Stroke

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Stroke

• Three Classifications
• Hemorrhagic, Ischemic, and Transient (TIA)
• Third leading cause of death
• Leading cause of disability
• More than 400,000/year in the US alone

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Stroke

• Greg Cuculino

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Presentation

• Weakness of one or more extremities
• Visual loss/visual field deficits/double vision
• Slurred speech
• Facial Droop
• Differentiate between central 7th nerve palsy
  (CVA) and a peripheral 7th nerve palsy
• If the patient can wrinkle the forehead it is a
  central nerve palsy, if not it is peripheral

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Presentation contd

• Dizziness
• Difficulty walking
• Difficulty communicating
• Expressive or receptive aphasia
• Decreased level of consciousness

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Risk Factors

• Age
• The risk doubles every decade
• HTN
• Smoking
• CAD
• Increased cholesterol
• A fib

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Hemorrhagic

• 10-15 of all strokes
• Higher mortality than ischemic strokes
• Tend to be more ill than ischemic strokes
• More likely to have headache, altered mental
  status, seizures, nausea, vomiting, or elevated
  blood pressure
• But none of these are reliable indicators of a
  bleed

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Causes

• Bleeding from damaged vessels from chronic
  hypertension, bleeding diasthesis, iatrogenic
  anticoagulation, cocaine, AVM, aneurysm,
  neoplasm, trauma
• Higher incidence in African Americans

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Misc

• ICH are usually found in the thalamus, putamen,
  cerebellum, and brain stem
• Not only does the hemorrhage cause damage, the
  resulting hematoma causes mass effect and further
  injury
• Only 20 of patients regain functional
  independence
• High 30 day mortality rate (40-80)
• 50 occur in the first 48 hours
• Seizures more common than in ischemic strokes

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Ischemic

• 85 of all strokes are ischemic
• Can be embolic,
• From the heart or carotids
• thrombotic,
• Carotids, intracerebral arteries,
  vasoconstriction due to migraines
• or due to flow disturbances
• Polycythemia, sickle cell disease, hypotension
• 25 occur in people UNDER 65!!!

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TIA

• A stroke-like deficit that resolves in under 24
  hrs
• 80 resolve within 60 minutes
• Median duration is 14 minutes
• A warning sign for a future stroke
• Precede nearly 30 of all strokes
• One third of TIAs will have a stroke within one
  month, 50 within one year

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Work-Up (Pre-Hospital)

• Recognition, Recognition, Recognition
• Cincinnati Pre-Hopsital Stroke Scale
• Facial droop, arm drift, speech
• ABCs
• Accu check
• Rapid Transport

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Work-Up (Initial)

• Labs
• CBC, BMP, PT/PTT
• Assessing electrolytes (esp. glucose) and
  evidence of polycythemia or coagulopathy
• ECG
• Evidence of dysrythmia (afib)
• CT without contrast
• CT more sensitive in ruling out bleeding than MRI

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Treatment

• Hemorrhagic CVAs
• Immediate neurology and neurosurgery consult for
  possible OR
• Correction of coagulopathy
• Blood Pressure management
• Must maintain mean arterial pressure between 90
  and 130 mm Hg
• Can use multiple medications

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Treatment cont..

• Admission to the ICU
• Expansion of the hematoma is the most common
  cause of neurologic deterioration within the
  first three hours
• 25 of patients will have a decrease in LOC
  within the first 5 hours
• Post stroke seizures may occur
• Many patients will get prophylactic dilantin

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TIAs

• Anti-platelet therapy
• Searching for any treatable cause
• Afib, carotid artery stenosis

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Ischemic Stroke

• The goal is to restore blood flow if possible and
  decrease the area injured
• To lyse or not to lyse
• TPA has demonstrated a statistically significant
  increase in full recovery of patients
• However, increase in bleeding complications
• BP management
• Differs for TPA or no TPA

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TPA

• Indications
• Ischemic CVA
• lt 3 hours from time of onset

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TPA contd..

• Contraindications
• lt18 y/o
• Mild CVA symptoms (NIHSS lt4)
• Rapidly improving symptoms
• Hypertension(BP gt 185/110 after treatment)
• Bleed on CT
• Platelets lt100K
• INR gt1.7

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Contraindications contd

• Stroke or significant trauma within 3 months
• History of ICH or SAH
• History of aneurysm, AVM, or brain tumor
• Hemorrhage within 21 days
• Major surgery within 14 days
• Other miscellaneous issues

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TPA

• Dose
• 0.9 mg/kg
• 10 over first minute then remainder over one hour

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BP management

• Lower systolic BP below 185 and diastolic below
  110 using labetolol, nipride, nitroglycerin,
  nicardipine, or others

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Non-TPA Treatment

• BP management
• If lower too much or too quickly can WORSEN
  symptoms
• Only treat if MAPgt150 mm Hg
• Can use multiple drugs but NOT sublingual
  procardia

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Treatment contd

• Anti-Platelet therapy/anticoagulation
• Aspirin/plavix/ aggrenox/coumadin/heparin
• Must assess swallowing prior giving po meds
• Cranial nerve assessment, handling of secretions,
  swallowing assessment
• If they fail, ASA per rectum

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