Posterior Circulation Stroke Jessica Heckenberger BSN RN

1
Posterior Circulation StrokeJessica Heckenberger
BSN RN
2
Stroke Statistics

• Stroke is the 5th leading cause of death in the
  U.S.
• Stroke kills almost 130,000 Americans each
  yearthats 1 out of every 19 deaths.
• On average, one American dies from stroke every 4
  minutes.
• Stroke costs the United States an estimated 38.6
  billion each year. This total includes the cost
  of health care services, medications to treat
  stroke, and missed days of work.

3
F.A.S.T.

• F-Face Drooping Does one side of the face droop
  or is it numb? Ask the person to smile. Is the
  person's smile uneven?
• A- Arm-Is one arm weak or numb? Ask the person to
  raise both arms. Does one arm drift downward?
• S-Speech Difficulty Is speech slurred? Is the
  person unable to speak or hard to understand? Ask
  the person to repeat a simple sentence, like "The
  sky is blue." Is the sentence repeated correctly?
• T-Time-What was the time the person was last
  known well?

4
Beyond Fast B.E. F.A.S.T

• B-Balance-Sudden trouble walking, dizziness, loss
  of balance or coordination
• E-Eyes-Sudden trouble seeing in one or both eyes

Vision
5
St. Lukes Primary Stroke Centers

• St. Lukes Allentown Campus
• St. Lukes Anderson Campus
• St. Lukes Bethlehem Campus

6
Posterior Circulation Stroke

• Posterior circulation stroke accounts for 20-25
  of ischemic strokes
• Specialist assessment and administration of
  intravenous tissue plasminogen activator are
  delayed in posterior circulation stroke compared
  with anterior circulation stroke
• Basilar occlusion is associated with high
  mortality or severe disability, especially if
  blood flow is not restored in the vessel if
  symptoms such as acute coma, dysarthria,
  dysphagia, quadriparesis, pupillary and
  oculomotor abnormalities are detected, urgently
  seek the input of a stroke specialist

7
The Posterior Circulation

• Vertebral arteries
• The basilar artery
• The posterior cerebral arteries and their
  branches

8
PCA Supply

• Posterior Circulation Brain Structures
• Brainstem (medulla, pons, and midbrain)
• Cerebellum
• Thalamus
• Hippocampus
• Areas of temporal and occipital cortex

9
Etiology

• Arterial atherosclerosis (large artery disease)
  and penetrating artery disease (lacunes).
• Cardiogenic embolization is more common than
  previously suspected and is responsible for
  20-50 of posterior circulation strokes
• Vascular obstruction or occlusion is the
  fundamental disorder leading to hypoperfusion

10
Time is Brain
11
Risk Factors

• Uncontrollable Risk Factors
• Age
• Gender
• Race
• Family history of stroke or TIA
• Personal history of diabetes

12
Risk Factors

• Medical Risk Factors
• Hypertension
• Heart disease (such as atrial fibrillation or
  left ventricular hypertrophy)
• Previous stroke or TIA
• Previous heart surgery
• Carotid artery disease
• Peripheral vascular disease
• Smoking

13
Signs and Symptoms

• 5 Ds
• Dizziness
• Diplopia
• Dysarthria
• Dysphagia
• Dystaxia

14
Signs and Symptoms

• Changes in eye movement-
• Visual field loss in one or both
• eyes.
• Ptosis
• Diplopia

15
Signs and Symptoms

• Dizziness/Vertigo
• Symptoms ranging from near-syncope,
  lightheadedness or faintness to a sensation of
  movement or disequilibrium, unsteadiness, or
  imbalance
• Vertigo with or without nausea and vomiting

16
Signs and Symptoms

• Dysphagia or dysarthria
• Crossed syndromes, consisting of ipsilateral
  cranial nerve dysfunction and contralateral long
  motor or sensory tract dysfunction are highly
  characteristic of posterior circulation stroke
• Sensory deficits (numbness, including loss of
  sensation or par aesthesia in any combination of
  extremities, sometimes including all four limbs
  or both sides of the face or mouth)
• Isolated reduced level of consciousness is not a
  typical stroke symptom but can result from
  bilateral thalamic or brainstem ischemia

17
Posterior Circulation Infarction According to
Anatomical Location and Vascular Territory
Affected

• Lateral medulla (intracranial vertebral artery
  infarct, also known as Wallenberg syndrome)
• Nystagmus, vertigo, ipsilateral Horners
  syndrome, ipsilateral facial sensory loss,
  dysarthria, hoarseness, and dysphagia
• Contralateral hemisensory loss in the trunk and
  limbpain and temperature
• Medial medulla
• Ipsilateral tongue weakness and later hemiatrophy
  of the tongue
• Contralateral hemiparesis of the arm and leg
• Hemisensory losstouch and proprioception
• Pons
• Hemiparesis or hemisensory loss, ataxic
  hemiparesis, dysarthria, horizontal gaze palsy
• Complete infarction causes locked-in syndrome
  with quadriparesis, loss of speech, but preserved
  awareness and cognition, and sometimes preserved
  eye movements

18
Locked-in Syndrome

• Locked-in Syndrome (LIS) results from a lesion to
  the brainstem, most frequently an ischemic
  pontine lesion. It results in severe impairments
  due to the complete disruption of the motor
  pathways controlling eyes, face, trunk and limb
  movements, including breathing, swallowing and
  phonation. However consciousness and cortical
  functions are preserved.
• LIS is defined as a syndrome characterized by
  preserved awareness, relatively intact cognitive
  functions, and by the ability to communicate
  while being paralyzed and voiceless.

19
Locked-in Syndrome

• Locked-in syndrome affects around 1 of people
  who have as stroke
• Individuals with LIS have the highest level of
  disability among stroke survivors
• It is a condition for which there is no treatment
  or cure, and it is extremely rare for patients to
  recover any significant motor functions.
• 90 die within four months of its onset
• Initial stroke primary cause of death (25 of
  cases)
• Voluntary cough is often impossible, and
  sometimes there is no reflex cough
• Aspiration pneumonias are more common during the
  acute phase
• Secondarily to infections such as pneumonia (40
  of cases)

20
Locked-in Syndrome

• Acute Phase
• Respiratory tract monitoring and cardiovascular
  support
• Thrombolysis or the prescription of blood
  thinners based on the type of vascular impairment
  
• Peg tube feeding
• Tracheostomy
• VTE prophylaxis
• Skin care management
• PT
• ROM
• Bracing
• Proper posturing in bed

21
Locked-In Syndrome

• Rehabilitation Phase
• Individuals use eye movements to communicate
• Communication devices (as computer with synthetic
  voice)
• Some individuals may be suitable for weaning from
  their tracheostomy as their condition improves
  during the first months
• Exercises to maintain range of motion, as well as
  breathing, eyes, head, trunk and limb control
  exercises are performed throughout the
  rehabilitation process.

22
Diagnosing

• History and physical exam
• Horners syndrome- ptosis, small pupil, and
  anhydrosis on the same side, bilateral small or
  fixed pupils, and ataxia may aid early diagnosis.
• Non-contrast CT of head
• CT angiography- identify basilar artery occlusion
  
• MRI

23
Management

• Thrombolysis
• Intra-arterial thrombolytic therapy
• Heparin Therapy
• Neurosurgery

24
tPA (Activase)

• Tissue plasminogen activator.
• Activase is indicated for the management of acute
  ischemic stroke in adults for improving
  neurological recovery and reducing the incidence
  of disability

25
Rationale for Use

• Limit size of infarct by dissolving clot
  restoring blood flow to ischemic brain.
• Prompt treatment with (t-PA) may promote
  reperfusion and improve functional outcomes for
  patient.

26
Time Frame

• Given intravenously within 3 hours of acute
  ischemic stroke (FDA)
• The window can be extended to 4.5 hours if
  patient meets additional criteria
• Goal Door to Needle Time
• Administer (t-PA) within 1 hour of arrival to
  hospital

27
Effects of tPA

• Binds to fibrin in a thrombus and converts
  plasminogen to plasmin which initiates local
  fibrinolysisTips the scale in the other
  direction.
• Fibrinolysis the breakdown of a blood clot.

28
Effects of tPA

• Fibrin strand
  Fibrin Strands

Activase (Alteplase)
29
Contraindication 0-3hr Window

• Evidence of intracranial hemorrhage
• Suspicion of subarachnoid hemorrhage on
  pretreatment evaluation
• Recent intracranial or intraspinal surgery,
  serious head trauma, or previous stroke
• Major surgery / serious trauma
• History of intracranial hemorrhage
• Uncontrolled hypertension at time of treatment
  (eg, gt 185 mm Hg systolic or gt 110 mm Hg
  diastolic)
• Allergy to t-PA
• Seizure at the onset of stroke (unless
  neuroimaging confirms ischemia)
• Active internal bleeding
• Glucose lt 50 or gt 400
• Known bleeding diathesis including but not
  limited to
• Current use of oral anticoagulants (eg, warfarin
  sodium) or an International Normalized Ratio
  (INR) gt 1.7or a prothrombin time (PT) gt 15
  seconds
• Administration of heparin within 48 hours
  preceding the onset of stroke and have an
  elevated activated partial thromboplastin time
  (aPTT) at presentation
• Platelet count lt 100,000/mm3

30
Contraindications 0 to 4.5 Hour Window

• CONTRAINDICATIONS - IN ADDITION TO THE 0 TO 3
  HOUR WINDOW
• Patient age
• Patient taking oral anticoagulation despite INR
  level
• History of both stroke and diabetes

31
Risk Factors

• Largest risk factors is bleeding

32
Benefits of tPA
33
Neurosurgical

• External ventricular drainage or decompression
  may be lifesaving in large volume cerebellar
  infarction with falling level of consciousness
  attributable to raised intracranial pressure or
  acute hydrocephalus.
• Emergency posterior fossa decompression with
  partial removal of the infarcted tissue may be
  lifesaving.

34
Diagnostic Work-up

• Diagnostic work-up done to
• Determine etiology of stroke
• Identify risk factors
• Determine most appropriate secondary stroke
  prophylaxis
• Anticoagulation
• Antiplatelet
• Statins

35
Cardiac Diagnostics

• Electrocardiogram
• Look for arrhythmias, conduction problems
• Transthoracic echocardiogram (TTE)
• screen for cardioembolic conditions
• Transesophageal echocardiogram (TEE)
• Screen for cardioembolic conditions
• Invasive test

36
Other Diagnostic Studies

• Carotid Doppler
• EEG

37
Inpatient Rehabilitation

• Speech Therapy
• Physical Therapy
• Occupational Therapy
• Dietary Consultation
• Multidisciplinary Rounds

38
Patient/ Family Education

• On going education from all disciplines
• Stroke Patient Education Binder
• Diagnosis
• Risk Factors
• Risk Factor Modification
• Family Risk
• Teach S/S of stroke
• Importance of taking medications
• Importance of regular medical follow-up
• Stroke Club

39
Stroke Prevention

• Hypertension
• BP lt 120/80 (after acute phase of stroke)
• Dietary changes, exercise, medications
• Smoking
• Cessation counseling
• Treatment (meds, hypnosis, etc..)
• Diabetes
• HgbA1C goal lt 7.0
• Meds, diet, exercise

40
Prevention Cont.

• Dyslipidemia
• Lipid Profile (goals)
• Total Cholesterol lt 200
• LDL lt 100 (lt70)
• HDL gt 35
• Triglycerides lt 200
• Meds, diet, exercise
• Obesity
• BMI gt 25
• Exercise for 30 minutes on most days

41
Stroke Data
90th Percentile SLA/B SLA/B SLRA SLRA SLM SLM SLQ SLQ SLW SLW
90th Percentile FY 14 FY 15 YTD FY 14 FY 15 YTD FY 14 FY 15 YTD FY 14 FY 15 YTD FY 14 FY 15 YTD
VTE Prophylaxis 98.65 98.7 100 100 100 100 100 100 100 100 100
Discharge Antithrombotics 98.92 100 100 100 100 100 100 100 100 100 100
Discharge Anticoagulation A. Fib. 94.12 100 100 100 100 100 100 100 100 100 100
Thrombolytic Therapy 89.47 85.7 90 66.7 50 50 ---- ---- ----- 100 ----
Antithrombotic by Day 2 98.53 98.7 100 100 94.7 100 100 100 100 100 100
Discharge Statin 98.15 99.6 99.1 100 100 100 100 95.7 95.7 96.2 96.2
Stroke Education 97.5 99.5 95.9 92 100 77.8 77.8 100 88.9 75 66.7
Rehab Assessment 98.8 100 100 100 100 100 100 100 100 100 100
Door to tPA 60 min 50 68.2 80 50 33.3 0 ---- ----- ----- 0 0
42

• Thank you
• And please always remember...

43
References

• http//brainfoundation.org.au/medical-info/205-loc
  ked-in-syndrome-lis
• http//cirrie.buffalo.edu/encyclopedia/en/article/
  303/
• http//www.bmj.com/content/348/bmj.g3175
• Lewandowski, C., Santhakumar, S., Posterior
  Circulation Stroke, Foundation for Education and
  Research in Neurological Emergencies. 2012.