Assessment of Hemorrhagic VS Ischemic Stroke As told by JJ Baumann MS, RN, CNS Cerebral Vessel Vignettes Couple of Clots • 70 year old female • Smoker • Mopping the floor and started feeling dizzy and tired • Witnessed sudden onset of aphasia, right sided weakness 12: 15 - last seen normal 12:40 - stroke code activated – pre hospital EMS states right side weakness 12:45 - Handsome paramedic arrives with patient who only has a right facial droop Time to relax? A. Don’t cancel stroke code. Let’s give tPA. B. Cancel stroke code, but still get imaging. C. Scold EMS for not knowing facial droop from complete weakness. D. Get EMS call back number, the charge nurse also thinks he is hot. CODE STEMI Déjà vu Cardiac cath lab – heart fixed. On the table, she suddenly stops talking and has right sided weakness. Stenting the Left ICA 48 Hours Later Her requests: 1. Thank paramedic that brought her to the hospital so quickly 2. Let her go home now My request: 1. Stop smoking! What is this? 200,000 cigarette packs, the same number of Americans who die every six months due to smoking. Smoking Under Pressure 62 year old male PMHx: Diabetes Hypertension Renal issues? Medications: 2 blood pressure medications 1 oral antiglycemic aspirin Intracranial Hemorrhage 9 am: sudden headache and left sided weakness Now what? A. B. C. D. Get frequent neuro exams? Have neurosurgery fix it? Stop the bleeding? Find the cause? Primary Hemorrhage • Amyloid – Lobar • HTN - Thalamus Basal Ganglia Pontine Cerebellum Secondary Hemorrhage • • • • • Coagulopathies Tumor AVM / aneurysm Illicit drug use Excess EtOH Getting sleepy… Frequent neuro checks Patient becoming more sleepy Head of bed > 30 degrees Done Blood pressure Titrating nicardipine gtt to keep SBP < 160 Fever control No fever Sedation Patient calm Surgical or medical? Deep territory, medical management CT scan • Bleed is stable • More swelling • Ventricles – no change Hyperosmolar Therapy Mannitol 3% NaCl 280-300 mOsm/kg Isotonic 0.45% Na D5W 300 to 320 mOsm/kg hypertonic hypotonic DO IT FOR THE BRAIN ! • • • • • • • Neuro exam Blood pressure control Head of bed Hyperosmolar therapy Sedation Fever control Prepare for EVD placement Stroke Code on ortho • • • • 72 yo male Hip fx POD 2 Sudden onset left facial droop & slurred speech Increased risk of MI/ PE 1 week after surgery and stroke 1-2 weeks after surgery. Patient is at increased risk of stroke after surgery if: They have had a stroke. They have atrial fibrillation. Risky Business? • • • • Hypertension Diabetes – type 2 Overweight There was something else, but…. Exacerbation of Old Symptoms • Metabolic – Electrolytes – Medications – Hypercarbia • Infectious – WBC – Fever Exacerbation of stroke symptoms by infection and metabolic perturbations – A diffusion-weighted MRI study S. Iyadurai, K. Knievel, M. Flaster (St. Louis, Phoenix, Las Vegas, US) If a Tree Falls in the Forest… 87 year old female EMS: Trauma! AMS following a non-witnessed fall at about 7 pm Family: Patient got up to get ready for bed. There was a loud thud in the bedroom, and she was found "down" by her vanity table gripping tightly unto her walker and chair and "shaking." Trauma Team: She sustained multiple lacerations, the worst of which is on her R forearm. Medications • diltiazem (CARDIZEM CD) 120 mg sustained release capsule • losartan (COZAAR) 25 mg tab • furosemide (LASIX) 20 mg tab • pantoprazole (PROTONIX) 40 mg delayed release tablet • acetaminophen (TYLENOL) 325 mg tab • Multi vitamin • Paroxysmal AF • CVA with residual R visual field neglect • High blood pressure • Congestive heart failure • Dementia Seeing the Trees for the Forest • Not clear if fall was mechanical • Fall not witnessed Pre-syncope? Seizure? TIA? X-rays, labs, spot EKG, MRI… Multiple acute infarctions posterior circulations . Posterior circulation – Vertebral and Basilar • Cranial nerve deficits – – – – – – • • • • • 3rd nerve palsy Nystagmus Vertigo Dysphagia Dysarthria Diplopia Cortical blindness / visual field loss Truncal or limb ataxia Spastic paresis Quadriplegia Weakness of facial, lingual, and pharyngeal muscles Now what? Acute treatment? - tPA - NIR Prevention? - ASA - Plavix / Aggrenox - Coumadin / Pradaxa CHADS2 Score in Atrial Fibrillation CHAD2 item Points Congestive heart failure 1 Hypertension (systolic >140 mmHg) 1 Age greater than 75 years 1 Diabetes 1 Prior cerebral ischemia / TIA 2 Annual Stroke Risk CHADS2 Score 0 1 2 3 4 5 6 Yearly risk of stroke 1.9% 2.8% 4.0% 5.9% 8.5% 12.5% 18.2% BF Gage et al. Validation of clinical classification schemes for predicting stroke. Results from the national registry of atrial fibrillation. JAMA 2001 285: 2864-2870. Balancing Act Two GI Bleeds requiring hospitalization in past 3 months CHADS Score is 5, 12.5% chance per year will have a stroke Grandma 82 year-old woman who lives with her daughter’s family. She needs help with groceries and preparing meals, but she is otherwise independent and enjoys life. Grandkids love her. Treat? 1:45 pm Unable to talk, right hemi (NIH – 22) 2:30 pm EMS arrives Stroke Code Number of patients who benefit (and are harmed) per 100 patients treated with tPA Grandma Lansberg et al. Stroke 2009 4:13 pm: tPA complete! Why has she not improved? Cath lab? Completed her stroke? tPA did not work? Neuro Interventional Radiology -Intra-arterial t-PA -Mechanical devices -Merci -Penumbra -Solitaire NIHSS 5-9 10-14 Chance large vessel occl 34% 42% >15 100% NIH > 12 95% chance large vessel occlusion Completed the Stroke? The Ischemic Penumbra Core Infarct Ischemic Penumbra: zone of salvageable tissue surrounding core infarct 4:15 pm: Start Stroke MRI with DWI and PWI … but a large PWI lesion A small DWI lesion Mean MTT 8 Mean XE-CT CBF 15 Mean Tmax 4s 4:46 pm: Case start 5:38 pm: The vessel is open Before Therapy After Therapy Courtesy of Maarten Lansberg, MD Home is Where the Brain Is! Walks home with family. Without treatment would likely have been severely disabled waiting for nursing home placement. Courtesy of Maarten Lansberg, MD Questions?