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Acute Stroke Evaluation

Acute Stroke Evaluation. Gabriel A. Vidal, MD Vascular Neurology Ochsner Medical Center October 14 th , 2009. Objectives. Review the history of stroke Discuss importance of evaluation of strokes emergently Summarize important historical data about strokes

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Acute Stroke Evaluation

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  1. Acute Stroke Evaluation Gabriel A. Vidal, MD Vascular Neurology Ochsner Medical Center October 14th, 2009

  2. Objectives • 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

  3. History of Stroke • 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

  4. Epidemiology • 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

  5. Important Medical History • History of the Present Illness • Time of symptom onset • Evolution of symptoms • Convulsion or loss of consciousness at onset • Headache • Chest pain at onset • Medical History • Prior intracerebral hemorrhage • Recent stroke • Recent head trauma or loss of consciousness • Recent myocardial infarction • Surgical History • Recent surgical procedures • Arterial puncture • Review of Systems • Gastrointestinal or genitourinary bleeding • Medications • Anticoagulant therapy

  6. Time of Symptom Onset • Patient last seen acting normal • Patient may have mild symptoms at onset • 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)

  7. Why is TIME so IMPORTANT? • Time directed therapeutics • Improved outcomes • Reduced complications • What if the patient goes back to normal while in the ER and symptoms re-start? • Clock re-starts

  8. Identifying Stroke Syndromes

  9. Acute Therapies • 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

  10. Other Therapies • IA t-PA • Can be used up to 6 hours • Mechanical thrombectomy • MERCI & PENUMBRA • May be used up to 8 hours for MCA strokes & up to 12 hours for basilar artery strokes • Combination (IV t-PA w other therapies) • Promising results • In clinical trials (IMS III)

  11. NIH Stroke Scale • 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

  12. NIH Stroke Scale • 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)

  13. Other Scoring Scales • Cincinnati Stroke Scale • Los Angeles Prehospital Stroke Screen (LAPSS) • ABCD2 Score • Predicts risk of stroke in patients with TIA

  14. ABCD 2 Score

  15. Basic Stroke Labs • 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

  16. Imaging • CT head • Ischemic vs hemorrhagic • CT Angiogram • Head and neck • MRI brain • MR Angiogram • Head and neck • Conventional angiography

  17. Stroke Mimics • 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

  18. References • 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". Stroke27 (8): 1427–34. • Kopito, Jeff (September 2001). "A Stroke in Time • Donnan GA, Fisher M, Macleod M, Davis SM (May 2008). "Stroke". Lancet371 (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.

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