Stroke

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Stroke

• Laura Lewis Mason RN, MS, ANP-C
• University at Buffalo Neurosurgery
• State University of New York

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Definition of Stroke

• Sudden loss of circulation to an area of the
  brain
• Ischemic strokes are caused by a brain embolism
  intracranial athererosclerosis and/or
  liopohyalinosis of small penetrating vessels.
  Ischemic strokes accounts for 80 of all strokes
• Hemorrhagic strokes are caused by ruptured
  aneurysms, AVMs, severe hypertension bleeding
  diathesis (malignancies) and trauma. Hemmorhagic
  stroke accounts for 20 of all strokes2
• Flow limitation (vessel dissection)

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Epidemiology

• In United States estimated 600,000 to 750,000
  strokes occur annually
• Ranks third among causes of death and first among
  causes of long term disability

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Diagnosis
Yearly Incidence in the US
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Projected number of strokes in US2002 - 2025
30,000 Aneurysms
Source Stroke, January 2004 J. P. Broderick, MD
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Epidemiology

• 1/3 recover
• 1/3 die
• 1/3 destroyed

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• Stroke Facts

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• Direct cost of stroke
• 60 Billion

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Cost

• Measured in loss of work, hospitalization,
  rehabilitation, and care of survivors in nursing
  homes
• Major cost or impact of a stroke is the loss of
  independence that occurs in 30 of survivors

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Stroke

• Most prevalent neurologic condition
• Most common discharge diagnosis to nursing homes
• Most common diagnosis treated in rehab
• LEADING CAUSE OF ADULT DISABILITY

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Stroke Survivors

• NIH study of survivors of ischemic stroke age 65
  and older
• 50 had partial paralysis
• 30 were unable to walk without assistance
• 19 had cognitive impairment
• 35 had depressive symptoms
• 26 were institutionalized in a nursing home

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Stroke IgnoranceGallup Survey

• 97 cant name stroke symptoms
• 44 had suffered CVA or had family with CVA
• lt50 identified brain as organ of insult
• Most fear CVA more than MI

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Acute Stroke Patients

• 25 correctly identified symptoms
• 24 seek medical help within 3 hours
• Patients with previous stroke not more inclined
  to seek medical help

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Why Dont CVA Patients Seek Treatment?

• Dont recognize symptoms
• Think symptoms will subside
• Think nothing can be done
• Worried about cost
• Denial - dont want fears confirmed
• Fear of hospitals

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Stroke

• 80 think their symptoms are not serious!!

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Symptoms of Stroke

• Sudden.
• Loss of vision in one eye or the other
• Weakness of the face, arm, or leg especially on
  one side of the body
• Sudden confusion or inability to speak
• Sudden loss of balance or incoordination
• Sudden severe headache

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• Stroke Awareness!!

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Risk Factors of a Stroke

• Unmodifiable factors
• Age Increase risk of stroke with increase in
  age. For every decade after 55 risk of stroke
  doubles. 2/3 of all strokes ocurr in people gt65
• Gender Mengt risk for stroke (1.25xs) but more
  women die from stroke
• Race/Ethnicity African Americans have double
  the risk than caucasian. AA between ages of 45-55
  have 4-5xs the stroke death rate than caucasian
• Family history genetic tendency for stroke risk
  factors, lifestyle, htn, diabetes

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Risk Factors for a Stroke

• Modifiable-
• Hypertension People with hypertension have a
  risk for stroke that is 4-6xs higher than the
  risk for those without htn.
• Heart Disease Atrial fibrillation- increases
  risk 4-6. Valve disease.
• Diabetes Three times the risk of stroke than
  those without diabetes
• Cholesterol High Cholesterol gt150
• Smoking doubles persons risk for ischemic stroke
  and increases persons risk for SAH by up to 3.5
• Alcohol Consumption
• Inactivity
• Blood dyscrasias/Malignancies
• Head and Neck Injuries May damage the
  cerebrovascular system, ie spontaneous carotid
  dissections
• Infections viral and bacterial infections
  combined with other risk factors add a small risk

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• Stroke Belt

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U.S. Stroke Belt
Source US Census Bureau Postcensal Population
Estimates (IDC9 430-438.9) (1991-1995)
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Stroke Risk

• Previous CVA
• TIA

10-fold increase
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• Management of risk factors can reduce stroke
  incidence by
• 50

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Risk Factor Modification

• Lipid reduction
• Blood pressure control
• Antiplatelet/anticoagulation therapy
• Smoking cessation
• Physical activity counseling
• Beta blockers post MI
• ACE inhibitors in CHF
• Hormone replacement counseling

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Acute Stroke

• Requires multidisciplinary care
• EMS involved in confirming signs and symptoms of
  stroke
• EMS initiates call to stroke center and
  transportation of patient to the ER

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Time is Brain
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Rapid Triage and Assessment

• Time is Brain
• Is the etiology of the neurological deficit
  ischemic, hemorrhagic or other system
  abnormalities?
• Determination of the etiology of stroke as well
  as time frame of when symptoms first occurred
  determines our treatment plan

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NIHSS

• 42 point scale comprised of 13 items that grade
  orientation, language, hemi-attention, motor,
  sensory, coordination, and visual deficits
• Rapidly determines severity and possible location
  of a stroke
• Score is associated with clinical outcome
• NIHSS 0 no deficit
• 5 is minor
• Helps identify those that are likely to respond
  to thrombolytic therapy and those at risk ( gt20)
• Is formally incorporated in the guidelines for
  thrombolytic therapy by the America Stroke
  Association

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Radiographic Evaluation

• CT head
• CT perfusion
• MRI diffusion/perfusion
• CT angiogram/MR angiogram
• Cerebral Angiography

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Aquilion One

• 320 x 0.5 mm detector rows with 16cm of coverage
• Table with 200cm scan range and 660 lb. maximum
  load

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Current Strategies For the Endovascular
Management of Acute Stroke

• Mechanical (Pull the clot out)
• Pharmacological (Dissolve the clot)
• Endovascular Bypass (Stent the vessel open)

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War on Stroke Tools

• Thrombolysis
• Intravenous
• Intra-arterial
• wire, snare, cage etc
• Angioplasty
• Stent
• Suction thrombectomy
• Ultrasound (IA / external)
• Other

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IV Thrombolysis

• marginally effective/limitations
• Large branch occlusions
• may cause intracerebral hemorrhage
• time window 3 hours
• mild to moderate stroke
• not much better than placebo
• NIHSS gt10 gt 75 decrease odds of recovery
  (STARS study)
• NINDS Trial Recanalization rates 26-40 (based
  on iv TPA data)
• Mortality 21

NIH Trial NEJM 95 3331581 MAST Trial Lancet
95 3461509 ECASS Trial JAMA 95
2741017 ECASS II Trial Lancet 98 3521245
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Intra-arterial ThrombolysisAdvantages

• Angiographic visualization of thrombus
• patients without thrombus dont get treated
• High concentration of lytic drugs locally in
  thrombus and lower systemic doses
• Improved titration of medication dose with
  angiographic visualization
• dissections can be treated

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Concentric Multi-Merci

• Multi-Merci Recanalization Rates
• 54.1 (60/111) Retriever alone
• 69.4 (77/111) Post Procedure

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PenumbraThrombus Perturbation and Aspiration
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Penumbra

• NIHSSgt8 and less than 8h from onset
• 81.6 revascularization to TIMI 2 or 3
• ICH symptomatic 11.2,
• asymptomatic 16.8
• NIHSS improved by gt/4 57.8
• Mortality at 30d 26.4

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Angioplasty/ StentLessons From the Heart

• Useful for underlying atheroma
• Occlusions refractory to reopening with other
  means
• Worthwhile to perform stenting to restore flow
  early
• Recanalization vs. sidebranch occlusion

Maverick OTW Balloon Catheter (Boston Scientific)
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• Case example
• 83 yo male
• acute RMCA stroke
• left plegic, R gaze preference, L facial droop,
  dysarthric
• NIHSS gt 10
• onset gt 14 hrs
• PMH paroxysmal afib (discovered on this
  admission)

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Initial CT perfusion relative CBV preservation
suggests ischemia rather than infarct, ie
salvageable!!
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Combo micro guidecath run demonstrates clot
location/size, distal patency
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After MERCI, integrilin, retavase, MERCI again ?
TIMI-II inferior division
clot still present
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s/p Gateway balloon angioplasty ? TIMI-III
inferior division, TIMI-II superior division
clot, no sup. M2
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Pre
Post
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preop CBF
preop TTP
postop TTP
area of infarct
area at risk
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• 76 year old woman with prior history of multiple
  brain
• Aneurysms clipped
• Unknown onset over 12 hours ago
• NIHSS 30
• History of atrial fibrillation off Coumadin for
  GI bleed

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CT perfusion bilateral PCA ischemia
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CTA shows midbasilar artery occlusion
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CTA shows tortous access
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Solution R radial artery access Initial angiogram
confirms mid-basilar occlusion
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MERCI retriever deployed
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Clot retrieved
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• Post intervention improvement
• from NIHSS 30 down to 4
• Discharge to rehab,
• Home in 2 weeks

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Acute Implantation of Intracranial Stents
Endovascular Bypass

• Advantages
• Time Immediate restoration of flow
• Success High recanalization rates (maybe 100)
• Currently only used in setting of previous device
  failure
• Could potentially do this earlier
• Technically straight forward for experienced
  operator

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Wingspan Stent

• Balloon angioplasty
• Stent placement
• Self-expanding
• Flexible
• Microcatheter delivery system

SUNY Buffalo FDA Sponsored IDE 9/07
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• Illustrative Cases

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Stent Assisted Revascularization for Stroke

• 26 year old female presents 3 hours out with R
  hemiparesis and aphasia
• NIHSS 9

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CT Perfusion shows established infarct in insula
with at risk L hemisphere
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Initial CTP, immediate post intervention and
delayed Head CT Post intervention NIHSS 1
Follow-up CT 48 hours later
Pre-Stent CT perfusion TTP
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Stent Assisted Revascularization in Stroke (SARIS)

• FDA approved IDE registry to evaluate safety of
  primary (no ia or iv thrombolysis or mechanical
  retrieval)wingspan stenting for acute stroke at
• University at Buffalo Barrow Neurological
  Institute

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SARIS Recanalization

• All patients achieved recanalization
• TIMI 2 40
• TIMI 3 60
• Plt0.0001 compared to presenting TIMI scores

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SARIS Clinical Improvement

• 65 improved 4 NIHSS points during
  hospitalization

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Are stents the answer?

• We dont know

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Are stents the answer?

• We dont know
• BUT..
• It sure looks promising!

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• Intra-arterial Treatment of Acute Stroke is
  beneficial
• Algorithms are for guidance must individualize
  treatment!
• Selection based on physiological imaging!
• Need technology designed for the brain!

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Thank you!