Assessment of Hemorrhagic VS Ischemic Stroke

As told by JJ Baumann MS, RN, CNS

Cerebral Vessel Vignettes

Couple of Clots• 70 year old female• Smoker • Mopping the floor

and started feeling dizzy and tired

• Witnessed sudden onset of aphasia, right sided weakness

12: 15 - last seen normal12:40 - stroke code activated – pre hospital

EMS states right side weakness12:45 - Handsome paramedic arrives with

patient who only has a right facial droop

Time to relax?

A. Don’t cancel stroke code. Let’s give tPA.B. Cancel stroke code, but still get imaging.C. Scold EMS for not knowing facial droop from

complete weakness.D. Get EMS call back number, the charge nurse

also thinks he is hot.

CODE STEMI

Déjà vu

Cardiac cath lab – heart fixed.

On the table, she suddenly stops talking and has right sided weakness.

Stenting the Left ICA

48 Hours LaterHer requests:1. Thank paramedic that brought her to the

hospital so quickly2. Let her go home now

My request:1. Stop smoking!

What is this?

200,000 cigarette packs, the samenumber of Americans who die

every six months due to smoking.

Smoking

Under Pressure62 year old malePMHx:

Diabetes Hypertension

Renal issues?Medications:

2 blood pressure medications

1 oral antiglycemicaspirin

Intracranial Hemorrhage

9 am: sudden headache and left sided weakness

Now what?

A. Get frequent neuro exams?B. Have neurosurgery fix it?C. Stop the bleeding?D. Find the cause?

Primary Hemorrhage

• Amyloid– Lobar

• HTN- Thalamus- Basal Ganglia- Pontine- Cerebellum

Secondary Hemorrhage• Coagulopathies• Tumor• AVM / aneurysm• Illicit drug use• Excess EtOH

Getting sleepy…

Frequent neuro checks Patient becoming more sleepy

Head of bed > 30 degrees Done

Blood pressure Titrating nicardipine gtt to keep SBP < 160

Fever control No fever

Sedation Patient calm

Surgical or medical? Deep territory, medical management

CT scan

• Bleed is stable• More swelling• Ventricles – no change

Hyperosmolar Therapy

Isotonic

hypertonic hypotonic

300 to 320 mOsm/kg

280-300 mOsm/kg0.45% Na

D5W

Mannitol

3% NaCl

DO IT FOR THE BRAIN !• Neuro exam• Blood pressure control• Head of bed• Hyperosmolar therapy• Sedation• Fever control• Prepare for EVD placement

Stroke Code on ortho• 72 yo male• Hip fx • POD 2• Sudden onset

left facial droop & slurred speech

Increased risk of MI/ PE 1 week after surgery and stroke 1-2 weeks after surgery.

Patient is at increased risk of stroke after surgery if:

They have had a stroke.They have atrial fibrillation.

Risky Business?

• Hypertension• Diabetes – type 2• Overweight• There was something

else, but….

Exacerbation of Old Symptoms

• Metabolic– Electrolytes– Medications– Hypercarbia

• Infectious– WBC– Fever

Exacerbation of stroke symptoms by infection and metabolic perturbations – A diffusion-weighted MRI studyS. Iyadurai, K. Knievel, M. Flaster (St. Louis, Phoenix, Las Vegas, US)

If a Tree Falls in the Forest…87 year old female

EMS: Trauma! AMS following a non-witnessed fall at about 7 pm

Family: Patient got up to get ready for bed. There was a loud thud in the bedroom, and she was found "down" by her vanity table gripping tightly unto her walker and chair and "shaking."

Trauma Team: She sustained multiple lacerations, the worst of which is on her R forearm.

Medications

• diltiazem (CARDIZEM CD) 120 mg sustained release capsule

• losartan (COZAAR) 25 mg tab • furosemide (LASIX) 20 mg tab • pantoprazole (PROTONIX) 40 mg delayed

release tablet • acetaminophen (TYLENOL) 325 mg tab • Multi vitamin

• Paroxysmal AF • CVA with residual R

visual field neglect• High blood pressure• Congestive heart failure• Dementia

Seeing the Trees for the Forest

• Not clear if fall was mechanical

• Fall not witnessed

Pre-syncope? Seizure? TIA?

X-rays, labs, spot EKG, MRI…

Multiple acute infarctions posterior circulations .

Posterior circulation – Vertebral and Basilar

• Cranial nerve deficits – 3rd nerve palsy– Nystagmus– Vertigo– Dysphagia– Dysarthria– Diplopia

• Cortical blindness / visual field loss• Truncal or limb ataxia• Spastic paresis• Quadriplegia• Weakness of facial, lingual, and pharyngeal muscles

Now what?

Acute treatment?- tPA- NIR

Prevention? - ASA- Plavix / Aggrenox- Coumadin / Pradaxa

CHADS2 Score in Atrial Fibrillation

CHAD2 item Points Congestive heart failure 1 Hypertension (systolic >140 mmHg) 1

Age greater than 75 years 1 Diabetes 1 Prior cerebral ischemia / TIA 2

Annual Stroke Risk

CHADS2 Score Yearly risk of stroke

0 1.9%1 2.8%2 4.0%3 5.9%4 8.5%5 12.5%6 18.2%

BF Gage et al. Validation of clinical classification schemes for predicting stroke. Results from the national registry of atrial fibrillation. JAMA 2001 285: 2864-2870.

Balancing Act

CHADS Score is 5, 12.5% chance per year will have a stroke

Two GI Bleeds requiring hospitalization in past 3 months

Grandma 82 year-old woman who lives with her daughter’s family. She needs help with groceries and preparing meals, but she

is otherwise independent and enjoys life. Grandkids love her.

Treat?

1:45 pm Unable to talk, right

hemi

(NIH – 22)2:30 pm

EMS arrivesStroke Code

Number of patients who benefit (and are harmed) per 100 patients treated with tPA

Lansberg et al. Stroke 2009

Grandma

4:13 pm: tPA complete!

Why has she not improved?Cath lab? Completed her stroke?tPA did not work?

Neuro Interventional Radiology

-Intra-arterial t-PA

-Mechanical devices-Merci-Penumbra-Solitaire

NIH > 1295% chance large vessel occlusion

NIHSS Chance large vessel occl

5-9 34%10-14 42%>15 100%

Completed the Stroke?The Ischemic Penumbra

Core Infarct

Ischemic Penumbra:

zone of salvageable tissue surrounding

core infarct

Mean MTT 8 Mean XE-CT CBF 15 Mean Tmax 4s

4:15 pm: Start Stroke MRI with DWI and PWI

A small DWI lesion … but a large PWI lesion

4:46 pm: Case start 5:38 pm: The vessel is open

Before Therapy After TherapyCourtesy of Maarten Lansberg, MD

Home is Where the Brain Is!

Walks home with family. Without treatment would likely have been

severely disabled waiting for nursing home placement.

Courtesy of Maarten Lansberg, MD

Questions?