NEUROLOGY FOR THE NON-NEUROLOGIST

RECOGNITION AND ACUTE MANAGEMENT OF DIFFERENT TYPES OF STROKE FEBRUARY 16, 2019

Thomas C. Hammond, M.D., FAAN

Marcus Neuroscience Institute

I HAVE NO FINANCIAL DISCLOSURES

WHAT IS STROKE?

A neurologic deficit due to problems with blood supply (or drainage) to a specific area of the nervous system.

Symptoms depend on loss of function of the territory served by the involved vessel, either in the central or peripheral nervous system.

Speed of onset is determined by whether arterial or venous supply is involved.

MORBIDITY AND MORTALITY OF STROKE

• The leading cause of serious, long-term disability in the US.

• 800,000 new (majority) or recurrent strokes occur annually in the US.

• Fifth most common cause of mortality in US. • 2.7% prevalence over age 20. • Cost is 14% of health care expenditure.

American Heart Association, Heart and Stroke Statistics – 2016 Update.

RESIDUAL EFFECTS OF STROKE, ASIDE FROM PARALYSIS AND SENSORY LOSS

• Labile emotion (mood swings, depression)

• Perceptual effects: Difficulty recognizing, understanding familiar objects

• Difficulty planning, carrying out simple tasks

• Loss of awareness (One-side neglect)

• Dysphagia (difficulty swallowing)

• Aphasia: difficulty putting thoughts into words or understanding speech

•Subarachnoid •Intraparenchymal

ARTERIAL STROKE

Other 4%

Cryptogenic 26%

Large Artery 17% Cardioaorticembolic 17%

Small artery 21%

Hemorrhagic 15%

Ischemic 85%

Albers GW, et al. Chest. 2004;126:483S512S.

PATHOLOGY

• Atherosclerosis • In situ thrombosis • Often complete

occlusion • High mortality

• Embolization (20%-50%) • Heart or proximal vessels • Artery to Artery

(vertebral stenosis/proximal plaque)

• May cause VBI • Good prognosis

• Subclavian steal syndrome • Symptoms brought on

by arm exercise

• Trauma- Dissection • Especially in the young

• Vertebral artery dissection

• Lacunar (small vessel disease)

STROKE RISK FACTORS

Mayo Clin Proc 2004;79 (10):1330-1340 with permission.

6X

2X 4X

Risk Factor Relative Risk

Reduction

Hypertension 10 mm Hg diastolic drop

for 56% drop in stroke

Diabetes 44% drop in

hypertensives

Smoking Cessation 50% drop first year.

Hyperlipidemia 12% drop in stroke, death, MI or carotid

endarterectomy

Non-valvular Atrial Fibrillation

68% Warfarin

21% ASA

90% DOAC

Adapted from Goldstein, et al. Circulation 2001;103:163-182

MODIFIABLE STROKE RISK FACTORS

NONMODIFIABLE STROKE RISK FACTORS

• Age

• Incidence doubles each decade after age 55

• Biological Sex

• Incidence is a third higher in men in younger ages

• Women live longer so have more strokes overall.

• Race

• Black Americans have a 60% higher risk of death or disability than whites.

• Heredity

• Family history of stroke/TIA (parental stroke<65 stroke risk triples)

• Genetic locus on chromosome 12p13

National Stroke Association

Greenberg S. N Engl J Med 2006;354:1451-1453

LARGE AND SMALL VESSEL DISEASE

PATHOGENESIS OF ARTERIOLOSCLEROSIS • Under the influence of high pressure:

• Replacement of smooth muscle by fibrocartilagenous tissue

• Elastic tissue becomes fragmented

• Onion skin type thickening on microscopy

• Lipohyalinosis:

• Thickening of vessel wall with hyaline material and lipid containing macrophages

• Narrowing or obliteration of lumen

• Some with focal dilatation

• Fibrinoid necrosis is usually associated with extremely high blood pressure, leading to necrosis of smooth muscle cells and extravasation of plasma proteins, which appear microscopically as fine granular eosinophilic deposits in the connective tissue of the vessel wall.

W. Rosenblum, M.D. Neuropathology for Medical Students

CEREBRAL VASCULAR ANATOMY

Reproduced from CNS Pathology Index by Permission.

Reproduced with permission.

SMALL VESSEL DISEASE LACUNAR SYNDROMES

VASCULAR TERRITORIES CEREBRAL HEMISPHERES

MIDDLE CEREBRAL ARTERY STROKE

• Main trunk • Hemiplegia • Hemianesthesia • Hemianopia • Aphasia (dominant) or denial and hemi-

neglect (nondominant)

• Upper division • Hemiparesis and sensory loss (arm and

face more affected than leg) • Expressive (Broca) aphasia (dominant),

denial and hemi-neglect (nondominant)

• Lower division • Receptive (Wernicke) aphasia without

hemiparesis (nondominant)

Adapted from Merritt’s Neurology From Ovid Full Text. NovaSoutheastern Institutional Subscription

ANTERIOR CEREBRAL ARTERY STROKE

• Weakness and sensory loss affecting leg more than arm.

• Impaired responsiveness (“abulia” or akinetic mutism), especially if bilateral.

• Alien hand syndrome. • Frontal type- forced grasping and

manipulating objects.

• Callosal type- loss of bimanual

coordination, intermanual conflict.

Adapted from Merritt’s Neurology From Ovid Full Text. NovaSoutheastern Institutional Subscription

POSTERIOR CEREBRAL ARTERY STROKE

• Occipital unilateral: hemianopia

• Occipital bilateral: cerebral blindness

• Thalamic: hemisensory, +/-delayed pain syndrome

• Subthalamic: Hemiballism

• Bilateral medial temporal lobe: amnesia

SILENT STROKE IS THE MOST COMMON

White patches are

Small vessel strokes involving

Cerebral white matter.

They are seen best on MRI

These silent strokes

cause

Unsteady gait/imbalance

Cognitive impairment

MODERN MAN AND ATHEROSCLEROSIS

THE HORUS STUDY: ATHEROSCLEROSIS IN 4 ANCIENT POPULATIONS EGYPT, PERU, PUEBLO U.S, ALEUTIANS; 34% HAD ATHEROSCLEROSIS

LARGE VESSEL ATHEROSCLEROTIC DISEASE AND TIA

NATURAL EVOLUTION OF TISSUE LOSS DURING ISCHEMIC STROKE

WOODY ALLEN ON STROKE:

My Brain?

It’s my Second

Favorite Organ

AHA/ASA FAST CAMPAIGN

FAST ASSESSMENT • FACE: Ask person to smile; is it uneven or drooping on one side?

•ARM: Ask person to hold both arms up in front of them; does one side drift downward (weakness)?

•SPEECH: Have person say a sentence (“The sky is blue”); is it slurred, strange, or halting?

• TIME: to call 911. TIME IS BRAIN!!!

STROKE IS A TIME CRITICAL EMERGENCY

• TIME IS BRAIN.

• Progressive stroke leads to worsened outcome or death.

• Stroke teams and infrastructure are in place to diagnose and treat stroke rapidly.

• Thirty-four percent of patients arrived within the 3-hour treatment window.

• Specialized stroke units decrease the overall morbidity and mortality of stroke.

• In 2007, rt-PA use hovered around 4% nationally. • 15% to 20% use in stroke centers.

NIHSS A TOOL TO ASSESS STROKE SEVERITY • NIH stroke scale is a tool used universally in stroke treatment centers as a quick

evaluation of stroke severity. Points are assigned for deficits in neurologic function that is commonly associated with stroke.

• Level of consciousness, orientation, following of simple commands, gaze abnormalities, and visual field deficits are scored.

• Weakness of the face, and limbs are graded; and limb ataxia assessed

• Sensation is assessed

• Language (naming items, describing a picture, and reading words and sentences) can identify aphasia and dysarthria

• Extinction (double simultaneous stimulation in vision and tactile realms) and inattention are graded

• Test can be performed in several minutes, a score 1 to 5 is a minor stroke, a score of 6 to 14 is moderately severe, and >15 is a severe stroke

IV THROMBOLYSIS WITH ALTEPLASE (IV TPA)

• Given in 0 to 3 hours after stroke onset yields approximately 30% increase in patients who are independent or can walk with a cane

• Given 3 to 4.5 hours after stroke onset yields approximately 15% increase

• Beyond 4.5 hours the hemorrhagic complications outweigh benefit

• The faster IV tPa is given the better the odds for good outcome

• New thrombolytic Tenecteplase in trials

• Early data suggest this is safer (less bleeding)

• Better recanalization up to 50% good results

• Newest trial extending window to the 4.5-24hr

STROKE 2019 • Recognize symptoms, FAST, call 911

• EMS contacts ER assesses severity of deficits: RACE score

• Interventional team and in house stroke team notified of imminent arrival

• Neuro evaluation done in ER Hallway for NIHSS score, labs drawn, history clarified with EMS and family, any tPa contraindications assessed; patient taken to CT for stat non-contrast study, if negative for blood then iv tPa bolus and drip started in CT unit; then CTA and CTP done, RAPID protocol, results in several minutes; iv tPa started in < 1hour (target < 30 minutes) safe up to 4.5 hr

• If large vessel occlusion (LVO) then intra-arterial intervention with stent retrievers, etc. (target groin puncture by 60 minutes, and vessel open by 90 minutes)

• Novel strategies on horizon for improving stroke recovery, neurotrophic factors, stem cells etc.

CT AND MRI MARKERS OF PENUMBRA

THROMBECTOMY TO OPEN MCA

VINTAGE TELEMEDICINE

I’ll be there

as

Soon as I

can!

TELESTROKE 2019

CASE DISCUSSED AT A STROKE MEETING IN RECENT YEARS (BRITISH HAVE CONSIDERED HOLDING IV TPA FOR > 80YO)

HYPERTENSIVE VASCULOPATHY

• Charcot-Bouchard aneurysms are areas of focal dilatation in the small vessel wall, which may thrombose, leading to vessel occlusion.

W. Rosenblum, M.D. Neuropathology for Medical Students

Aneurysmal dilation

Qureshi A et al. N Engl J Med 2001;344:1450-1460

Mortality at 6 months up to 58%

MOST COMMON SITES INTRACEREBRAL HEMORRHAGE

Qureshi A et al. N Engl J Med 2001;344:1450-1460

SITES OF HYPERTENSIVE HEMORRHAGE

A. Lobar

B. Basal Ganglia

C. Thalamus

D. Pons

E. Cerebellum

Penetrating

end-arteries,

50-200

microns,

decreased

compliance,

weakened

vessel walls

• Putamen 55%

• Lobar 15%

• Thalamus 10%

• Pons 10%

• Cerebellum 10%

Smirniotopoulos - USU - 2008

INTRAPARENCHYMAL HEMORRHAGE

• High (30-35%) 30 day mortality for medium to large bleeds.

• Clots ≥30 ml

• 1.5% independent in one month.

• Clots ≥60 ml, Glasgow Coma Scale ≤8

• Mortality 90%.

• Anticoagulation ass. bleed mortality • Warfarin: 50%

• NOAC: 28%

• Hematoma growth within first 24 hour cause of secondary neurological deterioration

Neuroradiology: The requisites by Yossem, Zimmerman and Grossman, Third Edition Mosby and 2010Qureshi A et al. N Engl J Med 2001;344:1450-1460

TREATMENT OF INTRACEREBRAL HEMORRHAGE

• Airway Breathe Circulate

• Dedicated stroke ICU better outcomes

• Assess ICH score

• Reverse anti-coagualants

• Control BP, current target < 160 systolic early and < 130/80 at D/C

• DVT protection

• Surgical decompression only clearly beneficial in Cerebellar hemorrhage

• Extracranial Ventricular Drainage for hydrocephalus

Stam, J. N Engl J Med 2005;352:1791-1798

VENOUS OCCLUSION CAUSING STROKE CT IMAGING OF SINUS THROMBOSIS

TESTING TO DEFINE THE TYPE OF STROKE

STROKE CLASSIFICATION

LIFE STYLE CHANGES AND STROKE

• Live a healthy lifestyle

• Exercise regularly

• Control Blood Pressure

• Target Cholesterol < 200, LDL <100 (<70 if Diabetic)

• Recognize stroke symptoms (FAST)

• Time is brain, if you have symptoms, call 911

• IV tPa leads to 30% improved outcome

• IA intervention is evolving rapidly, and with advanced neuro-imaging we can often salvage brain, often out to 24 hours

PERHAPS BEST ADVICE FOR STROKE PREVENTION

“THE FUTURE AIN’T WHAT IT USED TO BE”