The Assessment and Early Management of TIA and Acute Stroke

1
The Assessment and Early Management of TIA and
Acute Stroke

• Richard H Guth, MD, MPH, FACEP
• Emergency Physician, Riverside Community
  Hospital, Riverside California

2
Acute Stroke and TIA Overview

• Definitions
• Differential Diagnosis Stroke Mimics
• Classification
• ER Priorities
• Stabilize and Treat
• Diagnose
• Decisions, decisions, decisions

3
Definitions

• Acute Stroke is the sudden loss of brain function
  caused by ischemia or hemorrhage
• TIA (Transient Ischemic Attack) is a temporary
  loss of brain function without infarction or
  hemorrhage

4
Differential Diagnosis (DD) Stroke Mimics

• Seizures
• Migraine auras
• Syncope
• Toxic/Metabolic abnormalities
• Hypoglycemia
• Hypoxemia, Hypercarbia
• Encephalopathies
• Infections
• Brain Tumors
• Functional (Conversion Reaction)

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DD Stroke Mimics Seizures

• Following a seizure a patient may exhibit
• Paresis or Paralysis
• Aphasia
• Neglect
• We refer to this phenomenon as Todds Palsy or
  Todds Paralysis
• Inquire about history of seizures and check
  patients medications for anticonvulsants
• Seizure may coincide with onset of SAH (10), ICH
  (8), or ischemic stroke (3)

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DD Migraine Auras

• Typical migraine aura may mimic stroke
• Gradual onset lasting less than 1 hr.
• Followed by headache
• Ophthalmic (homonymous visual disturbance)
• Hemiparesthetic
• Hemiparetic
• Hemiplegic
• Aphasic
• If atypical or prolonged may be difficult to
  distinguish from acute stroke

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Migraine, continued

• Migraine with Stroke may be cause, consequence,
  coincidence, or mimic.
• Migraine may cause vasospasm with changes in
  cerebral blood flow.
• Women of child-bearing age with classic migraine
  who smoke or have hypertension or take oral
  contraceptives have particularly increased risk
  of stroke.

8
DD Syncope

• Syncope (fainting) is caused by abrupt reduction
  in cerebral perfusion
• Common types of syncope include
• Vaso-vagal (neurocardiogenic)
• Orthostatic
• Situational (urination, defecation, cough, etc.)
• Cardiac arrhythmia or ischemia
• Recovery from syncope is usually rapid and
  complete

9
DD Toxic/Metabolic

• Hypoglycemia measure glucose and give 50mls of
  50 dextrose IV when indicatedor treat on
  suspicion alone because THE BRAIN REQUIRES
  GLUCOSE!
• Hypoxemia from bronchoconstriction,
  hypoventilation, pulmonary embolus, pneumonia,
  etc.
• Hypercarbia from hypoventilation, chronic
  bronchitis, pulmonary hypertension, etc.

10
Metabolic, continued

• Hepatic encephalopathy (elevated ammonia levels
  often caused by GI bleeding)
• Uremia (elevated BUN, creatinine levels)

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Acute Stroke Classification

• Hemorrhagic Stroke
• Intracerebral Hemorrhage (ICH)
• Subarachnoid Hemorrhage (SAH)
• Ischemic Stroke
• Thrombotic
• Embolic
• Hypoperfusion
• Transient Ischemic Attack (TIA)
• Will be discussed in reverse order

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Anatomy Blood Supply of Brain

• Source Wikipedia

13
Arteries at the Base of the Brain
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Acute Stroke/TIA Pathophysiology Subtypes of
Brain Ischemia

• Thrombosis of large or small vessel caused by
  atherosclerosis
• May be local (in situ) atherosclerotic
  occlusive disease
• Thrombus superimposed on atheroma with low-flow
  or
• May result from artery to artery embolization of
  thrombotic material
• Small vessel (lacunar) occlusion
• Involves small penetrating end-artery territory
  hypoperfusion
• Lipohyalinosis caused by hypertension is often
  cause of occlusion
• Embolic (cardioaortic embolic) from remote source
• Left atrium or L. ventricular thrombus
• Recent MI (within one month)
• Atrial Fibrillation and flutter
• Valvular heart disease rheumatic, prosthetic,
  mechanical, bacterial endocarditis
• Patent foramen ovale allows venous thrombus to
  embolize to arterial circ
• Cardiomyopathy/CHF

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TRANSIENT ISCHEMIC ATTACK (TIA)

• TIA is a temporary loss of brain function caused
  by ischemia without infarction
• TIA Incidence in US 300,000500,000/yr
• TIA lasts less than 1 hrusually less than 5
  minutes
• No evidence of infarction by neuroimaging
• Many TIAs are actually small strokes
• TIA is a medical emergency

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TIA Signs and Symptoms

• Motor dysfunction 1 or both extremities, same
  side weakness, clumsiness
• Sensory numbness, loss of sensation,
  paresthesias of 1 or both extremities, same side
• Speech dysfunction aphasia
• Vision loss in 1 eye or part of 1 eye
• Vision homonymous hemianopsia
• Combinations of the above

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TIA, continued

• Risk of stroke after TIA may be as high as 15
  within 30 days.
• Many patients with TIA will have stroke within 48
  hours Medical Emergency!
• Decision Admit for workup/treatment? Consider
  ABCD2 score Age, BP, Clinical, Duration,
  Diabetes
• Age 60 or greater 1pt.
• BP Systolic 140 or diastolic 90 1pt
• Clinical Unilateral motor weakness 2pts,
  abnormal speech 1pt
• Duration 60 min. or more 2pts, 10-59 min.
  1pt
• Diabetes present 1pt
• A score of 6-7 means high risk of stroke in 48
  hrs. (8.1)
• A score of 4-5 means moderate risk (4.1) score
  of 0-3 low risk (1)

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TIA Initial Evaluation

• History and Physical Examination
• Laboratory Testing
• ECG
• Brain Imaging CT and/or MRI Scan (preferred per
  2009 AHA/ASA guidelines)
• Neurovascular studies Carotid Doppler
  Ultrasound, CTA, or MRA

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TIA Decision How Treat?

• Decision How can we prevent stroke after TIA?
• Aspirin (81-325mg/day) is inexpensive and quite
  effective
• Clopidogrel (75mg/day)
• Aspirin plus dipyridamol (200/25mg bid)

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TIA, continued Treatment

• Control Blood Pressure(when safe)
• Statin therapy to lower lipids
• Control blood sugar in diabetics
• Consider timely (within 2 weeks) carotid
  endarterectomy in patients with 70 or greater
  stenosis.
• For high surgical-risk patients stenting may be
  acceptable alternative treatment

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ISCHEMIC STROKE BRAIN ATTACK!

• Sudden loss of neurological function with
  infarction of CNS tissue
• Signs and symptoms are highly variable and depend
  upon the site of the tissue injury, but there are
  some common presentations Middle Cerebral
  Artery Stroke is one example
• Unilateral weakness/paralysis of face, arm and
  leg contralateral to brain injury
• Speech disturbance Motor aphasia is classic when
  dominant hemispere is involved
• Visual disturbance, unilateral partial or
  complete loss of vision

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Posterior Circulation Strokes Signs and Symptoms

• Involve Basilar and/or vertebral arteries, with
  damage to brain stem and cerebellum
• Commonly cause
• Vertigo
• Diplopia
• Tinnitus, hearing loss
• Dysarthria
• Dysphagia
• Gait ataxia
• Crossed motor weakness or sensory symptoms
• Crossed means face on one side and extremities
  on opposite side

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Emergency Room Approach to Stroke Patient

• Stabilize and Treat
• Manage airway
• Correct hypoglycemia
• Rapid Diagnostic Evaluation
• Decisions
• Candidate for thrombolysis?
• How Best Manage blood pressure? Controversial
  May do more Harm than Good
• Do not treat acutely unless extreme (220
  systolic, 120 diastolic) or other indication,
  such as acute MI, CHF, aortic dissection, acute
  renal failure, ecclampsia, etc. and then
  cautiously lower by up to 15

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ACUTE STROKE Rapid Diagnostic evaluation

• Routine lab studies CBC, Chemistry Panel, PT,
  PTT, lipids
• ECG
• Chest X-Ray
• Stat CT Scan of brain, con-contrast, with skilled
  interpretation to identify or rule out hemorrhage

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ACUTE STROKE HISTORY PHYSICAL EXAMINATION

• Rapid Complete but Focused History
• Establish time of onset of symptoms
• Search for prior TIAs
• Activity at onset or just prior to onset of
  symptoms
• Associated symptoms
• Clues for possible stroke mimics

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ACUTE STROKE PHYSICAL EXAM

• Palpate pulses, listen for bruits
• Auscultate heart, listen for murmurs (valvular
  heart disease, patent foramen ovale), irregular
  rhythm (Atrial Fibrillation)
• Neurological Exam
• Rapid
• Focused

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DECISIONS, DECISIONS, ETC.

• Is this patient having a stroke? Stroke Mimic?
• Can the type of stroke be determined?
• Is this patient a candidate for thrombolysis?
• Should there be immediate treatment of
• Blood Pressure? (Not usually)
• Blood Glucose? (avoid hypo/hyper glycemia)
• Body Temperature? (normalize)
• What is the ideal body/head position for this
  patient? (consider risk of vomiting with
  aspiration, elevate with hemorrhage, flat with
  ischemic stroke)

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Hemorrhagic Stroke ICH

• Intracerebral Hemorrhage (ICH)
• Bleeding into the brain causes local hematoma
  which gradually enlarges
• Causes include HYPERTENSION, Trauma, Bleeding
  diathesis, illicit drug use, vascular
  malformations

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HEMORRHAGIC STROKE SAH

• Subarachnoid Hemorrhage SAH
• Rupture of arterial aneurysm is major cause
• Causes sudden, severe headache (The worst
  headache of my life.)
• May be preceeded by a very small sentinel bleed
  which presents the ER physician with an
  opportunity to prevent a major stroke.
  Unfortunately, most sentinel bleeds are
  misdiagnosed and this opportunity is lost.
• Most are visible on CT scan with newer equipment
• Consider LP in patient with neg CT scan
• SAH often leads to coma and death if bleeding
  continues. Consult neurosurgeon.

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STROKE AND TIA CONCLUSIONS

• Prevention is the best treatment
• Handle TIA as Medical Emergency to prevent stroke
• Use aspirin, clopidogrel, etc., anticoagulation
  for atrial fibrillation, and carotid
  endarterectomy for symptomatic carotid artery
  stenosis
• Prevent Recurrent Stroke
• Manage risk factors smoking, hypertension,
  diabetes, hyperlipidemia, obesity, etc.
• Look for stroke mimics and treat appropriately
• Handle Blood Pressure with Care
• Try to Limit the Damage through attention to body
  temperature, blood glucose, ventilation, head
  position, treatment of infection, etc.

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Thank you very much for your attention.

• Acknowledgements
• UpToDate.com
• Wikepedia