acute brain attack 911

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

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


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


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


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.


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


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


CT SCAN NOT AVAILABLENo specific emergent drug treatment recommendedNeuroprotectionConsult a neurologist or neurosurgeonEarly supportive rehabilitation


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


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


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


EMERGENT DIAGNOSTICSComplete Blood CountBlood sugar (CBG, HGT, RBS)PT/PTTSerum Na and K+Electrocardiogram (ECG)Plain CT Scan of brain ASAP


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


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)



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)


EMERGENT DIAGNOSTICS:

Complete blood count,

Blood Sugar,

PT/PTT,

Serum Na, K

Electrocardiogram,

Plain CTscan of the brain


EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)

Non-cardioembolic (Thrombotic/Lacunar)

- May give aspirin 160-325mg/day

- Neuroprotection

- If cerebellar infarct, consult neurosurgeon ASAP


Place of Treatment: Hospital, Intensive Care Unit or

Acute Stroke Unit


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

acute brain attack 911

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