ACUTE BRAIN ATTACK - 911

RUBEN T. DELA CRUZ MD, FPNA

ACUTE STROKE UNIT- MANILA ADVENTIST MEDICAL CENTER

OBJECTIVES
STROKE IMPACT KNOW THE CLASSIFICATION OF STROKES HOW TO DIAGNOSE STROKES GUIDELINES FOR ACUTE STROKE TREATMENT

STROKE IMPACT
STROKE IS BRAIN ATTACK ! Sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathology. No. 2 Killer worldwide No. 1 Killer in Asia- Western Pacific, China, and Japan 20 million people every year with 5 million deaths Locally: 500 strokes per 100,000 population

CLINICAL STROKE CLASSIFICATION

TIA AND MILD STROKE MODERATE STROKE SEVERE STROKE

TIA and MILD STROKE

Transient Ischemic Attack- deficits resolved within 24 hours including transient blindness in one eye OR ALERT Patient with any of the ff: a. mild pure motor weakness of one side of the body. b. pure sensory deficit c. slurred speech but intelligible d. vertigo with incoordination e. visual field defects alone f. combination of a and b

MODERATE STROKE
Awake patient with significant motor and/or sensory and/or language and/or visual deficit OR Disoriented, drowsy, or stuporous patient but with purposeful response to painful stimuli

SEVERE STROKE
Comatose patient with nonpurposeful response, decorticate, OR Decerebrate posturing to painful stimuli or comatose patient with no response to painful stimuli

DIAGNOSING STROKE

1. Clinical (80%)
History, Physical & Neurological Exam
* Establish the time of onset of symptoms
Sudden, focal, Loss of function

2. Neuroimaging (20%)
* Cranial CT scan is the initial imaging study of choice

ROLE of DIAGNOSTIC EXAM

Confirm & establish the clinical diagnosis Rule out stroke mimickers Determine pathologic type Infarct, ICH, SAH Determine etiology & stroke mechanism Screen for medical & neurologic complications of stroke

COMMON STROKE MIMICKERS

Seizures Systemic infection Brain tumor Toxic-metabolic enceph Positional vertigo Syncope Trauma Subdural hematoma Herpes enceph Transient global amnesia Dementia Demyelinating dse Cervical spine fracture Myasthenia gravis Parkinsons dse Hypertensive enceph Conversion disorder Bells palsy

DIFFERENTIAL DIAGNOSIS OF STROKE

If any of the ff conditions is present, STROKE is probably UNLIKELY .
Pure hemifacial weakness (e.g. Bells palsy) Fever prior to onset of symptoms Trauma Recurrent seizures Weakness with atrophy Recurrent headaches
SSP Guidelines for the Prevention & Management of Brain Attack, 2003

With the advent of numerous diagnostic modalities, appropriate sequential diagnostic examinations are most important to confirm the clinical diagnosis of stroke.

First-line (emergent) diagnostic exam Second-line diagnostic investigations

EMERGENT DIAGNOSTIC EXAM

Plain Cranial CT

CBC, PT/ PTT, Blood sugar

Electrocardiogram

SSP Guidelines for the Prevention & Management of Brain Attack, 2003

SECOND-LINE DIAGNOSTIC STUDIES

(To Identify Etiology and Stroke Mechanism)

Neurovascular Studies
Carotid Duplex Transcranial Doppler studies(TCD) Catheter Angiography CT Angiography Magnetic Resonance Angiography (MRA)

Cardiac investigation
Echocardiography 24 hour Holter

SECOND-LINE DIAGNOSTIC STUDIES

(To Identify Etiology and Stroke Mechanism)

Hematologic Studies
Hypercoagulable states Protein C, S, Fibrinogen Antithrombin III

APAS - ANA, Anticardiolipin Ab, Lupus anticoagulant Homocysteine

Drug Levels e.g. Metamphetamine Biopsy e.g Vasculitis, Temporal arteritis Genetic Familial homocystinuria, MELAS, CADASIL

Neuroimaging in Acute Stroke

Plain Cranial CT is recommended

Hyperacute 3 hours

12 hours

48 hours

First-line modality imaging in suspected stroke cases Widely available, relatively inexpensive, non - invasive & quick Accurately differentiates hemorrhagic and ischemic strokes Should be performed & interpreted ASAP

RATIONALE FOR NEUROIMAGING

Identify the lesion (is it a stroke?) Determine the type of stroke (ischemic or hemorrhage?) Localize the stroke (where is it?) Quantify the lesion (how large is it?) Determine the age of the lesion

BASIC CONCEPTS Cranial computed (x-ray) tomography scan

Air, Fluid (e.g. CSF, infarction) = hypodense
Bone, calcification, blood = hyperdense

CT FINDINGS in HYPERACUTE INFARCTION (0 - 6 hrs)

Almost 60% of CT scans done in the first few hours of ischemic stroke: NORMAL

However, the following signs may be seen: Hyperdense artery (dense MCA sign) Obscuration of lentiform nuclei Loss of grey-white interphase along lateral insula (insular ribbon sign) Effacement of sulci

Dense Artery sign

Insular Ribbon sign (loss of insular stripe)

Early signs of infarction on Cranial CT

Obscuration of lentiform nuclei

Effacement of sulci

CRANIAL CT in ACUTE ISCHEMIC STROKE

Infarction: focal hypodense area in cortical,

subcortical, or deep gray or white matter, following a vascular territory, or watershed distribution

CT FINDINGS in SUBACUTE / CHRONIC INFARCTION

Wedge-shaped large cortical infarct

Round / ovoid small subcortical infarcts

CT FINDINGS in SUBACUTE / CHRONIC INFARCTION

Subacute R-ICA infarct

Subacute L-MCA infarct

CT FINDINGS in INTRACEREBRAL HEMORRHAGE

Hyperdense lesion in left lentiform nucleus with hypodense rim (vasogenic edema)

Common Sites of Hypertensive ICH

Common Sites of Hypertensive ICH

Cranial CT of Hemorrhagic Stroke

Stroke Society of the Philippines recommendations for computation of hematoma volume

Planimetric Method or Pixel Method Modified Kothari method (ABC/2)

Measurement of Hematoma Volume

Modified Kothari Method AxBxC / 2

Select the CT slice with the largest area of hemorrhage
A - greatest hemorrhage diameter B - diameter 90 degrees to A C - no of CT slices with hemorrhage x by the slice thickness*
A
Hemorrhage > 75% of the largest area = 1 slice Hemorrhage > 25 75% of the largest area = 0.5 slice Hemorrhage < 25% of the largest area - 0

Interpretation of Hematoma Volume for Supratentorial Hemorrhages

< 30cc small medical

30 50cc
> 50cc

moderate
large surgical

* Factor in age, neurologic status, concomitant medical conditions

CT SCAN FINDINGS in SUBARACHNOID HEMORRHAGE

DIAGNOSING STROKE:
Other Neuroimaging Techniques

Advantages of Cranial MRI

More sensitive in detecting small lesions / lacunar infarcts early infarction brainstem / post fossa lesions Can detect lesions as early as 6 hours from onset of stroke (as early as 90 mins. for Diffusion MRI)

Slow flow (absence of normal flow void) in involved artery

DWI: acute infarct appears bright

Early signs of infarction on MRI

T1
Parenchymal signal changes (hypointense on T1)

T2
Parenchymal signal changes (hyperintense on T2)

MAGNETIC RESONANCE IMAGING in BRAINSTEM INFARCTION

T1

T2 R Pontine Infarction

R medullary Infarction

DIAGNOSING STROKE:
Other Neuroimaging Techniques

Limitations of Cranial MRI

More expensive & less widely available Longer acquisition time compared to CT (difficult in uncooperative patients) Contraindicated in patients with metallic implants (e.g. pacemaker) Not sensitive in detecting acute hemorrhage

MRI is not sensitive in detecting HEMORRHAGE

ACUTE

Pontine Hemorrhage
Cranial MRI
Cranial CT scan

NEUROVASCULAR EVALUATION

Ultrasound Techniques

Catheter Angiography
CT Angiography MR Angiography

RATIONALE for NEUROVASCULAR EVALUATION

Identifying occlusive arterial disease

(Is there blockage ?)

Localizing the occlusion

(Where ?, carotid ?, intracranial ?)

Quantifying the degree of stenosis

(How severe ?)

Determining the pathology

(Athero ?, dissection ?, others ?)

Identifying other vascular lesions

Recommendations for Neurovascular Imaging in Patients with Stroke

A non-invasive screening technique is indicated as an initial diagnostic test Conventional radiographic angiography may be indicated based on findings of non-invasive screening procedures (i.e. severe stenosis, occlusion)

Cerebral arteriography may also be required when a diagnosis of vasculitis, dissection, vascular malformation needs confirmation or exclusion

VASCULAR ULTRASOUND NEUROSONOLOGY

Carotid/vertebral Duplex

Transcranial Doppler (TCD)

CAROTID DUPLEX

Established technique to identify extracranial carotid / vertebral artery disease Advantages: non-invasive, bedside availability, low cost

Disadvantages: operator dependent, unable to differentiate occlusion from near occlusion

TRANSCRANIAL DOPPLER

Established technique to evaluate basal intracranial arteries Established utility in stroke (e.g. stenosis, vasospasm, ICP, vasomotor reactivity) Advantages: non-invasive, bedside availability, low cost, allows serial monitoring, detects micro emboli Disadvantages: operator dependent, poor temporal window, circle of Willis variation

TCD APPLICATION in STROKE

Stenosis / occlusion Emboli detection Collateralization Vasospasm Increased ICP / Brain death Cerebral Autoregulation

MAGNETIC RESONANCE ANGIOGRAPHY

CT ANGIOGRAPHY

Other NonInvasive

Neurovascular Imaging
Procedures

CATHETER ANGIOGRAPHY Gold standard

Severe Carotid Stenosis

Vertebral Artery Stenosis

MCA Stenosis

CATHETER ANGIOGRAPHY

AV Malformation

Aneurysm

Cost, availability, invasive procedure Risks (vascular damage, stroke, ionizing radiation, reaction to contrast) Exclusion: poor renal function, absent femoral pulses, coagulopathy
Venous angioma

CARDIAC EVALUATION

Holter Monitoring

2 D Echocardiography

Recommendations for Echocardiography in Patients with Stroke Clinical evidence of heart disease Less than or equal 45 years of age Older patients, without evidence of extra or intracranial occlusive disease or other obvious cause Abrupt occlusion of major peripheral or visceral artery Suspect embolic disease (non-lacunar syndrome, multiple arterial territory involvement) Clinical therapeutic decision will depend on results of echocardiography

Transthoracic vs Transesophageal Echocardiography

TTE Preferred

TEE Preferred

LV thrombus LV dyskinesia Mitral stenosis Mitral annular calcification Mitral valve prolapse

Atrial thrombus Atrial appendage thrombus Atrial septal aneurysm Patent foramen ovale Aortic arch athero / dissection

Proper use of diagnostic examinations in stroke requires an understanding of:

Underlying disease process Principles of test involved Advantages & limitations of each procedure How each investigation influences patient management

SUMMARY
Rule out stroke mimickers History, PE & NE should be done immediately on patients with stroke Do emergent diagnostic tests to determine patients eligibility for rTPA

SUMMARY
CT scan remains to be the most important brain imaging test. Cranial MRI is not recommended for routine evaluation of acute stroke patients Differentiation of ischemic & hemorrhagic stroke is important because of marked difference in the management Second line diagnostic tests need not be done in the ER setting and should not delay treatment

GUIDELINES FOR TIA AND MILD STROKE

MANAGEMENT PRIORITIES Ascertain clinical diagnosis of stroke or TIA Exclude common stroke mimickers Monitor and manage blood pressure SBP = 220 or DBP= 120 MAP= 130 Avoid precipitous drop in BP> 20% of baseline MAP No rapid-acting sublingual agents Use oral or easily titratable IV antihypertensive Ensure appropriate hydration. No hypotonic IV fluids

GUIDELINES FOR TIA AND MILD STROKE

EMERGENT diagnostics
Complete Blood count (CBC) Blood sugar (CBG, HGT, or RBS) Electrocardiogram (ECG) PT/PTT (Atrial Fibrillation or possible cardioembolic source) Plain CT Scan Of brain as soon as possible

GUIDELINES FOR TIA AND MILD STROKE

EARLY SPECIFIC TREATMENT FOR THROMBOTIC OR LACUNAR STROKE (CTSCAN CONFIRMED) Aspirin 160-325 mg start as early as possible for 14 days Neuroprotection Early rehabilitation within 72 hours

GUIDELINES FOR TIA AND MILD STROKE EARLY SPECIFIC TREATMENT FOR CARDIOEMBOLIC (CTSCAN CONFIRMED) Anticoagulation with IV heparin or subcutaneous LMWH Or Aspirin 160-325 mg/day (If anticoagulation not available) Neuroprotection Early rehabilitation within 72 hours If infective endocarditis is suspected, give antibiotics and do not anticoagulate.

GUIDELINES FOR TIA AND MILD STROKE

EARLY SPECIFIC TREATMENT FOR HEMORRHAGIC If there is suspicion of nonhypertensive cause for ICH (e.g. AVM, aneurysm), REFER to neurosurgeon. Neuroprotection Early rehabilitation with in 72 hrs

GUIDELINES FOR TIA AND MILD STROKE EARLY SPECIFIC TREATMENT FOR T.I.A. Aspirin 160-325 mg/ day If crescendo T I A (multiple events within hours, Increasing severity and duration of deficits), consider ANTICOAGULATION with intravenous heparin

GUIDELINES FOR TIA AND MILD STROKE CT SCAN NOT AVAILABLE No specific emergent drug treatment recommended Neuroprotection Consult a neurologist or neurosurgeon Early supportive rehabilitation

GUIDELINES FOR TIA AND MILD STROKE PLACE OF TREATMENT Admit to Hospital (Stroke Unit) 1. Stroke onset within 48 hours 2. Patients requiring specific active intervention for any of the following: a. BP control, monitoring, and stabilization b. Cardiac stabilization, incl. Atrial fibrillation, CHF, acute MI c. Hydration d. Anticoagulation, if ICH ruled out by CT

GUIDELINES FOR TIA AND MILD STROKE

PLACE OF TREATMENT

Admit to Hospital (Stroke Unit)

3. Rapidly worsening deficits 4. >4 TIAs in 2 weeks prior to consult 5. 1-4 TIAs in 2 weeks but high risk (multiple events within hours, increasing severity and duration of deficits

GUIDELINES FOR TIA AND MILD STROKE PLACE OF TREATMENT URGENT OUTPATIENT WORK-UP 1. Single TIA more than 2 weeks ago 2. 1-4 TIAs in 2 weeks, but not high risk (no change in severity and duration of deficit, cardiac arrhythmia, carotid bruit) 3. Transient monocular blindness alone 4. Stable mild strokes occurring > 48 hrs not requiring specific active intervention *Advise immediate re-consult if there is worsening of deficit.

GUIDELINES FOR MODERATE STROKE MANAGEMENT PRIORITIES 1. Basic emergent supportive care (ABC of resuscitation) 2. Monitor and manage blood pressure. Treat if SBP>220; DBP>120; MAP= >130 Precautions: Avoid precipitous drop in BP >20% MAP No Sublingual agents 3. Exclude stroke mimickers 4. Identify co-morbidities (cardiac dis. Gastric ulcer, etc) 5. Recognize and treat early signs of increased ICP

GUIDELINES FOR MODERATE STROKE EMERGENT DIAGNOSTICS Complete Blood Count Blood sugar (CBG, HGT, RBS) PT/PTT Serum Na and K+ Electrocardiogram (ECG) Plain CT Scan of brain ASAP

GUIDELINES FOR MODERATE STROKE EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED) Ischemic- Noncardioembolic (Thrombotic/ Lacunar) - If within 3 hours of stroke onset, consider rtPA treatment and refer to specialist - Aspirin 160-325 mg/day start as early as possible - Neuroprotection - Early supportive rehabilitation

GUIDELINES FOR MODERATE STROKE

EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)

CARDIOEMBOLIC - If within 3 hours of stroke onset consider rtPA ` treatment and refer to specialist - Aspirin 150- 325 mg/day start as early as pos. - Early anticoagulation if source of embolism can be demonstrated - Neuroprotection - Early supportive rehabilitation * If infective endocarditis is suspected, give antibiotics and DO NOT anticoagulate

GUIDELINES FOR MODERATE STROKE

EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED) HEMORRHAGIC - Supportive treatment: 1. Mannitol 20% 0.5 mg/kg BW q 6 h for 2- 5 days 2. Neuroprotection - Neurosurgery consult for hematomas distorting or displacing 4th ventricle - Within 12-24 h, recommended surgery for hematoma: 1. size 10-30 cc (non-dominant subcortical frontal/temporal) 2. size >30 cc (subcortical, putaminal, cerebellar) - Early supportive rehabilitation

GUIDELINES FOR MODERATE STROKE CT SCAN NOT AVAILABLE = USE SCORING SYSTEM Likely Ischemic
No specific emergent drug Tx. Neuroprotection Refer to Specialist Early Supportive Rehabilitation

Likely Hemorrhagic
Refer to Neurologist/ Neurosurgeon further Dx workups and/or subsequent surgery Neuroprotection Early supportive rehabilitation

GUIDELINES FOR SEVERE STROKE

Management Priorities Basic Emergent supportive care (ABC of Resus.) Neurovital signs: BP; PR, CR, RR, Temp, Pupils. Glasgow Coma scale, Recognize and Treat early signs of increased ICP Monitor and manage blood pressure. Treat if SBP is 220 or DBP of 120 or MAP of 130. Precautions: *Avoid precipitous drop in BP >20% of MAP *Do not use sublingual agents Ascertain clinical Dx; exclude stroke mimickers Identify co-morbidities (cardiac dis. Gastric ulcer, etc)

GUIDELINES FOR SEVERE STROKE

EMERGENT DIAGNOSTICS: Complete blood count, Blood Sugar, PT/PTT, Serum Na, K Electrocardiogram, Plain CTscan of the brain

GUIDELINES FOR SEVERE STROKE

EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED) Non-cardioembolic (Thrombotic/Lacunar) - May give aspirin 160-325mg/day - Neuroprotection - If cerebellar infarct, consult neurosurgeon ASAP - Early supportive rehabilitation Place of Treatment: Hospital, Intensive Care Unit or Acute Stroke Unit

GUIDELINES FOR SEVERE STROKE

EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED) HEMORRHAGIC - Supportive Treatment: 1. Mannitol 20% 0.5 mg/kg q 6h for 2-5 days 2. Neuroprotection - Neurosurgery consult if: 1. Patient not herniated, hematoma in putamen, subcortical, cerebellum and goal is to reduce mortality 2. Herniated patient but family is willing 3. ICP monitoring contemplated and salvage surgery is considered Place of Tx.: Intensive Care Unit

BRING HOME MESSAGE

STROKE IS BRAIN ATTACK! STROKE IS AN EMERGENCY! STROKE IS TREATABLE! STROKE IS PREVENTABLE!

CIFIC TREATMENT