)
• Diagnosed on CT-angiogram, MRI (including T1
  fat-saturated imaging) or conventional
  angiography

35
Arterial Dissection Treatment

• Controversial anticoagulation is frequently used
  to prevent recurrent emboli, however the
  symptomatic recurrence rate appears to be low
• If high-grade stenosis with hypoperfusion, acute
  stenting may be considered
• May want to exercise caution if there is
  intracranial verterbral artery dissection,
  because of risk of dissecting aneurysmal
  subarachnoid hemorhage
• Most will heal over 3-6 months (90) with no
  residual stenosis

36
Day 0
Day 10
Day 45
37
Case 4

• 25 year woman, healthy
• Delivered at 34 weeks because of pre-eclampsia
• Escalating diffuse bitemporal headache without
  thunderclap headache

38
Differential

• Migraine
• Tension headache
• Pre-eclampsia
• Venous sinus thrombosis

39
(No Transcript)
40
Returns 5 Days Later
41
(No Transcript)
42
Cerebral Venous Sinus Thrombosis

• Risk factors include pueperium, smoking,
  inherited thrombophilia (esp factor V Leiden and
  prothrombin gene mutation), oral contraceptive
  pill, other hypercoagulable states,
  otitis/mastoiditis
• Diagnosed by MR venography, CT venography or
  conventional angiography
• Treated with intravenous heparin
• In most cases, it is relatively safe to give even
  when hemorrhagic venous infarct is present
• Endovascular thrombolysis has been performed in
  medically refractory cases

43
When to Suspect Venous Sinus Thrombosis

• Persistent unrelenting headache
• Presence of risk factors
• Headache with neurological symptoms/signs
• Bilateral leg weakness may indicate perisagittal
  edema/infarction from superior sagittal sinus
  thrombosis
• Headache with seizure
• Peri-sinus hemorrhage
• Pattern of infarction that doesnt match arterial
  territories

44
Thanks for Your Attention