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KDvoyashkina Stroke and TIA

Overview of the Etiology, Pathology, and Epidemiology of Cerebral Vascular Accident
by

Kamilya Dvoyashkina

on 26 January 2015

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Transcript of KDvoyashkina Stroke and TIA

Stroke and TIA
NEUROLOGY
Epidemiology
Nearly 130,000 Americans die from stroke yearly
USA
4th leading cause of death
Every 4 min one American dies from stroke
The world
According to the World Health Organization
Etiology
Patho/Ischemic stroke
Patho/Hemorrhagic stroke
Causes:
1. Thrombosis due to atherosclerosis.
- large arteries
- small arteries (Lacunar infarcts)
2. Embolism
- CHF, MI, A-fib, Endocarditis.
Clinical
TREATMENT
A
N
A
G
E
M
M
E
N
T
PREVENTION
PANCE

- ACS
- PCS
-Cerebellum
- Brain stem
- Spinal cord lesion
NIHHS Neuro PE: 7
Focused Neuro Exam
Presentatio
Hemorrhagic stroke treatment:
Aneurysm treatment
1. Coil Embolization
2. Clamp placement


AVM treatment
Decompressive cranectomy
Exclusion criteria
History:
1. Trauma, CVA, MI last 3 months
2. Surgery last 14 days
3. Hx of intracranial hemorrhage
4. GI or GU bleeding for the last 21 days
5. Arterial puncture of non compressible site for the last 7 days
6. Use of Dabigatran, Lovenox in the last 48 hrs
7. Stroke symptoms improving
8. BP>185/110
9. Active neoplasm, chemotherapy
10. Active bleeding/Trauma/Fracture
11. Age<18
2. Risk factors reduction
TIA/CVA
HTN
High cholesterol
Alcohol consumption
DM
Smoking
CAD
Anti-thrombotics
References
World Health Organisation (1978). Cerebrovascular Disorders (Offset Publications). Geneva: World Health Organization. ISBN 92-4-170043-2. OCLC 4757533

Transient Ischemic Attack (TIA) - brief episode of neurological disfunction due to focal temporary cerebral ischemia without cerebral infarction.
1. Large artery low flow
Carotid stenosis - 70%
CEA #1
Stenting #2

2. Embolic TIA
Diagnosis:
Thorough H&P
CT of brain/US carotids
ECHOEKG with Dopler
EKG/Labs
Admit all TIAs
Plavix if CAD & TIA
Wafarin if TIA due to Afib
Aggrenox® (aspirin/extended-release dipyridamole) 25 mg/200 mg capsules
Treatment:
Blood supply to the brain. Review.
Stroke claims 6.2 million lives each year
Loss of blood flow to the brain
3. Global loss of blood

flow

(Watershed stroke)
1. Intracerebral
HTN
Trauma
AVM
Drugs
Bleeding disroder

2. Subarachnoid
Aneurysm rupture
Bleeding
#1 cause of long term disability
Question 1
A 69 year-old female is transported via EMS to ED due to progressively worsening right-sided weakness that began 1 hr ago. Vital signs: BP 178/100 mmHg; pulse 94, irregular; respirations 18, non-labored, SaO2 - 96%, on room air. PE reveals right-sided facial drooping, dysphasia, muscle strength 2/5 in right side extremity weakness. Non-contrast CT scan is negative for intracranial hemorrhaging. Which of the following medications is the best to tx this pt's condition?
A. Labetolol IV
B. Alteplase IV
C. Heparin IV
D. Aspirin PO
E. Lovenox IV
Question 2
A 53 year-old male had a 50 min episode of numbness, weakness and heaviness of the left upper and lower extremities approximately 6 hrs ago. He is brought to ED for evaluation, where he was given Aspirin 325 mg orally. At the time of examination he is alert and asymptomatic. A left carotid bruit is heard. No neurological deficits are noted. CT scan of the brain is negative for hemorrhage. The most appropriate next step is :
Question 3
A 42 yo male presents for a routine physical. Both of his parents had ischemic strokes in their 80's. He is a non-smoker, BP is 120/80, pulse 74/minutes and regular, RR 14/minute. Cardiac exam is unremarkable, no bruits. Which of the following studies should be ordered to further evaluate this pt's risk of having a stroke?
Question 4
Question 5
A 72 yo hispanic female presents to the ED with sings and symptoms of an acute ischemic stroke. The initial CT scan is normal. Her BP is 168/102. What is the most appropriate treatment for the blood pressure of this patient?


A. Administer Alteplase IV
B. Administer Clopidogrel 75 mg orally
C. Obtain a carotid sonogram
D. Obtain CT of the brain with contrast
E. D/C to rehab with PT/OT
A. Electrocardiogram
B. MRI of the brain
C. Carotid Doppler US
D. Fasting lipid profile
E. Non-contrast CT scan of the brain

Which of the following etiologies is the most common cause of nontraumatic subarachnoid hemorrhage (SAH)?
A. Arteriovenous malformation (AVM)
B. Cerebral aneurysm
C. Anticoagulant state
D. Poorly controlled HTN
E. Sickle cell desease
A. Nicardipine IV
B. Clonidine PO
C. Close monitoring
D. Atenolol PO
E. Labetolol IV
C
HF
H
ypertension
A
ge>75
D
iabetes
S
(2) prior stroke
2 or above=Wafarin

S/S
Cortical signs=Large vessel stroke
Anterior circulation stroke:
carotids-->anterior and middle cerebral
MCA: Arm>leg weakness
ACA: Leg>arm weakness

Aphasia, abulia, visual disturbances, muteness, homonymous hemianopia +/- hemiparesis
Posterior circulation
stroke:

Lacunar strokes:
small arteries, best outcome
Watershed stroke:
hypoperfusion (global blood loss), CHF, severe hypotension, arrhythmia
Left brain: left gaze, aphasia

Right brain: right gaze, neglect
Cerebellar function
VANISHE'D:
V
ertigo
A
taxia
N
ystagmus
I
ntention tremor
H
eel-shin test
D
ysdiadochokinesia
B
road gate
www.helpcampus.com
- Motor, sensory, or ataxic hemiparesis

Differentials: NOT a stroke

Post-ictal period of seizure
Hypoglycemia
Multiple sclerosis
Brain neoplasm
Intoxication
Peripheral vestibulopathy
Migraine



http://www.phillystroke.org/content/learn_about_stroke/act_fast.asp

NIHSS stroke scale:

0 - no stroke
1-4 - minor stroke
5-15 - moderate stroke
15/20 - 25 - moderate/severe
21-42 - severe stroke
NIHSS (National Institute of Health Stroke Scale)

Standardized method used by health care professionals to measure the level of impairment. Must be NIHSS certified.

Purpose:
Clinical assessment tool to determine whether the degree of disability is severe enough to warrant the use of tPA
Research
Scores are added to determine how severe is the brain attack

Silent stroke:
no outward symptoms
Hemorrhagic Stroke:
- sudden onset
Symtoms
: N/V/LOC, HA, light intolerance, stiff neck, seizure, stupor and coma
Sings:
focal deficits
90min+90min+90min= 4.5 hours

Administer t-PA within 180 min
ID
Brainstem stroke
:
Key: AMS, abnormal
VS, esp. respirations

1. History: time of onset
2. PE
3. Neuro part of PE
4. Admit to ICU
1. LOC (GCS)
2. CN exam (facial, gag)
3. Visual exam,
neglect
4. Motor
5. Sensory
6. Cerebellar
7. Language
NIHSS Language:

0
Document:
Do not state "CN II-XII intact"; state "cheek, eye, shoulder shrug, and tongue fxn were tested to be normal".
"the L sided weakness & dysphagia are consistent with an anterior ciculation stroke".
CORE
1. ABCs
2. Elevate head 30 degrees
3. If no gag reflex --> intubate
LABs
1. CBC with platelets
2. Electrolytes, BUN, creatinine, glucose
3. Cardiac enzymes and troponin
4. Coags: PT, PTT and INR
5. Oxygen saturation
6. Lipid profile
Imaging studies:
1. Non-contrast CT of the brain
2. Electrocardiogram
3. +/- CT angiography and perfusion
4. MRI of the brain
5. Catheter angiography?
Managment/Treatment
t-PA (Tissue pasminogen activator)

Inclusion criteria: ALL must be present.
1. Clinical dx of CVA
2. Neurological deficits
3. Onset within the last 4.5 hours
4. NO exclusion criteria
Management
Labs:
1. Platelets<100,000
2. Serum glucose<50
3. INR>1.7
4. Increased PTT>15 sec
Evaluation/LABs/Imaging
t-PA exclusion criteria:

Imaging:
1. Hemorrhage on CT
2. Multilobar Infarct>33% of cerebral hemisphere
Call Stroke Team
1. Determine the cause of bleeding
2. Call interventional neurosurgeon
3. Stabilize the patient: control BP
4. Stop wafarin, aspirin
5. Transfuse factor VII a(initiator of thrombin generation) or transfuse blood clotting factors
6. Control pressure in the brain by placing ventriculostomy tube into ventricle.
7. Surgery within 48-72 hrs after hemorrhage,
or 2 weeks later.
1. Embolization
2. Radiosurgery/surgery
Non dominant cerebral infarction+cerebral edema
I
A
Question 1
A 69 year-old female is transported via EMS to ED due to progressively worsening right-sided weakness that began 1 hr ago. Vital signs: BP 178/100 mmHg; pulse 94, irregular; respirations 18, non-labored, SaO2 - 96%, on room air. PE reveals right-sided facial drooping, dysphasia, muscle strength 2/5 in right side extremity weakness. Non-contrast CT scan is negative for intracranial hemorrhaging. Which of the following medications is the best to tx this pt's condition?
A. Labetolol IV
B. Alteplase IV
C. Heparin IV
D. Aspirin PO
E. Lovenox IV
Question 2
A 53 year-old male had a 50 min episode of numbness, weakness and heaviness of the left upper and lower extremities approximately 6 hrs ago. He is brought to ED for evaluation, where he was given Aspirin 325 mg orally. At the time of examination he is alert and asymptomatic. A left carotid bruit is heard. No neurological deficits are noted. CT scan of the brain is negative for hemorrhage. The most appropriate next step is :
A. Administer Alteplase IV
B. Administer Clopidogrel 75 mg orally
C. Obtain a carotid sonogram
D. Obtain CT of the brain with contrast
E. D/C to rehab with PT/OT
Question 3
A. Electrocardiogram
B. MRI of the brain
C. Carotid Doppler US
D. Fasting lipid profile
E. Non-contrast CT scan of the brain
A 42 yo male presents for a routine physical. Both of his parents had ischemic strokes in their 80's. He is a non-smoker, BP is 120/80, pulse 74/minutes and regular, RR 14/minute. Cardiac exam is unremarkable, no bruits. Which of the following studies should be ordered to further evaluate this pt's risk of having a stroke?
Question 4
Which of the following etiologies is the most common cause of nontraumatic subarachnoid hemorrhage (SAH)?
A. Arteriovenous malformation (AVM)
B. Cerebral aneurysm
C. Anticoagulant state
D. Poorly controlled HTN
E. Sickle cell desease
Question 5
A 72 year-old hispanic female presents to the ED with sings and symptoms of an acute ischemic stroke. The initial CT scan is normal. Her BP is 168/102. What is the most appropriate treatment for the blood pressure of this patient?
A. Nicardipine IV
B. Clonidine PO
C. Close monitoring
D. Atenolol PO
E. Labetolol IV
Mechanical Thrombectomy
Solitaire FR thrombectomy
procedure
MERCI retriever devices
Endovascular
often used in adjunct with tPA
C SE
2001
59 yo Caucasian female with acute onset of
right sided weakness and aphasia
. She was at the restaurant when her sister noted symptoms. Time of onset: 25 min ago.
PE/NEURO
General exam: unremarkable, RRR
NEURO exam:
1. GCS - 8
2. CN: cheeks, shoulders shrug, and tongue function were tested to be normal
3. Visual exam: left gaze preference
4. Motor: R sided weakness
5. Sensory: decreased sensation on right
face, arm, and leg
6. Cerebellar: WNL
7. Language: global aphasia
Acute anterior circulation stroke
Large vessles: ICA, MCA
Focal deficits
Candidate for IV t-PA
PMH:
HTN, DM type 2, HLD
Medications:
Premarin, Metformin, Lisinopril
Vitals:
BP 174/100 mm Hg LUR, HR 100b/pm, T36.8C oral, RR 20b/pm, O2 96% on room air
Post d/c management
1. Rehab--> PT/OT
3. Therapy: statins, antithrombotics
Labs:
WBC 10.2 K/mL, Hgb 12.4g/dL, Hct 34.7%, MCV 85.3fL, platelet count 480,000 mcL, PT 12 sec, PTT30 sec, serum glucose 105 mg/dL, INR 1 (normal value 0.8-1.2)
CT brain: normal

CT perfusion study
Left ICA stenosis
CT angiogram
- Large Left MCA perfusion defect
Symptomatic focal high grade stenosis of the left middle cerebral artery (M1 segment) was an isolated finding
http://www.ohsu.edu/dottercarotid_stenting.htm
Admitted to ICU
D/C to rehab with PT/OT
Global Grand Rounds: Acute Stroke Therapy presented by Karl E. Misulis, MD, PhD . Paterson in Medical Emergency Disease. Retreived from http://www.biomedox.com/media/global-grand-rounds-acute-stroke-therapy-presented-by-karl-e-misulis-md-phd_e4778a858.html
Neurology: www.helpcampus.com

Hemorrhagic stroke. Retrieved from http://www.uptodate.com/contents/hemorrhagic-stroke-treatment-beyond-the-basics#H3
Natarajan S K, Karmon Y, Siddiqui A, Levy E, Hopkins L N. Intracranial Stent-assisted Revascularization for Acute Ischemic Stroke. Vascular Disease Management, 6 (6): 177-185. 2009.
A review of the blood supply (vascular anatomy) to the human brain. Produced and narrated by Cal Shipley, M.D. Retrieved from http://www.trialimage.com
Completing the Neurologic Exam in Emergency Departments CVA Patientshttp://www.ferne.org/Lectures/neuroexam%20tiacva%201001.htm (neuro exam

http://www.mdcalc.com/nih-stroke-scale-score-nihss/
http://www.ncbi.nlm.nih.gov/pubmed/24350870
www.helpcampus.com
Aggrenox® (aspirin/extended-release dipyridamole) 25 mg/200 mg
https://hcp.aggrenox.com/mechanism-of-action.html
http://www.paeasy.com.ezproxylocal.library.nova.edu/
https://nova.myexammaster.com/
Stroke - rapid death of brain tissue due to disturbances in blood flow.
Kamila Dvoyashkina
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