Transcript Acute Stroke Evaluation

Acute Stroke Evaluation
Gabriel A. Vidal, MD
Vascular Neurology
Ochsner Medical Center
October 14th, 2009
Objectives
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Review the history of stroke
Discuss importance of evaluation of strokes emergently
Summarize important historical data about strokes
Briefly present the acute treatment options
Describe acute stroke and TIA measuring scales
Identify a basic group of tests that should be done
urgently for the evaluation of acute strokes
Compare acute stroke to stroke mimics
History of Stroke
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Hippocrates (460 to 370 BC) was first to describe the phenomenon
of sudden paralysis that is associated with ischemia
– Apoplexy, from the Greek word meaning "struck down with violence”,
first appeared in Hippocratic writings to describe this phenomenon2,3
In 1658, in his Apoplexia, Johann Jacob Wepfer (1620–1695)
identified hemorrhagic stroke
– Identified the main arteries supplying the brain
– Identified the cause of ischemic stroke when he suggested
that apoplexy might be caused by a blockage to those vessels.1
Epidemiology
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Second leading cause of death in the Western world
– After heart disease and before cancer4
– Causes 10% of deaths worldwide5
– Disability affects 75% of stroke survivors enough to decrease
their employability6
– 30 to 50% of stroke survivors suffer post stroke depression7
Prior to 1995 there were no acute therapies for acute
stroke
Important Medical History
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History of the Present Illness
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Time of symptom onset
Evolution of symptoms
Convulsion or loss of consciousness at onset
Headache
Chest pain at onset
Medical History
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Prior intracerebral hemorrhage
Recent stroke
Recent head trauma or loss of consciousness
Recent myocardial infarction
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Surgical History
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Review of Systems
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Medications
– Recent surgical procedures
– Arterial puncture
– Gastrointestinal or genitourinary bleeding
– Anticoagulant therapy
Time of Symptom Onset
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Patient last seen acting normal
– Patient may have mild symptoms at onset
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Difficult onset
– Patient woke up with symptoms
 LKN: when he went to bed (if seen by someone)
= Specially if aphasic
– Patient seen well while resting
 LKN: before he went to rest (if seen by someone)
Why is TIME so IMPORTANT?
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Time directed therapeutics
– Improved outcomes
– Reduced complications
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What if the patient goes back to normal while in the ER
and symptoms re-start?
– Clock re-starts
Identifying Stroke Syndromes
Acute Therapies
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IV t-PA
– (1995) NINDS t-PA trial
 IV t-PA given within 3 hours of onset of symptoms
 30% relative risk reduction of disability at 3 months
 6% symptomatic hemorrhagic complication
– (2008) ECASS-III
 IV t-PA given within 4.5 hours of onset of symptoms
 Significantly better outcomes with IV t-PA vs placebo without more
complications
 Selected patients
– (2009) Analysis of ECASS-III
 Benefit per 100 patients treated was 16.3 and harm per 100 was 2.7
Other Therapies
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IA t-PA
– Can be used up to 6 hours
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Mechanical thrombectomy
– MERCI & PENUMBRA
– May be used up to 8 hours for MCA strokes & up to 12 hours for
basilar artery strokes
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Combination (IV t-PA w other therapies)
– Promising results
– In clinical trials (IMS III)
NIH Stroke Scale
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Systematic assessment tool that provides a quantitative
measure of stroke-related neurologic deficit
Originally designed as a research tool to measure
baseline data on patients in acute stroke clinical trials
Widely used as a clinical assessment tool to evaluate
acuity of stroke patients, determine appropriate
treatment, and predict patient outcome
Valid for predicting lesion size and can serve as a
measure of stroke severity
15-item neurologic examination stroke scale used to
evaluate the effect of acute cerebral infarction
NIH Stroke Scale
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1a. Level of Consciousness (0-3)
1b. LOC Questions (0-2)
1c. LOC Commands (0-2)
2. Best Gaze (0-2)
3. Visual (0-3)
4. Facial Palsy (0-3)
5 & 6. Motor Arm and Leg (0-4)
7. Limb Ataxia (0-2)
8. Sensory (0-2)
9. Best Language (0-3)
10. Dysarthria (0-2)
11. Extinction and Inattention (formerly Neglect) (0-2)
Other Scoring Scales
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Cincinnati Stroke Scale
Los Angeles Prehospital Stroke Screen (LAPSS)
ABCD2 Score
– Predicts risk of stroke in patients with TIA
ABCD 2 Score
Basic Stroke Labs
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CBC w diff
– Platelet count may affect therapy
CMP
– Blood sugar  stroke mimics
– Renal function  contrast, BP management
– Liver function  statins, coagulation profile
Coagulation times
– PT, PTT, INR  coagulopathies, anticoagulation therapy,
contraindications of certain therapies based on INR values
Imaging
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CT head
– Ischemic vs hemorrhagic
CT Angiogram
– Head and neck
MRI brain
MR Angiogram
– Head and neck
Conventional angiography
Stroke Mimics
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Post-ictal deficits (Todd paralysis)
Hypoglycemia
Migraine (hemiplegic, with aura)
Hypertensive encephalopathy
Reactivation of prior deficits
Mass lesions
Subarachnoid hemorrhage
Peripheral vestibulopathy
Conversion reaction
Non-convulsive status epilepticus (basilar stroke)
Metabolic encephalopathies
References
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National Institute of Neurological Disorders and Stroke (NINDS) (1999).
"Stroke: Hope Through Research". National Institutes of Health.
Thompson JE (01 Aug 1996). "The evolution of surgery for the treatment
and prevention of stroke. The Willis Lecture". Stroke 27 (8): 1427–34.
Kopito, Jeff (September 2001). "A Stroke in Time
Donnan GA, Fisher M, Macleod M, Davis SM (May 2008).
"Stroke". Lancet 371 (9624): 1612–23.
The World health report 2004. Annex Table 2: Deaths by cause, sex and
mortality stratum in WHO regions, estimates for 2002. Geneva: World
Health Organization. 2004.
Coffey C. Edward, Cummings Jeffrey L, Starkstein Sergio, Robinson
Robert (2000). Stroke - the American Psychiatric Press Textbook of
Geriatric Neuropsychiatry (Second ed.). Washington DC: American
Psychiatric Press. pp. 601–617.
Senelick Richard C., Rossi, Peter W., Dougherty, Karla (1994). Living with
Stroke: A Guide for Families. Contemporary Books, Chicago.