Stroke and TIA

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Stroke and TIA

• Dr. Tallam
• Prepared by T. Gifford

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Definitions

• Stroke any disease process that interrupts
  blood flow to the brain
• Ischemic 80
• Hemorrhage 20

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Ischemic Stroke

• Thrombotic
• Most common
• Atherosclerosis
• Vasculitis
• Dissection
• Polycythemia
• Hypercoagulable
• Develop over minutes to hours
• Often previous TIA in same distribution

• Embolic
• Intravascular material is released occluding
  vessel downstream
• No underlying vascular disease at site
• Valvular vegetations
• Mural thrombi
• Cardiac tumors
• Fat embolism
• Drug injection

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Ischemic Stroke

• Hypoperfusion
• Usually from cardiac failure
• Less common
• Symptoms wax and wane as blood pressure changes.

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Hemorrhagic Stroke

• Types
• Intracranial hemorrhage (ICH)
• Bleeding directly into parenchyma from weakened
  small arterioles
• Non traumatic subarachnoid (SAH)
• Blood leaks from cerebral vessel into
  subarachnoid space
• Berry aneurysm rupture

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Clinical

• History
• HTN
• CAD
• DM
• A-fib
• Valve repair
• Recent MI
• Recent TIA

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Physical Exam

• Febrile R/O infection
• Skin
• Janeway lesions
• Osler nodes
• Bleeding dyscrasias
• Cardio/Lungs
• Rales
• S3
• Carotid bruit

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Physical Exam

• Fundoscopic exam
• Papilledema
• Mass lesion
• Cerebral vein thrombosis
• HTN crisis
• Pre-retinal hemorrhage
• SAH

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Neurological Exam

• Goal
• Localize CNS lesion
• NIH Scale

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Neurological Exam

• Level of consciousness
• Visual assessment
• Motor function
• Cerebellar function
• Sensation and neglect
• Language
• Cranial nerves

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Stroke Syndromes

• TIA
• Neurological deficit that resolves within 24
  hours (some say 30min)

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Ischemic Stroke Syndromes

• Anterior cerebral artery infarction
• Contralateral leg weakness greater than arm
  weakness
• Mild cortical sensory deficits

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Ischemic Stroke Syndromes

• Middle cerebral artery infarction
• Contrlateral weakness and numbness
• Variably affecting the face and arm greater than
  leg
• If dominant hemisphere aphasia often present
• Neglect / inattention non dominant hemisphere
• Homonymous hemianopsia / gaze toward infarct
  common

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Ischemic Stroke Syndromes

• Posterior cerebral artery infarction
• May be unaware of symptoms
• Minimal motor involvement
• Light touch / pin prick reduced
• Vertibrobasilar syndrome
• Posterior circulation compromised
• Crossed neurological defecits
• Ipsilateral CN deficit, contralateral motor
  weakness
• Dizziness, vertigo, diploplia
• Wallenberg syndrome
• Ipsilateral loss facial pain and temp with
  contralateral in body

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Ischemic Stroke Syndromes

• Basilar artery syndrome
• Quadraplegia
• Coma
• Locked in syndrome
• Lesion in pontine tectum with complete muscle
  paralysis with exception of upward gaze
• Cerebellar infarction
• drop attack, vertigo, H/A, N/V, neck pain
• After 6-12 hours cerebral edema develops
• MRI / MRA surgical decompression

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Ischemic Stroke Syndromes

• Lacunar infarct
• Pure motor or sensory deficits caused by infarct
  of small penetrating arteries
• Associated with chronic hypertension
• Primarily in pons and basal ganglia
• Arterial dissection
• Associated with trauma / turning of head or
  spontaneously
• Hypertension is risk factor
• Severe neck pain, H/A hours to days before
  symptoms

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Hemorrhagic StrokeSyndromes

• ICH
• Clinically indistinguishable from infarction
• H/A, N/V proceed deficit.
• Cerebellar hemorrhage
• Sudden onset dizziness, vomiting, truncal ataxia,
  inability to walk
• May be associated with gaze palsy and stupor

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Hemorrhagic Stroke Syndromes

• SAH
• Severe constant H/A often in occipital or nuchal
  area
• Vomiting common, decrease LOC
• Sentinal hemorrhage
• Sudden presentation

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Diagnosis

• Education
• Patients (911 usage)
• EMS careful ID of onset if possible
• Triage
• Antithrombolysis screening

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Diagnosis

• Tests
• Emergent non contrast CT
• Ischemic strokes need at least 6 hours before
  visibility
• Identifies all parenchymal bleeds gt1cm and 95 of
  SAH (if done within 12 hours)
• Lumbar puncture
• If high suspicion of SAH persists after CT
• EKG
• Identify a-fib or AMI
• Labs
• MRI / MRA
• Carotid ultrasound

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Differentials

• Epidural / Subdural
• Hyponatremia
• Postictal paralysis (Todd)
• HTN encephalopathy
• Brain tumor / Abscess
• Meningitis / encephalitis
• Hyperosmotic coma
• Wernicke encephalopathy

• Labyrinthitis
• Drug toxicity
• Bell palsy
• Complicated migraine
• Meniere disease
• Demyelinating disease

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Treatment

• General
• ABCs, O2, Monitor
• HOB elevated
• Cardiac monitor
• IV access
• Judicious fluids
• Refrain from glucose containing fluids (no
  evidence to support)

• Seizures
• Treat seizure with ativan and load with
  fosphenytoin.
• No prophylaxis

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Treatment

• Hypertension
• Consider persistent elevation gt220 systolic for
  treatment
• Use easily titratable meds
• Lebatelol
• Enalaprit
• NTG paste
• May need to treat to qualify for tPA

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Thrombolysis

• NINDS study
• Milticenter, randomized, double-blind, placebo
• 624 patients
• At 3 months, rtPA group was 30 more likely to
  have minimal or no disability
• Symptomatic ICH 6.4 compared to 0.6
• Other studies have had variable results

• FDA approved for ischemic stroke in 1996
• Supported by
• AHA
• AAN
• ACEP

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Thrombolysis

• Pre Screen
• tPa Dose
• 0.9mg/kg, max 90 mg
• 10 as bolus
• Remainder over 60 min
• No ASA or Heparin in 24 hours after
  administration

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Treatment in tPA Non-Candidates

• Goal of secondary stroke prevention
• Antiplatelets
• ASA 50-300mg daily
• Reduced risk by 20-25
• Dipyridamole 200 mg BID
• Reduced risk by 15 alone
• Dipyridamole ASA
• Reduced risk by 37
• Plavix 75 mg daily
• Marginally superior to ASA

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Treatment in tPA Non-Candidates

• Goal of secondary stroke prevention
• Anticoagulants
• UFH efficacy lacking, possible harmful
• Increased rate ICH
• Decreased rate recurrent ischemic stroke
• The use of UFH, LMWH or heparinoids is therefore
  not recommended for stroke or TIA treatment based
  on current evidence
• Warfarin is indicated for those with A-fib and
  TIA

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Treatment

• Cerebellar infarction
• Early neurosurgical consultation

• TIA
• New onset
• Admit for evaluation of sources of emboli or
  stenosis
• Some recommend UFH when
• Known high grade stenosis
• Cardioembolic source (except infective
  endocarditis)
• Crescendo TIAs
• TIAs despite antiplatelets
• Early carotid endarterectomy if gt70 stenosis

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Treatment

• ICH
• Treat severe hypertension
• SBP gt220
• DBP gt120
• Slow reduction unless cardiac failure or
  dissection
• Elevate HOB 30 degrees
• Increased ICP
• Hyperventilation
• Paco2 target 30-35
• Osmotherapy
• Mannitol 1.0 g/kg IV
• Target lt310 mOsm/kg
• Lasix 10 mg IV

• Consider seizure prophylaxis
• Surgical consultation

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Treatment

• SAH
• Rebleed and vasospasm are major complications
• Keep SBP lt 160
• Nimodipine 60 mg q 6 hr
• Reduces incidence and severity of vasospasm
• Prophylactic phenytoin
• Antiemetics
• Surgical consultation