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2013 Seventh Annual NKY TBIConference
3/22/13
1
UC Neuroscience Institute UC Neuroscience Institute
Sheital Bavishi, DOAssistant Professor University of Cincinnati
Department of Physical Medicine and RehabilitationDirector Brain Injury Program
University of Cincinnati
UC Neuroscience Institute
• Affects more than 700,000 people in the USannually
• Third leading cause of death
• One of the most common causes of long-term disability, certainly one of the mostserious and life-changing
UC Neuroscience Institute
Ischemic, 85%
ICH, 10%
SAH, 5%
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
• Stroke: focal neurologic deficit caused bycerebrovascular 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 resolvingcompletely within 24 hours
UC Neuroscience Institute
• 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
UC Neuroscience Institute
• Carotid arteries– Internal: brain– External: face
“anteriorcirculation”
• Vertebral arteries“posteriorcirculation”
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
• Catheterangiography
• CT angiography• MR angiography
Contrast dye injected in bloodstream makes vessels show up
UC Neuroscience Institute
UC Neuroscience Institute
Aneurysm AVM
Artery stenosis Tumor
Stroke
blockage
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
• Limiting cellular injury• Reperfusion
• Preventing Systemic Complications• Preventing Neurologic Complications
• Rehabilitation
UC Neuroscience Institute
• Maintain cerebral perfusion– auto-regulation/adequate blood pressure (BP)
• Maintain cerebral oxygenation --(allow increasedoxygen extraction as compensatory mechanism foraltered perfusion)
• Maintain normothermia -- (increased temp =increased oxygen metabolism/demand)
• Maintain euglycemia -- (hyperglycemia exacerbatesischemic damage)
UC Neuroscience Institute
• Acute stroke– Clot dissolve (tPA)– Clot retrieval
• Aneurysm– Coil– Glue
• Artery stenosis– Angioplasty & stent
• AVMs and tumors– Glue (embolization)
Onyx glue
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
Clot retrieval• Device grabs and
pulls clot out• Suction catheter
aspirates clot
Clot-buster (tPA)• Drug dissolves clot• Give within 4.5 hours
UC Neuroscience Institute
• A clot-busting drugcalled t-PA (tissueplasminogenactivator) givenwithin 3 hoursafter stroke onset
• New data suggesttime window outto 4 ½ hours
UC Neuroscience Institute
• BOTTOM LINE: Appropriate patientswithout contraindications should betreated at 0-3 hours, as per the NINDSstudy protocol.
• TIME IS BRAIN: the soonertreatment is started, the greaterthe odds ratio of favorableoutcome
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
blockage t-PA restoresblood flow
UC Neuroscience Institute
UC Neuroscience Institute
Inflate balloon andinject for 2 minutes,let Onyx solidify for3 minutesthen re-perfuse
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
• Bypass reroutes an artery from outsideof skull into a brain artery to protectblood supply to brain before clipping theaneurysm bypass
UC Neuroscience Institute
UC Neuroscience Institute
Medications– Blood thinner– Cholesterol reduction– Blood pressure
control Endarterectomy
– Surgery removesplaque
Angioplasty &stenting– Balloon compresses
plaque and stentholds artery open
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
• Angioplasty & stenting– Restores vessel
diameter– Reduces clot risk
UC Neuroscience Institute
UC Neuroscience Institute
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
UC Neuroscience Institute
Dilated arteries and veins with nocapillary bed
UC Neuroscience Institute
• Goal is to reducesize of nidus and toocclude arterialfeeders difficult toaccess surgically
• Surgical dissectionand control of fragiledeep feedingarteries significantlyimproved
• Embolization alonewill not cure
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
• Prevent medical and neurologicalcomplications
• 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
UC Neuroscience Institute
• Aspiration (feeding tube, intubation)• DVT (subQ Heparin)• Infection (leading cause of late
death)• Skin Breakdown
UC Neuroscience Institute
• Increased intracranial pressure– hemorrhagic transformation– cytotoxic edema
• Edema maximal at 36-72 hours, usuallymanifests as decline in level ofconsciousness
• Herniation is leading cause of death inacute setting
(fatal arrhythmia is second)
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
• 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 yetpresent
UC Neuroscience Institute
• 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
UC Neuroscience Institute
• Spasticity Management• Neurogenic bowel and bladder• Constraint-Induced therapy• Body-weight supported treadmill
training• Splints and bracing• Pain Syndromes• Psychosocial Considerations
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
• Acute hospital therapies• Acute Inpatient rehabilitation• Short-term skilled rehabilitation• Transitional Rehabilitation programs• Day Rehabilitation programs• Outpatient therapy• Home Health therapy
UC Neuroscience Institute
The Stroke Recovery Center at Drake is amulti-disciplinary evaluation andtreatment program for those individualswith physical and cognitive deficits froma previous CVA, designed to maximizeindependence and function.
UC Neuroscience Institute
• Stroke Recovery Center:– refers now to the full spectrum of services--
from acute rehab on• START
– Stroke Team Assessment and RecoveryTreatment (START) Program
– The START program is the outpatientmultidisciplinary team evaluation
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
The therapeutic plan may bedeveloped around:
• out patient rehabilitation services,• research programs, or• a combination of both
UC Neuroscience Institute
The Stroke Recovery Center wasonly one of five programs of thistype identified in the UnitedStates
(as of July 2008)
UC Neuroscience Institute
To provide collaborative care thatimproves the function and qualityof life of people with strokes whilescientifically advancing the field ofstroke recovery.
2013 Seventh Annual NKY TBIConference
3/22/13
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UC Neuroscience Institute
To be the premier destination forthe most innovative, aggressiveand comprehensive treatment forpeople with stroke.
UC Neuroscience Institute
Dr. Brett Kissela
ProfessorCo-Director, Neurology
Residency ProgramVice-Chair of Education
and Clinical ServicesDepartment of
NeurologyUniversity of Cincinnati
Dr. Mark Goddard
Associate ProfessorChairman, Department of
Physical Medicine andRehabilitation
University of CincinnatiRehabilitation Medical
Director – Drake Center
UC Neuroscience Institute
Questions?
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