Diagnosis and Diagnosis and Management of acute Management of acute

ischemic strokeischemic stroke

Stroke-DefinitionStroke-Definition

• Acute loss of vascular perfusion to a Acute loss of vascular perfusion to a region of the brain resulting in region of the brain resulting in ischemia and loss of neurologic ischemia and loss of neurologic function and/or tissue destructionfunction and/or tissue destruction

• Can be hemorrhagic or ischemic in Can be hemorrhagic or ischemic in etiologyetiology

Stroke definition Stroke definition continuedcontinued

• Neurologic dysfunction can take the Neurologic dysfunction can take the form of a deficit in any neurologic form of a deficit in any neurologic domain including motor, sensory or domain including motor, sensory or cognitive.cognitive.

• Typical symptoms can include Typical symptoms can include weakness, incoordination, visual loss, weakness, incoordination, visual loss, language (production or language (production or comprehension). comprehension).

Stroke pathophysiologyStroke pathophysiology

• Ischemic: embolic, thrombotic, Ischemic: embolic, thrombotic, vasculitic or hypoperfusion, arterial vasculitic or hypoperfusion, arterial dissection.dissection.

• Hemorrhagic: intraparenchymal or Hemorrhagic: intraparenchymal or subarachnoid. subarachnoid.

EpidemiologyEpidemiology

• In U.S. 795,000 strokes per year, In U.S. 795,000 strokes per year, 625,000 are ischemic625,000 are ischemic

• There are currently 4.4 million There are currently 4.4 million stroke survivors in the U.S.stroke survivors in the U.S.

• 33rdrd leading cause of death in U.S. leading cause of death in U.S. and in other industrialized countries.and in other industrialized countries.

Epidemiology continuedEpidemiology continued

• Number one cause of disability in Number one cause of disability in the U.S.the U.S.

-26% will need assistance with -26% will need assistance with ADLs.ADLs.

-30% will need walking assistance-30% will need walking assistance

-26% will require admission to long -26% will require admission to long term care facilityterm care facility

EpidemiologyEpidemiology

• Stroke occurs in all age groups Stroke occurs in all age groups including childrenincluding children

• 75% of all stroke occur in the age 65 75% of all stroke occur in the age 65 and older groupand older group

• The age adjusted risk of death due to The age adjusted risk of death due to stroke in blacks is 1.49 compared with stroke in blacks is 1.49 compared with whites.whites.

Clinical presentationClinical presentation

• Acute neurologic deficitAcute neurologic deficit

• Sudden hemiparesis/hemiplegia, loss Sudden hemiparesis/hemiplegia, loss of language function (receptive or of language function (receptive or expressive), dysarthria, loss of vision expressive), dysarthria, loss of vision in one or both eyes, sudden ataxia, in one or both eyes, sudden ataxia, hemibody numbness, vertigo, hemibody numbness, vertigo, diplopia, clumsiness, sudden onset diplopia, clumsiness, sudden onset headache (thunderclap)headache (thunderclap)

Important history to Important history to obtainobtain

HPI:HPI:• Absolute onset of symptomsAbsolute onset of symptoms• Presence of progressing or Presence of progressing or

“stuttering symptoms”“stuttering symptoms”• Attempt to localize with questions to Attempt to localize with questions to

isolate particular vascular territory: isolate particular vascular territory: Anterior versus posterior, left or Anterior versus posterior, left or rightright

Pertinent PMHPertinent PMH

• Assessment of risk factors: DM, HTN, HLP, Assessment of risk factors: DM, HTN, HLP, coagulopathies, A-fib, CHF, previous coagulopathies, A-fib, CHF, previous stroke, cardiac arrhythmias, cancer, stroke, cardiac arrhythmias, cancer, pregnancy, recent surgeries, recent TIA, pregnancy, recent surgeries, recent TIA, migraine or other HA hxmigraine or other HA hx

• Medications:Medications: anticoagulants, anticoagulants, antihypertensives, antiplatelet agents.antihypertensives, antiplatelet agents.

• SHx:SHx: tobacco, ETOH, drug use, tobacco, ETOH, drug use, supplements supplements

Pertinent family historyPertinent family history

• Stroke, coagulopathies, DM, Stroke, coagulopathies, DM, rheumatologic conditions (young rheumatologic conditions (young patients).patients).

Ischemic Stroke Ischemic Stroke classificationclassification

• Anatomic: Anterior (carotid) versus Anatomic: Anterior (carotid) versus posterior (vertebrobasilar) circulation, posterior (vertebrobasilar) circulation, and dominent versus non-dominant and dominent versus non-dominant hemisphere.hemisphere.

• Large vessel versus small vessel Large vessel versus small vessel (lacunar)(lacunar)

• Embolic versus thrombotic.Embolic versus thrombotic.

MCA infarctMCA infarct

Lacunar strokesLacunar strokes

Anatomy of a strokeAnatomy of a stroke

Anterior circulationAnterior circulation

Anterior circulation Anterior circulation symptomssymptoms

• Monocular visual loss (Amaurosis Monocular visual loss (Amaurosis fugax)fugax)

• Language dysfunction: aphasiaLanguage dysfunction: aphasia• Hemimotor: Face/arm>leg, Hemimotor: Face/arm>leg,

leg>face/armleg>face/arm• Hemisensory symptomsHemisensory symptoms• ApraxiaApraxia• Hemivisual symptoms (also posterior Hemivisual symptoms (also posterior

circulation)circulation)

Localizing anterior Localizing anterior circulation strokescirculation strokes

Posterior circulation Posterior circulation symptomssymptoms

• VertigoVertigo• AtaxiaAtaxia• Isolated Hemimotor dysfunction: Isolated Hemimotor dysfunction:

Arm=leg=face (Pontine stroke).Arm=leg=face (Pontine stroke).• DiplopiaDiplopia• DysarthriaDysarthria• HiccupsHiccups• Hearing lossHearing loss

DiagnosisDiagnosis

• Based on history of acute onset Based on history of acute onset neurologic deficit in localizable neurologic deficit in localizable vascular territoryvascular territory

• Associated objective clinical Associated objective clinical neurologic exam findingsneurologic exam findings

• Supported with specific neuro-Supported with specific neuro-imaging CT and MRI findingsimaging CT and MRI findings

DiagnosisDiagnosis

Must localize process before Must localize process before creating differential creating differential

diagnosis and ordering diagnosis and ordering imagingimaging

Important neurologic exam Important neurologic exam findingsfindings

• Level of consciousness, orientation Level of consciousness, orientation **Usually preserved with most focal **Usually preserved with most focal strokes**strokes**

• Higher cortical functions: Language Higher cortical functions: Language comprehension and fluency, naming, comprehension and fluency, naming, praxis, left-right orientation, praxis, left-right orientation, calculation,calculation,

neglectneglect

Neurologic findingsNeurologic findings

• Cranial nerves: Pupils and extraocular Cranial nerves: Pupils and extraocular movements: affected by brainstem movements: affected by brainstem involvementinvolvement

• Vision: Monocular versus binocular, Vision: Monocular versus binocular, visual field testing.visual field testing.

• Facial movement: upper versus lower Facial movement: upper versus lower face involvement: important in face involvement: important in differentiating brainstem (nuclear 7differentiating brainstem (nuclear 7thth) ) versus central 7versus central 7thth palsy palsy

• Swallowing/gagSwallowing/gag

Neurologic Exam Neurologic Exam findingsfindings

• Motor: weakness-pyramidal patternMotor: weakness-pyramidal pattern

tone: increased or tone: increased or decreaseddecreased

posturing, pronator drift posturing, pronator drift • Sensory: negative sensory Sensory: negative sensory

symptoms-central patternsymptoms-central pattern• Reflexes: hyper-reflexia, Babinksi Reflexes: hyper-reflexia, Babinksi

signsign• Gait: hemiparetic, apraxic or ataxicGait: hemiparetic, apraxic or ataxic

Initial managementInitial management

• ABCsABCs• O2O2• IV fluidsIV fluids

Initial Diagnostic testingInitial Diagnostic testing

• Vital signs including temperatureVital signs including temperature• Labs: Glucose, coags, chemistry, Labs: Glucose, coags, chemistry,

CBCCBC• EKGEKG• Non contrast Head CTNon contrast Head CT• Cardiac enzymesCardiac enzymes

Head CT pros and cons Head CT pros and cons

ProsPros• Can be obtained quicklyCan be obtained quickly• Sensitive to identifying intracranial acute Sensitive to identifying intracranial acute

bloodblood

ConsCons

• Ischemic changes may not show for 6+ hoursIschemic changes may not show for 6+ hours• Less sensitive to processes in posterior fossaLess sensitive to processes in posterior fossa

Ischemic stroke Ischemic stroke managementmanagement

• Determine level of impairment, NIH Determine level of impairment, NIH stroke scale can be helpfulstroke scale can be helpful

• Antiplatelet therapy or tPAAntiplatelet therapy or tPA• Blood pressure management, maintain Blood pressure management, maintain

MAP 100-130, SBP <220, DBP<120MAP 100-130, SBP <220, DBP<120

use labetalol IVP, enalaprilat IVP or use labetalol IVP, enalaprilat IVP or Nitroprusside gtt if needed.Nitroprusside gtt if needed.

Ischemic stroke Ischemic stroke managementmanagement

• Determine appropriateness for IV tPA Determine appropriateness for IV tPA or intravascular intervention (IA tPA, or intravascular intervention (IA tPA, mechanical clot removal)mechanical clot removal)

• Recent recommendations made for Recent recommendations made for expanding IV tPA window to 4.5 expanding IV tPA window to 4.5 hours but tPA should still be hours but tPA should still be administered ideally within 1 hour of administered ideally within 1 hour of patient presentation. patient presentation.

Additional stroke Additional stroke managementmanagement

• Admission to telemetry bedAdmission to telemetry bed• Continued IV hydrationContinued IV hydration• DVT preventionDVT prevention• NPO until speech pathology eval if NPO until speech pathology eval if

indicated.indicated.• Evaluate for signs of co-existent Evaluate for signs of co-existent

infectioninfection• Statin therapy?Statin therapy?

Additional EvaluationsAdditional Evaluations

• MRI brain with DWI, MR angiographyMRI brain with DWI, MR angiography• Carotid duplex neck for anterior Carotid duplex neck for anterior

circulation strokescirculation strokes• MRA neck for posterior circulation strokesMRA neck for posterior circulation strokes• CT angiography- sometimes indicatedCT angiography- sometimes indicated• Echocardiogram +/- bubble study (in Echocardiogram +/- bubble study (in

young)young)• Conventional angiography rarely indicatedConventional angiography rarely indicated

MRI-DWIMRI-DWI

MRI-DWIMRI-DWI

DWI and PWI (perfusion DWI and PWI (perfusion weighted)weighted)

Additional evaluationsAdditional evaluations

• RPR, homocysteine, fasting lipid RPR, homocysteine, fasting lipid profile, lipoprotein a, ESR or CRPprofile, lipoprotein a, ESR or CRP

• Rheumatologic studies and Rheumatologic studies and hypercoagulation panel if indicated hypercoagulation panel if indicated (stroke in young) (stroke in young)

Stroke complicationsStroke complications

• Aspiration/pneumoniaAspiration/pneumonia• DVTsDVTs• FallsFalls• DepressionDepression• Secondary hemorrhageSecondary hemorrhage• Increased intracranial pressureIncreased intracranial pressure

Stroke prognosisStroke prognosis

• In Framingham and Rochester studies In Framingham and Rochester studies the 30 day mortality after stroke was the 30 day mortality after stroke was 19%. The one year survival rate was 77%19%. The one year survival rate was 77%

• In the Framingham heart study, 31% of In the Framingham heart study, 31% of stroke survivors needed help caring for stroke survivors needed help caring for themselves, 20% needed help ambulating themselves, 20% needed help ambulating and 71% had some impairment in and 71% had some impairment in vocational capacity.vocational capacity.

What about TIAsWhat about TIAs

• These represent transient focal These represent transient focal interruptions in cerebral blood flow interruptions in cerebral blood flow and can be embolic or thrombotic. and can be embolic or thrombotic.

• TIAs confer a 10% risk of stroke in 30 TIAs confer a 10% risk of stroke in 30 days.days.

• Half of all strokes that follow a TIA Half of all strokes that follow a TIA occur within the first 48 hours.occur within the first 48 hours.

Work-up of TIAsWork-up of TIAs

• The diagnosis of a TIA often rests on a The diagnosis of a TIA often rests on a clinical history of a localizable focal clinical history of a localizable focal vascular event in the context of known vascular event in the context of known stroke risk factors.stroke risk factors.

• These should be evaluated aggressively These should be evaluated aggressively with hospital admission, telemetry, and with hospital admission, telemetry, and a search for a embolic source or other a search for a embolic source or other predisposition for an ischemic stroke.predisposition for an ischemic stroke.

Questions?Questions?