Stroke: Understanding and Overcoming Cerebral Vascular Injuries

1. Stroke: Understanding and Overcoming Cerebral Vascular Injuries Sheital Bavishi, DO Assistant Professor University of Cincinnati Department of Physical Medicine and Rehabilitation Director Brain Injury Program University of Cincinnati

2. Stroke: A Public Health Problem • Affects more than 700,000 people in the US annually • Third leading cause of death • One of the most common causes of long-term disability, certainly one of the most serious and life-changing

3. Stroke Subtypes SAH, 5% ICH, 10% Ischemic, 85%

4. Definition • 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

5. Risk Factors • Non-modifiable: • Age, Race, Gender, Family history • Modifiable/Treatable: • Hypertension --obesity • Diabetes --alcohol/drug consumption • TIA’s/previous strokes --oral contraceptives • Cardiac disease (?PFO) --migraine headaches • Atrial fibrillation --cigarette smoking • Hypercholesterolemia --autoimmune/inflammatory disease • Hypercoagulable states --homocysteine

6. Blood supply of the brain • Carotid arteries • Internal: brain • External: face“anterior circulation” • Vertebral arteries “posterior circulation”

7. Imaging blood vessels • Contrast dye injected in blood stream makes vessels show up Catheter angiography CT angiography MR angiography

8. Types of Stroke

9. Angio - what it shows blockage Aneurysm AVM Stroke Artery stenosis Tumor

10. Treatment • Limiting cellular injury • Reperfusion • Preventing Systemic Complications • Preventing Neurologic Complications • Rehabilitation

11. Limiting Cellular Injury:Vital Signs • Maintain cerebral perfusion– auto-regulation/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)

12. Conditions treated with endovascular techniques Onyx glue • Acute stroke • Clot dissolve (tPA) • Clot retrieval • Aneurysm • Coil • Glue • Artery stenosis • Angioplasty & stent • AVMs and tumors • Glue (embolization)

13. Stroke treatments Clot retrieval • Device grabs and pulls clot out • Suction catheter aspirates clot Clot-buster (tPA) • Drug dissolves clot • Give within 4.5 hours

14. Treatment for Ischemic Stroke: t-PA 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

15. IV t-PA • 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

16. blockage t-PA restores blood flow

18. Aneurysm gluing: Onyx Inflate balloon and inject for 2 minutes, let Onyx solidify for 3 minutes then re-perfuse

19. Cerebral artery bypass bypass Bypass reroutes an artery from outside of skull into a brain artery to protect blood supply to brain before clipping the aneurysm

20. Artery Stenosis

21. Carotid artery stenosis • Medications • Blood thinner • Cholesterol reduction • Blood pressure control • Endarterectomy • Surgery removes plaque • Angioplasty & stenting • Balloon compresses plaque and stent holds artery open

22. Intracranial artery stenosis • Angioplasty & stenting • Restores vessel diameter • Reduces clot risk

23. Ischemic Stroke

24. Intracerebral Hemorrhage (ICH)

25. Subarachnoid Hemorrhage (SAH)

26. Arteriovenous malformation (AVM) Dilated arteries and veins with no capillary bed

27. Embolization prior to surgery 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

28. Secondary Prevention—all stroke patients • 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

29. Systemic Complications • Aspiration (feeding tube, intubation) • DVT (subQ Heparin) • Infection (leading cause of late death) • Skin Breakdown

30. Neurologic Complications • 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)

31. Neurologic Complications (cont) • 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

32. Rehabilitation • 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

33. Rehabilitation Spasticity Management Neurogenic bowel and bladder Constraint-Induced therapy Body-weight supported treadmill training Splints and bracing Pain Syndromes Psychosocial Considerations

34. Levels of Rehabilitation Acute hospital therapies Acute Inpatient rehabilitation Short-term skilled rehabilitation Transitional Rehabilitation programs Day Rehabilitation programs Outpatient therapy Home Health therapy

35. Stroke Recovery Center At Drake 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.

36. Stroke Recovery Center At Drake -- START 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

37. Stroke Recovery Center At Drake -- START The therapeutic plan may be developed around: out patient rehabilitation services, research programs, or a combination of both

38. Stroke Recovery Center At Drake -- START The Stroke Recovery Center was only one of five programs of this type identified in the United States (as of July 2008)

39. Mission To provide collaborative care that improves the function and quality of life of people with strokes while scientifically advancing the field of stroke recovery.

40. Vision To be the premier destination for the most innovative, aggressive and comprehensive treatment for people with stroke.

41. Medical Directors Dr. Brett Kissela Professor Co-Director, Neurology Residency Program Vice-Chair of Education and Clinical Services Department of Neurology University of Cincinnati Dr. Mark Goddard Associate Professor Chairman, Department of Physical Medicine and Rehabilitation University of Cincinnati Rehabilitation Medical Director – Drake Center

42. Questions?