GOALS & OBJECTIVES

• REVIEW CLINICALLY RELEVANT NEUROANATOMY

• ANATOMY INVOLVED IN STROKE SYNDROMES

• DISCUSS PRE-HOSPITAL AND HOSPITAL EVALUATION OF PATIENTS SUSPECTED OF STROKE

• ENHANCE PERSPECTIVE FOR PRE-HOSPITAL PROVIDERS

• CLINICAL PEARLS TO OPTIMIZE PATIENT CARE

• PROVIDE CASE-BASED CLINICAL SCENARIOS FOR KNOWLEDGE ASSESSMENT AND TUTORIAL

• IMPROVE PRE-HOSPITAL PROVIDER AWARENESS OF STROKE/MIMICS

STROKE PATHOLOGY & EPIDEMIOLOGY • STROKE IS AN INFARCT OF THE BRAIN

• A CLOTTED BLOOD VESSEL CUTS OFF BLOOD SUPPLY CAUSING DEATH OF THE TISSUE THAT VESSEL SUPPLIES

• RISK FACTORS: HYPERTENSION, DM, SMOKING, AGE, ATRIAL FIBRILLATION

• DISTINCT FROM INTRACRANIAL HEMORRHAGE

• NATIONALLY, EACH YEAR:

• 795,000 PEOPLE HAVE A STROKE

• 5TH LEADING CAUSE OF DEATH

• LOCALLLY:

• >350 PATIENTS SUSPECTED OF STROKE PRESENTED TO UF HEALTH-JACKSONVILLE IN 2016

• APPROXIMATELY 60% AS PRE-HOSPITAL STROKE ALERTS AND 40% STROKE ALERTED IN ED

NEUROANATOMY

• CENTRAL NERVOUS SYSTEMCerebellummovement, balance,

speech

Cranial Nerves

MOTORHOMONCULUS• ACA=ANTERIOR CEREBRAL ARTERY

• MCA=MIDDLE CEREBRAL ARTERY

• EXTREMITY WEAKNESS IS EVIDENT IN THE

OPPOSITE SIDE THAN THE BRAIN AFFECTED

• THIS IS BECAUSE NERVES THAT CONTROL

EXTREMITY MOVEMENT CROSS SIDES IN

THE BRAIN STEM AS CONNECTS WITH

SPINAL CORD

ACA

MCA

VASCULAR DISTRIBUTION

ANTERIOR

CIRCULATION

POSTERIOR

CIRCULATION

1

2

3 4

56 789

101112

Pons

Medulla

Midbrain

• MIDBRAIN

• CN3-4

• PONS

• CN5-8

• MEDULLA

• CN9-12

1

2

34

56 789

101112

Midbrain

CRANIAL NERVESLooks down

Looks lateral

All other directions

CNS LESION BY VASCULAR DISTRIBUTIONANTERIOR CIRCULATION LESION• ANTERIOR AND MIDDLE CEREBRAL ARTERIES ARISE FROM CAROTID ARTERY—ANTERIOR CIRCULATION

• MCA—CORTEX, UPPER LIMB AND FACE, WERNICKE’S/BROCA’S AREA (LEFT BRAIN)

• WEAKNESS OF OPPOSITE SIDE, LOSS OF SENSATION

• APHASIA (DIFFICULTY SPEAKING)

• ACA—CORTEX, LOWER LIMB

• WEAKNESS OF OPPOSITE SIDE, LOSS OF SENSATION

• LATERAL STRIATE ARTERY—INTERNAL CAPSULE

• WEAKNESS OF OPPOSITE SIDE, SENSATION INTACT

• INFARCT DUE TO UNMANAGED HYPERTENSION

PUTTING IT TOGETHERPOSTERIOR CIRCULATION LESION• POSTERIOR CEREBRAL ARTERY ARISES FROM VERTEBRAL ARTERY—POSTERIOR CIRCULATION

• “CEREBELLAR SIGNS” AND CRANIAL NERVE INVOLVEMENT CAN HELP IN DETERMINING IF “DIZZINESS” OR VERTIGO IS

SIGNIFYING A POSTERIOR CIRCULATION STROKE

• PICA—CN 8, 9, 10, SYMPATHETIC ANS FIBERS, CEREBELLUM, LATERAL SPINOTHALAMIC TRACT

• VERTIGO (DIZZINESS), VOMITING, NYSTAGMUS (ABNORMAL EYE MOVEMENT), DYSPHAGIA (DIFFICULTY SWALLOWING),

HOARSENESS, DECREASED GAG REFLEX

• HORNER’S SYNDROME ON SAME SIDE—EYELID DROOP, SMALL PUPIL, LACK OF SWEAT

• ATAXIA—UNSTEADY GAIT, DYSMETRIA—CANNOT COORDINATE FINGER-TO-NOSE

• DECREASED PAIN/TEMP SENSATION AT LIMBS OF OPPOSITE SIDE

• AKA--LATERAL MEDULLARY SYNDROME

PUTTING IT TOGETHERPOSTERIOR CIRCULATION LESION• AICA—CN 5,7,8, ANS SYMPATHETIC FIBERS, CEREBELLUM, SPINOTHALAMIC TRACT

• DECREASE IN TASTE, SALIVATION, LACRIMATION, CORNEAL REFLEX

• FACIAL PARALYSIS OF SAME SIDE

• VERTIGO, VOMITING, NYSTAGMUS, DECREASED HEARING

• HORNER’S SYNDROME OF SAME SIDE

• ATAXIA, DYSMETRIA

• DECREASED PAIN AND TEMP SENSATION OF SAME SIDE

• AKA--LATERAL PONTINE SYNDROME

APHASIA VS. DYSARTHRIA• APHASIA– CLEAR SPEECH, DIFFICULTY COMMUNICATING

• ASSOCIATED WITH LEFT MCA DISTRIBUTION

• ANTERIOR CIRCULATION

• DIFFERENT TYPES:

• BROCA’S, WERNICKE’S, GLOBAL, CONDUCTION

• DYSARTHRIA– SLURRED SPEECH

• ASSOCIATED WITH CEREBELLAR OR CRANIAL NERVE DYSFUNCTION

• POSTERIOR CIRCULATION

CASE—YOU ARRIVE ON SCENE

• 59 YO M W/ HX HTN, P/W RIGHT FACIAL DROOP AND RIGHT UPPER EXTREMITY WEAKNESS, SPEECH

DIFFICULTY. CO-WORKERS CALLED 911 AFTER NOTICING HE WASN’T ACTING RIGHT WHEN ARRIVING AT

WORK. LAST SEEN NORMAL AT 4 AM AFTER WAKING UP (4.5 HOURS AGO), PER WIFE WHO IS ALSO

PRESENT ON SCENE. WIFE STATES NORMAL STATE OF HEALTH PRIOR. DENIES OTHER COMPLAINTS. NO

CP/ABDOMINAL PAIN/SOB/FEVER/CHILLS/TRAUMA. HX PROVIDED BY WIFE AND CO-WORKERS, LIMITED

BY CONDITION.

CASE—FIELD ASSESSMENT

• VS:

• 98.7F ORAL, HR 102, BP 142/88, RR 14, O2 96% RA, ACCUCHECK 119

• EXAM:

• ALERT, NO DISTRESS, A&O X1 (TO SELF ONLY), SPEAKS IN 1 WORD SENTENCES, CLEAR SPEECH BUT

CONFUSED RESPONSE, + RIGHT FACIAL DROOP, RIGHT UPPER EXTREMITY WEAKNESS. LEFT UPPER

EXTREMITY AND BOTH LOWER EXTREMITIES HAVE FULL STRENGTH. NO EYE/TONGUE DEVIATION.

• STROKE ALERT PAGED FROM FIELD

EVALUATION—PRE-HOSPITAL

• LAMS score >4 correlates with NIHSS, and

is highly predictive of large artery

Anterior Circulation stroke

• ACA and MCA arterial distributions

previously discussed

EVALUATION—PRE-HOSPITAL

EVALUATION—PRE-HOSPITAL

EVALUATION—ED• NIHSS/MNIHSS

• ASSESSES SEVERITY OF STROKE

• ALSO AT THIS POINT

• VITALS

• LIKELY HYPERTENSIVE

• POSSIBLY MILD FEVER

• POCT GLUCOSE, EKG, CXR, CT HEAD

• LABS:

• CBC, BMP, PT/INR, PTT

1

0

2

0

2

2

0

000

1

2

0

111

0

EVALUATION—ED

• COOPERATIVE EFFORT WITH ED,

NEUROLOGY, AND

INTERVENTIONAL RADIOLOGY

• WITHIN 6.5 HOURS OF ONSET,

PAGE STROKE ALERT

• NIHSS 4 OR MORE:

• CT HEAD

• CONSIDER TPA

• NIHSS 6 OR MORE:

• CTA HEAD/NECK

• CONSIDER IR

IV TPA• ALTEPLASE—TISSUE PLASMINOGEN ACTIVATOR

• “CLOT BUSTER”, THROMBOLYSIS, ACTIVELY DISSOLVES CLOT

• RISK OF BLEEDING

EVALUATION—INTERVENTIONAL RADIOLOGY

• WINDOW ABOUT 8 HRS

• VOLUME <90 CC ON DWI MRI

• ASPECTS SCORE

• INTERVENTIONAL METHODS:

• CATHETER DIRECTED THROMBOLYSIS WITH INTRA-ARTERIAL TPA

DIRECTLY TO CLOT

• CLOT EXTRACTION

• LESS BLEEDING RISK AND MORE LIBERAL TIME WINDOW THAN IV TPA

• LIMITED TO LARGE VESSEL OCCLUSION AND SMALL INFARCT SIZE

EVALUATION—NEUROLOGY

EVALUATION—NEUROLOGY

• MRS

TIA?ED EVALUATION

BACK TO OUR PATIENT

• NON-CONTRAST CT HEAD

• NO HEMORRHAGE (HEMORRHAGE SHOWS UP WHITE--HYPER DENSITY)

• + LEFT MCA DISTRIBUTION HYPO DENSITY (DARK AREA)

• ACUTE STROKE

• CAN BE SUBTLE

• CT CAN BE COMPLETELY NORMAL STROKE IS EARLY

ACA

MCA

INTRACRANIAL HEMORRHAGE• SUBARACHNOID

• HEADACHE—SUDDEN, MAXIMAL, DIFFERENT FROM USUAL

• STROKE-LIKE SX OR SIGNS, MENINGISMUS (STIFF NECK)

• NON-TRAUMATIC: COMMONLY ANTERIOR COMMUNICATING ARTERY ANEURYSM RUPTURE

• TRAUMA

• SUBDURAL

• BRIDGING VEINS, ELDERLY, TRAUMA

• EPIDURAL

• TEMPORAL BONE TRAUMA, MIDDLE MENINGEAL ARTERY

• LUCID INTERVAL

• INTRAPARENCHYMAL

• TRAUMA, INVOLVES CORTEX

SAH

SDHEDH

CASE CONTINUED

• PATIENT IS OUTSIDE OF TPA TIME WINDOW

• >4.5 HOURS SINCE ONSET

• INTERVENTIONAL RADIOLOGY CONSIDERING INTERVENTION, PENDING MRI

• THROUGH ED COURSE

• PATIENT BECOMES LESS RESPONSIVE, MORE CONFUSED/AGITATED, ELEVATED CORE TEMP—102F

• INTERVAL DECLINE IN MENTAL STATUS MEANS MORE LIKELY EVOLVING PROCESS, SUCH AS EXPANSION OF PENUMBRA

(AREA OF BRAIN AFFECTED BY INFARCT), INFECTION, OR HEMORRHAGE (PATIENT HAD A NEGATIVE CT FOR HEMORRHAGE)

• INTUBATED FOR AIRWAY PROTECTION/ANTICIPATED COURSE

CASE CONTINUED– FINAL DX: MENINGITIS

• DEFINITIVE DX/TX AND HOSPITAL COURSE

• LUMBAR PUNCTURE—CSF TESTING: GRAM POSITIVE DIPLOCOCCI SUGGESTIVE OF PNEUMOCOCCUS

• MRI

• LEFT TEMPORAL MENINGITIS/ENCEPHALITIS W/ ASSOCIATED MIDDLE EAR INFECTION C/W CHOLESTEATOMA

• NO ACUTE INFARCT OR HEMORRHAGE

• S/P LEFT TYMPANOMASTOIDECTOMY, INFRATEMPORAL MIDDLE POSTAURICULAR CRANIAL FOSSA

CRANIOPLASTY

• EXTUBATED, DISCHARGED 12 DAYS LATER, NO RESIDUAL DEFICITS TO DATE

MANY PATHOLOGIES MIMIC STROKE • STROKE MIMICS—METABOLIC, INFECTIOUS, AUTOIMMUNE, VASCULAR, ONCOLOGIC, PSYCHIATRIC

• ICH, COMPLICATED MIGRAINE, HTN ENCEPHALOPATHY

• BLOOD SUGAR ABNORMALITIES, HYPOKALEMIA/HYPONATUREMIA

• LABRYNTHITIS/MENIERE’S (INNER EAR PROBLEMS), DEMYELINATING DISEASE, GUILLAIN-BARRE SYNDROME

• MENINGITIS/ENCEPHALITIS, BOTULISM, BELL’S PALSY

• TODD’S PARALYSIS/SEIZURE, WERNICKE’S ENCEPHALOPATHY

• CAROTID/VERTEBRAL/AORTIC DISSECTION, CAVERNOUS SINUS THROMBOSIS

• MASS/EDEMA, HYDROCEPHALUS, TRAUMA

• DRUG TOXICITY, CONVERSION DISORDER

PRE-HOSPITAL STROKE ALERT PEARLS• TIME LAST SEEN AT NORMAL---ASK PATIENT, ASK FAMILY, ASK AGAIN

• WAS IT A ‘WAKE-UP’ STROKE?

• WHAT IS BASELINE, PROGRESSION OF SX?

• GET YOUR ACCUCHECK BEFORE PAGING STROKE ALERT

• HX—DRUGS/INGESTIONS/MEDS? AMS STATIC OR DYNAMIC/HEADACHE/CHEST PAIN?

• LOW GRADE FEVER MAY BE PRESENT WITH STROKE BUT ALSO MAY FOREBODE INFECTIOUS PROCESS

• PATIENT MAY PRESENT AS SEEMINGLY ONLY CONFUSED OR APHASIC

• SEIZURES:

• CAN RESULT FROM STROKE

• CAN CAUSE STROKE-LIKE SYNDROME, NOT A REAL STROKE (TODD’S PARALYSIS)

• IN PATIENT’S WITH ELEVATED ICP, EKG CAN LOOK LIKE CARDIAC STRAIN

• CAN ALSO BE HAVING A CARDIAC EVENT

• AVOID HYPOTENSION AND HYPOXEMIA

EKG in patient with elevated ICP

PRE-HOSPITAL STROKE ALERT PEARLS• ACCUCHECK BEFORE PAGING STROKE ALERT,

• LISTEN TO YOUR PATIENT—ATTENTION TO SYMPTOMS/SIGNS/VITALS!

• USE PRE-HOSPITAL SHORTENED NIHSS TO ASSESS SEVERITY

• HAS BEEN FOUND TO BE ACCURATE AND USEFUL

• COMMUNICATE LAMS SCORE ON ARRIVAL TO ED

• MAY BE DYNAMIC, WILL HELP GUIDE HOSPITAL CARE

CONCLUSIONS• STROKE CAN HAVE MANY FORMS AND MANY MIMICS

• DIFFICULT TO DISCERN PRE-HOSPITAL

• HISTORY, PHYSICAL, VITALS ARE INTEGRAL

• LOW THRESHOLD FOR STROKE ALERT, EXPEDITE CARE FOR DEFINITIVE DX/TX

• MAY BE END UP BEING A DIFFERENT DX, BUT EQUALLY OR MORE LIFE THREATENING PATHOLOGY

• KNOWING UNDERLYING ANATOMY AND PEARLS AND PITFALLS CAN HELP WITH STROKE ASSESSMENT

• PRE-HOSPITAL ASSESSMENT AND CARE IS CRUCIAL TO ED AND INPATIENT MANAGEMENT

• STROKE ALERTS FROM THE FIELD EXPEDITE HOSPITAL CARE

• WHAT YOU DO MATTERS!

THANKS & REFERENCES• JOSEPH SABATO, M.D.

• ANDREW SCHMIDT, D.O.

• CLINICAL NEUROANATOMY MADE RIDICULOUSLY SIMPLE, 3RD ED

• ATLAS OF HUMAN ANATOMY 5TH ED

• TINTINALLI’S EMERGENCY MEDICINE MANUAL, 7TH ED

• EMERGENCY DEPARTMENT RESUSCITATION OF THE CRITICALLY ILL

• LIFE IN THE FAST LANE

• BOARD REVIEW SERIES-GROSS ANATOMY, 5TH ED

• GRAY’S ANATOMY FOR STUDENTS

• USMLE FIRST AID

• MDCALC

• CENTER FOR DISEASE CONTROL

• AMERICAN HEART ASSOCIATION