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Clinical Aspects of Stroke

Clinical Aspects of Stroke. Pierre Fayad, MD Reynolds Centennial Professor & Chairman, Department of Neurological Sciences University of Nebraska Medical Center, Omaha, NE. “Stroke”. APOPLEXY from Greek “Apo Plexe” meaning “a stroke”.

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Clinical Aspects of Stroke

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  1. Clinical Aspects of Stroke Pierre Fayad, MD Reynolds Centennial Professor & Chairman, Department of Neurological Sciences University of Nebraska Medical Center, Omaha, NE

  2. “Stroke” • APOPLEXY from Greek “Apo Plexe” meaning “a stroke”. • Anyone seized by sudden disability was thought to be “struck down” by the Gods. Haubrich WS. Medical Meanings: A Glossary of Word Origins. Publisher: American College of Physicians 2003

  3. Steps in Neurologic Evaluation Gather information • Chief complaint • Symptoms, evolution • Physical examination Analysis • Localization • Pattern of disease • Comparison to clinical database Gather information • Diagnostic tests Diagnosis & Treatment

  4. Steps in Stroke Evaluation Gather information • Chief complaint • Symptoms and history: risk factors, chronologic evolution • Physical examination: vascular and neurologic Analysis • Localization: CNS level, large vessel, branch, … • Pattern of disease: tempo, risk factors • Comparison to clinical datatbase Gather information • Diagnostic tests: location, size, type, mechanism Diagnosis & Treatment

  5. What Is A “STROKE”? • CLINICAL DEFINITIONof focal neurologic deficit, • of vascular etiology, lasting > 24 HOURS. • Diagnosis is dependent on neurologic deficit and • NOT imaging. • “Generic term for a clinical syndrome that includes • infarction, hemorrhage, and SAH.” NINDS Classification of CVD III. Stroke 1990, 20:627-680

  6. Types of Stroke • Ischemic Stroke • Brain damage from lack of blood flow • Occlusion of blood vessel • Thrombosis, embolism • Hemorrhagic stroke • Rupture of blood vessel • Brain damage from blood invasion

  7. Stroke Subtypes: Stroke Data Bank Stroke Data Bank, Foulkes et al, Stroke 1988;19:547

  8. Definition of Transient Ischemic Attack • Classic definition • A sudden, focal neurologic deficit lasting less than 24 hours, presumed to be of vascular origin, and confined to an area of the brain or eye perfused by a specific artery • Proposed definition • A brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of acute infarction Albers GW et al. N Engl J Med. 2002;347:1713-1716.

  9. Inclusion criteria: Objective:Outcome measures: Total events: TIA by ED physicians Short-term risk of strokeafter ED diagnosisRisk of stroke and otherevents during the 90 daysafter index TIA 25.1% Outcome events 12.7% 15 % 10.5% Within90 days 10 % 2.6% 2.6% 5.3% 5 % Within48 hr 0 % Stroke CV event Death Recurrent TIA Short-term Prognosis after Emergency Department Diagnosis of TIA Johnston SC, et al. JAMA 2000;284:2901-2906.

  10. US Stroke Facts 2003 • Incidence • 700,000 new or recurrent stroke yearly • One stroke every 45 seconds • Mortality • 168,000 Stroke-related death yearly (1 of 14 deaths) • Third leading cause of death after heart and cancer • One stroke-related death every 3 minutes • Of every 5 stroke deaths: 2 men, 3 women • Costs • $51 billion in 2003 for stroke related medical costs and disability American Stroke Association

  11. Stroke Risk Factors Modifiable Medical Conditions • Hypertension • Cardiac disease • Atrial fibrillation • Hyperlipidemia • Diabetes mellitus • Carotid stenosis • Prior TIA or stroke • Behaviors • Cigarette smoking • Heavy alcohol use • Physical inactivity Non-Modifiable Age, Gender, Race, Heredity

  12. Goals For Acute Stroke Care • Rapid triage and identification of stroke • Stroke type: Ischemic vs Hemorrhagic • Eligibility for “acute stroke therapy” • Determine size, location, & vascular territory • Establish plans for efficient Management & discharge • Stabilization & prevention of complications • Determine etiology & mechanism • Initiate secondary stroke prevention strategies • Initiate rehabilitation assessment and therapy

  13. Intracerebral Hemorrhage

  14. Hypertensive ICH: Post-Mortem

  15. Clinical Features Suggestive Of ICH • Severe headache • Depressed consciousness • Nausea and vomiting • Horizontal diplopia • Papilledema and pre-retinal hemorrhages.

  16. ICHSx

  17. CAUSES OF INTRACRANIAL HEMORRHAGE HTN 50% Amyloid angiopathy 12% Anticoagulants 10% Tumors 8% Prescription and street drugs 6% AVMs and aneurysms 5% Miscellaneous 9%

  18. Charcot-Bouchard Microaneurysms

  19. Intracranial Vascular Malformations

  20. ICH - General Management • Nutrition • DVT prophylaxis • Hydration and electrolytes • Acute arterial hypertension • Intracranial hypertension • Hydrocephalus • Seizure prophylaxis and treatment • Surgery and decompression AHA Special Writing Group, Stroke 1999;30:905-915

  21. Dose-Ranging Study: rFVIIa in Preventing Early Hematoma Growth in Acute ICH • Multicenter, international, Phase II study, 400 patients, CT < 3 hrs from Sx, Rx < 60 min CT. • Arms: Placebo, 40, 80, 160 mcg/kg • Significantly reduces • 45-62% RR Dose-dependent hematoma growth • 38% RR Mortality • Significantly improves • Global functional outcome (mRS and BI) at 90 days • Small increase in the risk of acute thromboembolic events Mayer SA et al. N Engl J Med. 2005;352:777-785.

  22. Subarachnoid Hemorrhage

  23. Subarachnoid Hemorrhage: Schematic

  24. Berry Aneurysm Rupture

  25. Location of Berry Aneurysms

  26. SAH Symptoms & Diagnosis

  27. IntracranialAneurysms Sx

  28. Aneurysm Coiling or Clipping Johnston SC, et al. Ann Neurol. 2000;48:11-19.

  29. SAH - Delayed Vasospasm • Facts • A leading cause of death and disability • Starts 3-5 d after SAH, and maximal at 3-14 d. • 20-30% delayed neurologic ischemic deficits. • Diagnosis • TCD, angiography. • Treatment • Nimodipine • Hypertensive, hypervolemic, hyperosmolar Rx (HHH) • Local IA papaverine -> transluminal angioplasty

  30. Ischemic Stroke

  31. Stroke Mimics • Metabolic • Hyper/hypoglycemia, Hyponatremia, Hypo/hyperthyroidism, Hepatic encephalopathy • Seizures • Subdural hematoma • Infections • Brain abscess, encephalitis, meningitis • Neoplasm • Drug overdose (also a cause of stroke). • Hypertensive encephalopathy • Psychogenic • Migraine

  32. Vascular Localization

  33. !!!Learn Neurology Stroke-By-Stroke!!!

  34. Brain Picture

  35. What The Brain Does

  36. Cortical Functional Localization

  37. Homunculus

  38. Localizing Stroke • Stroke affects three main areas of the brain • Left hemisphere • Right hemisphere • Brainstem/cerebellum • Neurologic deficits patterned in syndromes according to brain part affected and location

  39. Cerebral Circulation

  40. Cerebral Vascular Territories

  41. Left (Dominant) Cerebral Hemisphere Syndrome • Aphasia. • Left gaze preference. • Right visual field cut. • Right hemiparesis. • RIght hemisensory loss.

  42. Right (Non-dominant) Cerebral Hemispheric Syndrome • Neglect (left hemi-inattention) • Right gaze preference. • Left visual field deficit. • Left hemiparesis. • Left hemisensory loss.

  43. Location Artery Dominant Non-dominant Frontal Lobe ACA Contralat LE weakness Abulia Contralat LE weakness Abulia MCA: ant division Expressive aphasia Contralat hemiparesis Ipsilat gaze deviation Aprosodia Contralat hemiparesis Ipsilat gaze deviation Parietal lobe MCA: post division Conduction aphasia Gerstman’s synd, HH Contral hypoesthesia Anosognosia, Apraxia, Contralateral neglect, Hypoesthesia, HH Temporal lobe MCA: post division Receptive aphasia, Contralateral HH Contralateral Hemianopia Occipital lobe PCA Alexia without agraphia Contralateral HH Contralateral Hemianopia Syndromes of Carotid Branch Occlusions

  44. Brainstem Syndrome • Crossed signs. • Hemiparesis or quadraparesis. • Hemisensory loss or sensory loss in all four limbs. • Eye movement abnormalities. • Oropharyngeal weakness. • Decreased consciousness. • Hiccups or abnormal respirations.

  45. Cerebellar Syndrome • Gait or limb ataxia • Vertigo, tinnitus • Nausea, vomiting. • Decreased Consciousness.

  46. Acute Stroke Therapy

  47. Platelets in Acute Vascular Events Platelets Collagen Thrombus Plaque AtheroscleroticVessel PlaqueRupture PlateletAdhesion, Recruitment, Activation,andAggregation ThrombusFormation ThromboticOcclusion MI Stroke Acute Peripheral Arterial Occlusion

  48. Cerebral Ischemia: Basic Mechanisms • Perfusion failure • Energy failure • Loss of membrane function • Edema • Cell death

  49. Ischemic Cascade Brott T et al, NEJM 2000,343:710-721

  50. ISCHEMIC PENUMBRA

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