Upload
md-specialclass
View
5.876
Download
0
Embed Size (px)
Citation preview
ACUTE BRAIN ATTACK - 911
RUBEN T. DELA CRUZ MD, FPNAACUTE STROKE UNIT- MANILA ADVENTIST MEDICAL CENTER
OBJECTIVES
STROKE IMPACT KNOW THE CLASSIFICATION OF
STROKESHOW TO DIAGNOSE STROKESGUIDELINES FOR ACUTE STROKE
TREATMENT
STROKE IMPACT
STROKE IS BRAIN ATTACK !Sudden onset of focal neurological
deficit lasting more than 24 hours due to an underlying vascular pathology.
No. 2 Killer worldwideNo. 1 Killer in Asia- Western Pacific, China,
and Japan20 million people every year with 5 million
deathsLocally: 500 strokes per 100,000 population
CLINICAL STROKE CLASSIFICATION
TIA AND MILD STROKEMODERATE STROKESEVERE STROKE
TIA and MILD STROKE
Transient Ischemic Attack- deficits resolved within 24 hours including transient blindness in one eye
ORALERT Patient with any of the ff:
a. mild pure motor weakness of one side of the body.b. pure sensory deficitc. slurred speech but intelligibled. vertigo with incoordinatione. visual field defects alonef. combination of a and b
MODERATE STROKE
Awake patient with significant motor and/or sensory and/or language and/or visual deficit
ORDisoriented, drowsy, or stuporous patient but
with purposeful response to painful stimuli
SEVERE STROKE
Comatose patient with nonpurposeful response, decorticate,
ORDecerebrate posturing to painful stimuli or
comatose patient with no response to painful stimuli
DIAGNOSING STROKE
1.1. Clinical – (80%) Clinical – (80%)
2. Neuroimaging – (20%) 2. Neuroimaging – (20%)
* Establish the time of onset of symptoms* Establish the time of onset of symptoms
* Cranial CT scan is the initial imaging * Cranial CT scan is the initial imaging study of choicestudy of choice
Sudden, focal,Sudden, focal,Loss of functionLoss of function
History, Physical & Neurological Exam History, Physical & Neurological Exam
ROLE of DIAGNOSTIC EXAM
Confirm & establish the clinical diagnosis
Rule out stroke “mimickers” Determine pathologic type
Infarct, ICH, SAH Determine etiology & stroke mechanism Screen for medical & neurologic
complications of stroke
COMMON STROKE “MIMICKERS”COMMON STROKE “MIMICKERS”
SeizuresSeizures Systemic infectionSystemic infection Brain tumorBrain tumor Toxic-metabolic encephToxic-metabolic enceph Positional vertigoPositional vertigo SyncopeSyncope TraumaTrauma Subdural hematomaSubdural hematoma Herpes encephHerpes enceph
Transient global amnesiaTransient global amnesia DementiaDementia Demyelinating dseDemyelinating dse Cervical spine fractureCervical spine fracture Myasthenia gravisMyasthenia gravis Parkinson’s dseParkinson’s dse Hypertensive encephHypertensive enceph Conversion disorderConversion disorder Bell’s palsyBell’s palsy
DIFFERENTIAL DIAGNOSIS OF STROKE
Pure hemifacial weakness (e.g. Bell’s palsy) Fever prior to onset of symptoms Trauma Recurrent seizures Weakness with atrophy Recurrent headaches
If any of the ff conditions is present, If any of the ff conditions is present, STROKE is probably UNLIKELY ….STROKE is probably UNLIKELY ….
SSP Guidelines for the Prevention & Management SSP Guidelines for the Prevention & Management of Brain Attack, 2003of Brain Attack, 2003
With the advent of numerous diagnostic modalities, appropriate sequential diagnostic examinations are most important to confirm the clinical diagnosis of stroke.
First-line (emergent) diagnostic exam
Second-line diagnostic investigations
CBC, PT/ PTT, CBC, PT/ PTT, Blood sugarBlood sugar
Plain Cranial CTPlain Cranial CT
EMERGENT DIAGNOSTIC EXAMEMERGENT DIAGNOSTIC EXAM
SSP Guidelines for the Prevention & Management SSP Guidelines for the Prevention & Management of Brain Attack, 2003of Brain Attack, 2003
ElectrocardiogramElectrocardiogram
SECOND-LINE DIAGNOSTIC STUDIES SECOND-LINE DIAGNOSTIC STUDIES (To Identify Etiology and Stroke Mechanism)(To Identify Etiology and Stroke Mechanism)
Neurovascular StudiesNeurovascular Studies Carotid DuplexCarotid Duplex Transcranial Doppler studies(TCD)Transcranial Doppler studies(TCD) Catheter AngiographyCatheter Angiography CT Angiography CT Angiography Magnetic Resonance Angiography (MRA)Magnetic Resonance Angiography (MRA)
Cardiac investigationCardiac investigation EchocardiographyEchocardiography 24 hour Holter24 hour Holter
Hematologic StudiesHematologic StudiesHypercoagulable states – Protein C, S, Hypercoagulable states – Protein C, S, Fibrinogen Fibrinogen Antithrombin IIIAntithrombin III
APAS - ANA, Anticardiolipin Ab, Lupus anticoagulantAPAS - ANA, Anticardiolipin Ab, Lupus anticoagulantHomocysteine Homocysteine
Drug LevelsDrug Levels – e.g. Metamphetamine – e.g. Metamphetamine
GeneticGenetic – Familial homocystinuria, MELAS, – Familial homocystinuria, MELAS, CADASILCADASIL
SECOND-LINE DIAGNOSTIC STUDIES SECOND-LINE DIAGNOSTIC STUDIES (To Identify Etiology and Stroke Mechanism)(To Identify Etiology and Stroke Mechanism)
BiopsyBiopsy – e.g Vasculitis, Temporal arteritis – e.g Vasculitis, Temporal arteritis
Plain Cranial CT is recommendedPlain Cranial CT is recommended
Neuroimaging in Acute StrokeNeuroimaging in Acute Stroke
Hyperacute3 hours
12 hours 48 hours
First-line modality imaging in suspected stroke casesFirst-line modality imaging in suspected stroke cases Widely available, relatively inexpensive, non - invasive & quickWidely available, relatively inexpensive, non - invasive & quick Accurately Accurately differentiatesdifferentiates hemorrhagic and ischemic strokeshemorrhagic and ischemic strokes Should be performed & interpreted Should be performed & interpreted ASAPASAP
RATIONALE FOR NEUROIMAGING
• Identify the lesion (is it a stroke?)
• Determine the type of stroke (ischemic or hemorrhage?)
• Localize the stroke (where is it?)
• Quantify the lesion (how large is it?)
• Determine the age of the lesion
BASIC CONCEPTS
Cranial computed (x-ray) tomography scan• Air, Fluid (e.g. CSF, infarction) = hypodense
• Bone, calcification, blood = hyperdense
CT FINDINGS in HYPERACUTE CT FINDINGS in HYPERACUTE INFARCTION (0 - 6 hrs)INFARCTION (0 - 6 hrs)
Almost 60% of CT scans done in the first few hours of ischemic stroke: NORMAL
However, the following signs may be seen:Hyperdense artery (“dense MCA sign”)Obscuration of lentiform nucleiLoss of grey-white interphase along lateral
insula (“insular ribbon sign”)Effacement of sulci
Early signs of infarction on Cranial CT
Dense Artery sign
Insular Ribbon sign (loss of insular stripe)
Obscuration of lentiform nuclei
Effacement of sulci
CRANIAL CT in ACUTE ISCHEMIC STROKE
• Infarction: focal hypodense area in cortical, subcortical, or deep gray or white matter, following a vascular territory, or watershed distribution
CT FINDINGS in SUBACUTE / CT FINDINGS in SUBACUTE / CHRONIC INFARCTIONCHRONIC INFARCTION
Wedge-shaped largeWedge-shaped largecortical infarctcortical infarct
Round / ovoid smallRound / ovoid smallsubcortical infarctssubcortical infarcts
Subacute R-ICA infarct
SubacuteL-MCA infarct
CT FINDINGS in SUBACUTE / CT FINDINGS in SUBACUTE / CHRONIC INFARCTIONCHRONIC INFARCTION
Hyperdense lesion Hyperdense lesion in left lentiform in left lentiform nucleus with nucleus with hypodense rim hypodense rim (vasogenic edema)(vasogenic edema)
CT FINDINGS in INTRACEREBRAL CT FINDINGS in INTRACEREBRAL HEMORRHAGEHEMORRHAGE
Common Sites of Hypertensive ICHCommon Sites of Hypertensive ICH
Common Sites of Hypertensive ICHCommon Sites of Hypertensive ICH
Cranial CT of Hemorrhagic Stroke
Stroke Society of the Philippines recommendations for computation of hematoma volume
Planimetric Method or Pixel MethodModified Kothari method (ABC/2)
A - greatest hemorrhage diameterB - diameter 90 degrees to AC - no of CT slices with hemorrhage x by the slice thickness*
Measurement of Hematoma VolumeMeasurement of Hematoma Volume
Modified Kothari Method
A x B x C / 2Select the CT slice with the largest area of hemorrhage
AB
Hemorrhage > 75% of the largest area = 1 sliceHemorrhage > 25 – 75% of the largest area = 0.5 sliceHemorrhage < 25% of the largest area - 0
Interpretation of Hematoma Volume for Supratentorial Hemorrhages
< 30cc small medical
30 – 50cc moderate
> 50cc large surgical
* Factor in age, neurologic status, concomitant medical conditions
CT SCAN FINDINGS in CT SCAN FINDINGS in SUBARACHNOID SUBARACHNOID HEMORRHAGEHEMORRHAGE
Advantages of Cranial MRIAdvantages of Cranial MRI
DIAGNOSING STROKE:DIAGNOSING STROKE: Other Neuroimaging TechniquesOther Neuroimaging Techniques
More sensitive in detecting More sensitive in detecting small lesions / lacunar infarctssmall lesions / lacunar infarcts early infarctionearly infarction brainstem / post fossa lesionsbrainstem / post fossa lesions
Can detect lesions as early as 6 hours from Can detect lesions as early as 6 hours from onset of stroke (as early as 90 mins. for onset of stroke (as early as 90 mins. for Diffusion MRI)Diffusion MRI)
Early signs of infarction on MRI
Slow flow (absence of normal flow void) in involved artery
Parenchymal signal changes(hypointense on T1)
T1
DWI: acute infarct appears bright
Parenchymal signal changes(hyperintense on T2)
T2
R medullary InfarctionR medullary Infarction
T1T2
MAGNETIC RESONANCE IMAGING in BRAINSTEM INFARCTION
R Pontine InfarctionR Pontine Infarction
Limitations of Cranial MRILimitations of Cranial MRI
DIAGNOSING STROKE:DIAGNOSING STROKE: Other Neuroimaging TechniquesOther Neuroimaging Techniques
More expensive & less widely available Longer acquisition time compared to CT (difficult in uncooperative patients) Contraindicated in patients with metallic
implants (e.g. pacemaker) Not sensitive in detecting acute hemorrhage
MRI is not sensitive in detecting ACUTE HEMORRHAGE
Cranial MRICranial MRI Cranial CT scanCranial CT scan
Pontine HemorrhagePontine Hemorrhage
NEUROVASCULARNEUROVASCULAREVALUATIONEVALUATION
Ultrasound TechniquesUltrasound Techniques
Catheter AngiographyCatheter Angiography
CT AngiographyCT Angiography
MR AngiographyMR Angiography
RATIONALE for NEUROVASCULAR EVALUATION
Identifying occlusive arterial disease (Is there blockage ?)
Localizing the occlusion (Where ?, carotid ?, intracranial ?)
Quantifying the degree of stenosis (How severe ?)
Determining the pathology (Athero ?, dissection ?, others ?)
Identifying other vascular lesions
Recommendations for Neurovascular Imaging in
Patients with Stroke
A non-invasive screening technique is indicated as an initial diagnostic test
Conventional radiographic angiography may be indicated based on findings of non-invasive screening procedures (i.e. severe stenosis, occlusion)
Cerebral arteriography may also be required when a diagnosis of vasculitis, dissection, vascular malformation needs confirmation or exclusion
Transcranial Doppler (TCD)Transcranial Doppler (TCD)Carotid/vertebral DuplexCarotid/vertebral Duplex
VASCULAR ULTRASOUND “NEUROSONOLOGY”
CAROTID DUPLEX
Established technique to identify Established technique to identify extracranial carotid / vertebralextracranial carotid / vertebral artery diseaseartery disease
Advantages: non-invasive, bedsideAdvantages: non-invasive, bedside availability, low costavailability, low cost
Disadvantages: operator Disadvantages: operator dependent, unable to differentiate dependent, unable to differentiate occlusion from near occlusion occlusion from near occlusion
TRANSCRANIAL DOPPLER
Established technique to evaluate basal intracranialEstablished technique to evaluate basal intracranial
arteriesarteries Established utility in stroke (e.g. stenosis, Established utility in stroke (e.g. stenosis,
vasospasm, vasospasm, ICP, vasomotor reactivity) ICP, vasomotor reactivity) Advantages: non-invasive, bedside availability, low Advantages: non-invasive, bedside availability, low
cost, allows serial monitoring, detects cost, allows serial monitoring, detects micro embolimicro emboli
Disadvantages: operator dependent, poor temporal Disadvantages: operator dependent, poor temporal window, circle of Willis variation window, circle of Willis variation
TCD APPLICATION in STROKE
Stenosis / occlusion Emboli detection Collateralization Vasospasm Increased ICP / Brain death Cerebral Autoregulation
MAGNETIC RESONANCE ANGIOGRAPHY
CT ANGIOGRAPHY
Other Non-Invasive
Neurovascular Imaging
Procedures
Severe Severe Carotid Carotid
StenosisStenosis
CATHETER ANGIOGRAPHY
Vertebral Vertebral Artery StenosisArtery Stenosis
MCA MCA StenosisStenosis
“ “ Gold Gold standard”standard”
AV MalformationAV Malformation
CATHETER ANGIOGRAPHY
Venous angiomaVenous angioma
AneurysmAneurysm
Cost, availability, invasive procedure Risks (vascular damage, stroke,
ionizing radiation, reaction to contrast) Exclusion: poor renal function, absent femoral pulses, coagulopathy
CARDIAC EVALUATION
Holter Monitoring 2 D Echocardiography
Recommendations for Echocardiography in Patients with Stroke …
Clinical evidence of heart disease Less than or equal 45 years of age Older patients, without evidence of extra or intracranial
occlusive disease or other obvious cause Abrupt occlusion of major peripheral or visceral artery Suspect embolic disease (non-lacunar syndrome, multiple
arterial territory involvement) Clinical therapeutic decision will depend on results of
echocardiography
LV thrombusLV thrombusLV dyskinesiaLV dyskinesiaMitral stenosisMitral stenosisMitral annular calcificationMitral annular calcificationMitral valve prolapseMitral valve prolapse
Atrial thrombusAtrial thrombus Atrial appendage thrombusAtrial appendage thrombusAtrial septal aneurysmAtrial septal aneurysmPatent foramen ovalePatent foramen ovaleAortic arch athero / Aortic arch athero / dissectiondissection
Transthoracic vs Transesophageal Echocardiography
TTE PreferredTTE Preferred TEE PreferredTEE Preferred
Proper use of diagnostic examinations in stroke requires an
understanding of: Underlying disease process Principles of test involved Advantages & limitations of each procedure How each investigation influences patient
management
SUMMARYSUMMARY
Rule out stroke mimickersRule out stroke mimickers
History, PE & NE should be done immediately History, PE & NE should be done immediately on patients with strokeon patients with stroke
Do emergent diagnostic tests to determine Do emergent diagnostic tests to determine patient’s eligibility for patient’s eligibility for rTPArTPA
SUMMARYSUMMARY
CT scan remains to be the most important brain CT scan remains to be the most important brain imaging test. Cranial MRI is not recommended imaging test. Cranial MRI is not recommended for for routine evaluation of acute stroke patientsroutine evaluation of acute stroke patients Differentiation of ischemic & hemorrhagic stroke is Differentiation of ischemic & hemorrhagic stroke is
important because of marked difference in the important because of marked difference in the management management
Second line diagnostic tests need not be done in the Second line diagnostic tests need not be done in the ER setting and should not delay treatmentER setting and should not delay treatment
GUIDELINES FOR TIA AND MILD STROKE
MANAGEMENT PRIORITIESAscertain clinical diagnosis of stroke or TIAExclude common stroke mimickersMonitor and manage blood pressure
SBP = 220 or DBP= 120MAP= 130Avoid precipitous drop in BP> 20% of baseline MAPNo rapid-acting sublingual agentsUse oral or easily titratable IV antihypertensive
Ensure appropriate hydration. No hypotonic IV fluids
GUIDELINES FOR TIA AND MILD STROKE
EMERGENT diagnosticsComplete Blood count (CBC)Blood sugar (CBG, HGT, or RBS)Electrocardiogram (ECG)PT/PTT (Atrial Fibrillation or possible
cardioembolic source)Plain CT Scan Of brain as soon as possible
GUIDELINES FOR TIA AND MILD STROKE
EARLY SPECIFIC TREATMENT FOR THROMBOTIC OR LACUNAR STROKE
(CTSCAN CONFIRMED)Aspirin 160-325 mg start as early as possible
for 14 daysNeuroprotectionEarly rehabilitation within 72 hours
GUIDELINES FOR TIA AND MILD STROKE
EARLY SPECIFIC TREATMENT FOR CARDIOEMBOLIC
(CTSCAN CONFIRMED)Anticoagulation with IV heparin or subcutaneous LMWHOr Aspirin 160-325 mg/day (If anticoagulation not
available)NeuroprotectionEarly rehabilitation within 72 hours If infective endocarditis is suspected, give antibiotics and
do not anticoagulate.
GUIDELINES FOR TIA AND MILD STROKE
EARLY SPECIFIC TREATMENT FOR HEMORRHAGIC If there is suspicion of nonhypertensive cause for ICH
(e.g. AVM, aneurysm), REFER to neurosurgeon.NeuroprotectionEarly rehabilitation with in 72 hrs
GUIDELINES FOR TIA AND MILD STROKE
EARLY SPECIFIC TREATMENT FOR T.I.A.Aspirin 160-325 mg/ day If crescendo T I A (multiple events within hours,
Increasing severity and duration of deficits),
consider ANTICOAGULATION with intravenous heparin
GUIDELINES FOR TIA AND MILD STROKE
CT SCAN NOT AVAILABLENo specific emergent drug treatment recommendedNeuroprotectionConsult a neurologist or neurosurgeonEarly supportive rehabilitation
GUIDELINES FOR TIA AND MILD STROKE
PLACE OF TREATMENT
Admit to Hospital (Stroke Unit)
1. Stroke onset within 48 hours
2. Patients requiring specific active intervention for any of the following:
a. BP control, monitoring, and stabilization
b. Cardiac stabilization, incl. Atrial fibrillation, CHF, acute MI
c. Hydration
d. Anticoagulation, if ICH ruled out by CT
GUIDELINES FOR TIA AND MILD STROKE
PLACE OF TREATMENT
Admit to Hospital (Stroke Unit)
3. Rapidly worsening deficits
4. >4 TIA’s in 2 weeks prior to consult
5. 1-4 TIA’s in 2 weeks but high risk (multiple events within hours, increasing severity
and duration of deficits
GUIDELINES FOR TIA AND MILD STROKE
PLACE OF TREATMENTURGENT OUTPATIENT WORK-UP
1. Singleingle TIA more than 2 weeks ago2. 1-4 TIA’s in 2 weeks, but not high risk (no
change in severity and duration of deficit, cardiac arrhythmia, carotid bruit)
3. Transient monocular blindness alone4. Stable mild strokes occurring > 48 hrs not
requiring specific active intervention*Advise immediate re-consult if there is worsening of deficit.
GUIDELINES FOR MODERATE STROKEGUIDELINES FOR MODERATE STROKE
MANAGEMENT PRIORITIES
1. Basic emergent supportive care (ABC of resuscitation)
2. Monitor and manage blood pressure. Treat if SBP>220; DBP>120; MAP= >130
Precautions: Avoid precipitous drop in BP >20% MAP
No Sublingual agents
3. Exclude stroke mimickers
4. Identify co-morbidities (cardiac dis. Gastric ulcer, etc)
5. Recognize and treat early signs of increased ICP
GUIDELINES FOR MODERATE STROKEGUIDELINES FOR MODERATE STROKE
EMERGENT DIAGNOSTICSComplete Blood CountBlood sugar (CBG, HGT, RBS)PT/PTTSerum Na and K+Electrocardiogram (ECG)Plain CT Scan of brain ASAP
GUIDELINES FOR MODERATE STROKEGUIDELINES FOR MODERATE STROKE
EARLY SPECIFIC TREATMENT
(CTSCAN CONFIRMED)
Ischemic- Noncardioembolic (Thrombotic/ Lacunar)
- If within 3 hours of stroke onset, consider rtPA treatment and refer to specialist
- Aspirin 160-325 mg/day start as early as possible
- Neuroprotection
- Early supportive rehabilitation
GUIDELINES FOR MODERATE STROKEGUIDELINES FOR MODERATE STROKE EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)
CARDIOEMBOLIC- If within 3 hours of stroke onset consider rtPA
` treatment and refer to specialist- Aspirin 150- 325 mg/day start as early as pos.- Early anticoagulation if source of embolism
can be demonstrated- Neuroprotection- Early supportive rehabilitation
* If infective endocarditis is suspected, give antibiotics and DO NOT anticoagulate
GUIDELINES FOR MODERATE STROKEGUIDELINES FOR MODERATE STROKE
EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)HEMORRHAGIC
- Supportive treatment:
1. Mannitol 20% 0.5 mg/kg BW q 6 h
for 2- 5 days
2. Neuroprotection
- Neurosurgery consult for hematomas distorting or displacing 4th ventricle
- Within 12-24 h, recommended surgery for hematoma:
1. size 10-30 cc (non-dominant subcortical frontal/temporal)
2. size >30 cc (subcortical, putaminal, cerebellar)
- Early supportive rehabilitation
GUIDELINES FOR MODERATE STROKEGUIDELINES FOR MODERATE STROKE
CT SCAN NOT AVAILABLE
= USE SCORING SYSTEM
Likely Ischemic Likely HemorrhagicNo specific emergent drug Tx.
Neuroprotection
Refer to Specialist
Early Supportive Rehabilitation
Refer to Neurologist/ Neurosurgeon further Dx workups and/or subsequent surgery
Neuroprotection
Early supportive rehabilitation
GUIDELINES FOR SEVERE STROKEGUIDELINES FOR SEVERE STROKE
Management PrioritiesBasic Emergent supportive care (ABC of Resus.)Neurovital signs: BP; PR, CR, RR, Temp, Pupils.Glasgow Coma scale,Recognize and Treat early signs of increased ICPMonitor and manage blood pressure. Treat if SBP is220 or DBP of 120 or MAP of 130. Precautions:
*Avoid precipitous drop in BP >20% of MAP*Do not use sublingual agents
Ascertain clinical Dx; exclude stroke mimickersIdentify co-morbidities (cardiac dis. Gastric ulcer, etc)
GUIDELINES FOR SEVERE STROKEGUIDELINES FOR SEVERE STROKE
EMERGENT DIAGNOSTICS:
Complete blood count,
Blood Sugar,
PT/PTT,
Serum Na, K
Electrocardiogram,
Plain CTscan of the brain
GUIDELINES FOR SEVERE STROKEGUIDELINES FOR SEVERE STROKE
EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)
Non-cardioembolic (Thrombotic/Lacunar)
- May give aspirin 160-325mg/day
- Neuroprotection
- If cerebellar infarct, consult neurosurgeon ASAP
- Early supportive rehabilitation
Place of Treatment: Hospital, Intensive Care Unit or
Acute Stroke Unit
GUIDELINES FOR SEVERE STROKEGUIDELINES FOR SEVERE STROKE
EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)HEMORRHAGIC
- Supportive Treatment:1. Mannitol 20% 0.5 mg/kg q 6h for 2-5 days2. Neuroprotection
- Neurosurgery consult if:1. Patient not herniated, hematoma in putamen,
subcortical, cerebellum and goal is to reduce mortality’
2. Herniated patient but family is willing3. ICP monitoring contemplated and salvage
surgery is considered Place of Tx.: Intensive Care Unit
BRING HOME MESSAGE
STROKE IS BRAIN ATTACK!STROKE IS AN EMERGENCY!STROKE IS TREATABLE!STROKE IS PREVENTABLE!
CIFIC TREATMENT