Transcript Document

Sheital Bavishi, DO
Assistant Professor University of Cincinnati
Department of Physical Medicine and Rehabilitation
Director Brain Injury Program
University of Cincinnati
UC Neuroscience Institute
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• Affects more than 700,000 people in the US
annually
• Third leading cause of death
• One of the most common causes of longterm disability, certainly one of the most
serious and life-changing
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SAH, 5%
ICH, 10%
Ischemic, 85%
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• Stroke: focal neurologic deficit caused by
cerebrovascular event lasting at least 24 hours;
usually of sudden onset
– ischemia: 80% (thrombosis, embolism,
hypotension)
– hemorrhage: 20% (subarachnoid,
intracerebral)
• TIA (transient ischemic attack): same as above,
caused by transient ischemia and resolving
completely within 24 hours
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• Non-modifiable:
• Age, Race, Gender, Family history
• Modifiable/Treatable:
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Hypertension
Diabetes
TIA’s/previous strokes
Cardiac disease (?PFO)
Atrial fibrillation
Hypercholesterolemia
Hypercoagulable states
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--obesity
--alcohol/drug consumption
--oral contraceptives
--migraine headaches
--cigarette smoking
--autoimmune/inflammatory disease
--homocysteine
• Carotid arteries
– Internal: brain
– External: face
“anterior
circulation”
• Vertebral arteries
“posterior
circulation”
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• Catheter
angiography
• CT angiography
• MR angiography
Contrast dye injected in blood
stream makes vessels show up
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blockage
Aneurysm
AVM
Artery stenosis
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Stroke
Tumor
• Limiting cellular injury
• Reperfusion
• Preventing Systemic Complications
• Preventing Neurologic Complications
• Rehabilitation
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• Maintain cerebral perfusion– autoregulation/adequate blood pressure (BP)
• Maintain cerebral oxygenation --(allow increased
oxygen extraction as compensatory mechanism for
altered perfusion)
• Maintain normothermia -- (increased temp =
increased oxygen metabolism/demand)
• Maintain euglycemia -- (hyperglycemia exacerbates
ischemic damage)
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• Acute stroke
– Clot dissolve (tPA)
– Clot retrieval
• Aneurysm
– Coil
– Glue
• Artery stenosis
– Angioplasty & stent
• AVMs and tumors
– Glue (embolization)
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Onyx glue
Clot-buster (tPA)
• Drug dissolves clot
• Give within 4.5 hours
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Clot retrieval
• Device grabs and
pulls clot out
• Suction catheter
aspirates clot
• A clot-busting drug
called t-PA (tissue
plasminogen
activator) given
within 3 hours
after stroke onset
• New data suggest
time window out
to 4 ½ hours
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• BOTTOM LINE: Appropriate patients
without contraindications should be
treated at 0-3 hours, as per the NINDS
study protocol.
• TIME IS BRAIN: the sooner
treatment is started, the greater
the odds ratio of favorable
outcome
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blockage
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t-PA restores
blood flow
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Inflate balloon and
inject for 2 minutes,
let Onyx solidify for
3 minutes
then re-perfuse
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• Bypass reroutes an artery from outside
of skull into a brain artery to protect
blood supply to brain before clipping the
bypass
aneurysm
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 Medications
– Blood thinner
– Cholesterol reduction
– Blood pressure
control
 Endarterectomy
– Surgery removes
plaque
 Angioplasty &
stenting
– Balloon compresses
plaque and stent
holds artery open
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• Angioplasty & stenting
– Restores vessel
diameter
– Reduces clot risk
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Dilated arteries and veins with no
capillary bed
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• Goal is to reduce
size of nidus and to
occlude arterial
feeders difficult to
access surgically
• Surgical dissection
and control of fragile
deep feeding
arteries significantly
improved
• Embolization alone
will not cure
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• Prevent medical and neurological
complications
• Risk factor modification
– Especially treatments for hypertension, diabetes,
high cholesterol and smoking cessation
• Appropriate medical or surgical therapy
– must know mechanism of stroke
– Echo to look for cardiac source
– Imaging to look for carotid source
– Otherwise, staged anti-platelet therapy
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• Aspiration (feeding tube, intubation)
• DVT (subQ Heparin)
• Infection (leading cause of late
death)
• Skin Breakdown
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• Increased intracranial pressure
– hemorrhagic transformation
– cytotoxic edema
• Edema maximal at 36-72 hours, usually
manifests as decline in level of
consciousness
• Herniation is leading cause of death in
acute setting
(fatal arrhythmia is second)
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• Seizures
– Approximately 4% of patients
– recur in 20-80% cases
– treat with anticonvulsants
• Depression
– As high as 75% incidence after stroke
– TREAT IT!!
– New study suggests that early SSRI might
improve outcome even if depression not yet
present
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• Benefit is well established
• Mechanism by which this facilitates
recovery is unclear
• Begin Occupational Therapy, Physical
Therapy, Speech Therapy immediately
• Recovery maximal in first weeks, months;
can continue
--DON’T GIVE UP!
--Recovery is the next great frontier for stroke and
brain injury
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Spasticity Management
Neurogenic bowel and bladder
Constraint-Induced therapy
Body-weight supported treadmill
training
• Splints and bracing
• Pain Syndromes
• Psychosocial Considerations
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Acute hospital therapies
Acute Inpatient rehabilitation
Short-term skilled rehabilitation
Transitional Rehabilitation programs
Day Rehabilitation programs
Outpatient therapy
Home Health therapy
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The Stroke Recovery Center at Drake is a
multi-disciplinary evaluation and
treatment program for those individuals
with physical and cognitive deficits from
a previous CVA, designed to maximize
independence and function.
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• Stroke Recovery Center:
– refers now to the full spectrum of services-from acute rehab on
• START
– Stroke Team Assessment and Recovery
Treatment (START) Program
– The START program is the outpatient
multidisciplinary team evaluation
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The therapeutic plan may be
developed around:
• out patient rehabilitation services,
• research programs, or
• a combination of both
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The Stroke Recovery Center was
only one of five programs of this
type identified in the United
States
(as of July 2008)
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To provide collaborative care that
improves the function and quality
of life of people with strokes while
scientifically advancing the field of
stroke recovery.
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To be the premier destination for
the most innovative, aggressive
and comprehensive treatment for
people with stroke.
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Dr. Brett Kissela
Dr. Mark Goddard
Professor
Co-Director, Neurology
Residency Program
Vice-Chair of Education
and Clinical Services
Department of
Neurology
University of Cincinnati
Associate Professor
Chairman, Department of
Physical Medicine and
Rehabilitation
University of Cincinnati
Rehabilitation Medical
Director – Drake Center
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Questions?
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