CVA

SAMIR TURK, M.D.

SYMPTOMS OF STROKES AND TIA

• PARALYSIS• NUMBNESS• LANGUAGE • VISUAL• ATAXIA• VERTIGO

CLINICAL PRESENTATION

• CORRELATES WITH OCCLUDED ARTERY• KNOWLEDGE OF BLOOD SUPPLY ALLOWS

LOCALIZATION• RADIOLOGICAL TESTING CONFIRMS

LOCALIZATION

MOTOR/SENSORY RULE

• BRAIN MEDIATES OPPOSITE SIDE-MOTOR/SENSORY

• BRAIN STEM – SAME SIDE OF FACE MOTOR/SENSATION

• CEREBELLUM –SAME SIDE FINE MOTOR

BLOOD SUPPLY

• 2 MAJOR TERRITORIES :

1- ANTERIOR CIRCULATION – ICA/MCA/ACA

2-POSTERIOR CIRCULATION –VERTEBRALS/BASILAR/POSTERIORCEREBRAL

MCA OCCLUSION

LEFT DOMINANT - 90%

LANGUAGE – RIGHT FACE AND ARM MOTOR AND SENSORYRIGHT SIDE NEGLECTEYES DEVIATE TO LEFT

LEFT ACA

• RIGHT LEG-- MOTOR AND SENSORY

• BEHAVIOR : ANGER/HOSTILITY

RIGHT MCA

• APROXIA• LEFT SIDED FACE/ARM MOTOR AND SENSORY• LEFT SIDED NEGLECT AND VISION LOSS• EYES DEVIATE TO RIGHT

RIGHT ACA

• LEFT LEG MOTOR AND SENSORY

• BEHAVIOUR : ANXIETY AND DEPRESSION

ICA OCCLUSON

• BOTH ACA AND MCA OCCLUSION• MONONUCLEAR BLINDNESS –OPTHALMIC

ARTERY OCCLUSION• PARTIAL HORNER SYNDROME : PTOSIS/MIOSIS

BUT ANHYDROSIS IS ABSENT

POSTERIOR CIRCULATION

• REMEMBER THE 5 D’s• 1-dizziness• 2-diplopia• 3-dysarthria• 4-dysphagia• 5-dystaxia

POSTERIOR CIRCULATION

• CROSSED FINDINGS : CRANIAL NERVES DEFICIT- IPSILATERAL MOTOR/SENSORY DEFICIT- CONTRALATERAL

VERTEBRAL OCCLUSION

• PRODUCES OCCLUSION IN PICA• LEADS TO LATERAL MEDULLARY SYNDROME

LATERAL MEDULLARY SYNDROME• 1- SPINOTHALAMIC TRACT- CONTRALATERAL DECREASE IN TEMP

AND PAIN • 2- 5TH CRANIAL NERVE PALSY –IPSILAT EYE PAIN,NUMB FACE AND

DECREASE CORNEAL REFLEX• 3- VESTIBULAR NUCLEUS – DIZZINESS/VOMITTING AND NYSTAGMUS• 4- INFERIOR CERBELLAR PEDUNCLE –IPSILAT.ATAXIA• 5- IPSILATERAL HORNER- LABILE BP AND TACHY• 6- HOARSNESS AND DYSPHAGIA• 7-ABNORMAL RESPIRATION

STROKE MIMICKS

• HYPOGLYEMIA• MASS LESIONS• SEIZURES• MIGRAINE• ENCEPHALOPATHIES• CONVERSION DISORDERS• PERIPHERAL VESTIBULOPATHIES

CHAMLEONS

• CONFUSION STATES• VIT DEF• MS• MOVEMENT DISORDERS• TRANSIENT GLOBAL AMNESIA

TREATMENT

• TRADITIONAL : SUPPORTIVE• THROMBOLYSIS : IV • THROMBOLYSIS : INTRAARTERIAL IN SITU• RETRIEVAL DEVICES

TREATMENT

• IV THROMBOLYSIS.

• TPA FOR TREATMENT OF CVA APPROVED IN 1996

• NINDS TRIAL

IV THROMBOLYSIS

• 31% OF THOSE WHO RECEIVED TPA HAD EXCELLENT OUTCOME

• 20% OF THOSE WHO DID NOT RECEIVE IV TPA HAD EXCELLENT RECOVERY

• 11% ABSPLUTE IMPROVEMENT

IV THROMBOLYSIS

TPAHEMORRHAGE 6.4%DEATH 11%

NO TPAHEMORRHAGE <1%DEATH 20%

INDICATION FOR IV TPA

• AGE >18• DEFINED TIME OF ONSET• WITHIN <3 HOURS• MEASURABLE NIHSS • NO CONTRAINDICATION

CONTRAINDICATION FOR IV THROMBOLYSIS

• MINOR SYMPTOMS OR IMPROVING• SEIZURE AT ONSET• STROKE OR HEAD TRAUMA < 3 MONTHS• ANY HX OF ICH• GI/GU HEMORRAGE < 3 WEEKS• MAJOR SURGERY < 3 WEEKS• NONCOMPRESSIBLE ARTERIAL PUNCTURE<7

DAYS

CONTRAINDICATION OF IV THROMBOLYSIS

• RECEIVED HEPARIN WITHIN 48 HRS AND PTT IS ABNORMAL

• BP > 185/100• INR >1.7• PLTS <100K• GLUCOSE <50 OR >400

IV TPA 3-4.5 HOURS

• SOME BENEFIT IN SELECTED PATIENTS• NOT FDA APPROVED• ADDITIONAL EXCLUSION CRITERIA : AGE>80 ON ORAL ANTICOAGULATION REGARDLESS OF INR NIH SCORE >25 HX OF STROKE AND DM

OTHER CONSIDERATIONS

• IF THERE IS CONTRAINDICATION TO IV LYSIS THEN CONSIDER : 1- INTRAARTERIAL LYSIS – LESS TPA 2- MECHANICAL RETRIEVAL DEVICES PENUMBRA SYSTEM OR MERCI DEVICESHOULD CONSIDER FOR ALL CASES OF NIHSS OF >10 AS THE CHANCE OF OPENING AN MCA OCCLUSION WITH IV LYSIS IS ONLY 15%

LIMITATIONS OF IV TPA

• ONLY 4% OF CVA PTS RECEIVE TPA

• 22% PRESENT WITHIN 3 HRS

• 51% OF THOSE PRESENTING WITHIN 2 HRS ARE INELIGIBLE

• POOR RECANALISATION RATES- M1 SEGMENT ONLY 13%

INTRAARTERIAL THROMBOLYSIS

• SAME AS IV THROMBOLYSIS – THE RISK OF BLEEDING IS HIGHEST WITH LAERGER STROKES

• RISK OF DISSECTION,PERFORATION AND DISTAL EMBOLISATION

• TECHNICALLY VERY DEMANDING AND CHALLENGING

• CEREBRAL VESSELS ARE VERY TORTUROUS

INTAARTERIAL THROMBOLYSIS

• ONLY FEW MG OF TPA IS NEEDED• MAY NEED AN HOUR OR MORE TO LYSE THE

CLOT• BEST TO DO WITHOUT INTUBATIONS IF

POSSIBLE• LARGER VESSELS MAY BE IMPOSSIBLE TO

OPEN WITH LYSIS ALONE

MEDICAL TREATMENT

• IS AS IMPORTANT AS LYSIS• BP MEDICATIONS SHOULD BE WITHHELD

UNLESS SBP >220 OR DBP>120• TREAT HYPOTENSION WITH SALINE AND

PRESSORS IF NEEDED• TREAT CARDIAC ARRYTHMIAS

MEDICAL TX

• TREAT HIGH BP BEFORE IV LYSIS IF SBP>185 OR DBP>110.

• USE IV LABETOLOL OR NICARDIPINE• AFTER LYSIS MAINTAIN SBP <180 OR DBP<100

MEDICAL TX

• HYPGLYCEMIA MAY MIMIC STROKES• HYPERGLYEMIA WITH BS > 140 HAS WORSE

OUTCOME

Dr. Turk

Basilar InterventionMay 2011

PRESENTATION

• 50 YEAR OLD MAN LIVES ALONE• WOKE UP FROM SLEEP WITH DIZZINESS AND

SEVERE NAUSEA AND ATAXIA• CALLED AMBULANCE• COLLAPSED . INTUBATED AND BROUGHT TO

ER COMATOSE

BASILAR ARTERY INTERVENTION

• IN ER FOUND TO BE TOTALLY UNRESPONSIVE• EMERGENCY MRA SHOWED TOTAL

OCCLUSION OF BASILAR ARTERY

ARCH ANGIO

BRACHIOCEPHALIC ARTERY

RIGHT ICA

RT VERTEBRAL

INFUSION CATHETER IN BASILAR ARTERY

REESTABLISHMENT OF FLOW

STENT ADVANCED TO BASILAR ARTERY

BASILAR ARETERY STENTED TO KEEP OPENED

LEFT CAROTID OCCLUSION

• 54 YEAR OLD MAN AT GRANDCHILD BIRTHDAY COLLAPSED

• PRESENTED TO ER WITHIN 30 MINUTES.• LEFT HEMIPARESIS WITH APHASIA• STUDIES SHOWED ACUTE RIGHT CEREBRAL

INFARCT• IV THROMBOLYSIS GIVEN 9O MG TPA• RECOVERED FULLY

L CAROTID OCCLUSION

• STUDIES SHOWED SEVERE STENOSIS OF LEFT CAROTID AND A SMALL INFARCT ON MRI/MRA

• STARTED ON PLAVIX AND ASPIRIN AND WAS PLANNED TO COME BACK FOR CEA WITHIN A WEEK OR TWO

• WHILE GETTING READY FOR DISCHARGE COLLAPSED AGAIN AND WAS COMATOSE

• DENSE RIGHT HEMIPARESIS AND APHASIA

INTERVENTION

• TAKEN PROMPTLY TO CATH LAB• ANGIO DONE

OCCLUDED LEFT ICA

OCCLUDED LEFT ACA AND PART OF MCA

Post PTA

Third patient

77 year old with sudden aphasia

• WAS FOUND TO HAVE NEW ONSET ATRIAL FIBRILLATION

OCCLUDED MCA

FLOW REESTABLISHED WITH 5 MG OF TPA