Acute Stroke: The Disease and Rapid Recognition• Timothy Hehr RN MA & Amy Castle RN

• April 11, 2014• Annual Conference for Professionals in

Brain Injury

Stroke Facts

Stroke is the fourth leading cause of death in the United States

795,000 people in the U.S. suffer strokes each year

133,000 deaths in the U.S. each year

– From 1998 to 2008, the stroke death rate fell approximately 35 percent and number of deaths fell by 19 percent

7,000,000 stroke survivors

© 2011 National Stroke Association

Stroke Facts

A leading cause of adult disability

Up to 80 percent of all strokes are preventable through risk factor management

On average, someone suffers a stroke every40 seconds in the United States

© 2011 National Stroke Association

Women & Stroke

Stroke kills more than twice as many American women every year as breast cancer

More women than men die from stroke and risk is higher for women due to higher life expectancy

Women suffer greater disability after stroke then men

Women ages 45 to 54 are experiencing a stroke surge, mainly due to increased risk factors and lack of prevention knowledge

© 2011 National Stroke Association

African Americans & Stroke

Incidence is nearly double that of Caucasians

African Americans suffer more extensive physical impairments

Twice as likely to die from stroke than Caucasians

High incidence of risk factors for stroke–Includes hypertension, diabetes, obesity,

smoking and sickle cell anemia© 2011 National Stroke Association

Hispanics & Stroke

Higher incidence among Mexican Americans than Caucasians

Mexican Americans are at increased risk for all types of stroke and TIA at younger ages than Caucasians

Spanish-speaking Hispanics are less likely to know stroke symptoms than English-speaking Hispanics, African Americans and Caucasians

© 2011 National Stroke Association

Well-known Stroke Survivors

• President Gerald Ford

• Teddy Bruschi

• Sharon Stone

• Della Reese

• Kirk Douglas

• Roy Horn of Siegfried & Roy

• Mary Kay Ash

• Charles Schultz

• Harry Caray

• Charles Dickens

• Ed Koch

• Ted Williams

© 2011 National Stroke Association

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Traumatic Brain Injury (TBI)and Stroke – is there an

Association?

Early studies suggest the answer is YES!

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Patients With Traumatic Brain InjuryPopulation-Based Study Suggests Increased Risk of Stroke

• Original Contributions; Clinical Sciences• Yi-Hua Chen, PhD; • Jiunn-Horng Kang, MD; • Herng-Ching Lin, PhD

- Stroke. 2011; 42: 2733-2739

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Stroke Occurrence

Total Patients With TBI Comparison Cohort

No. % No. % No. %

3-Mo follow-up    Yes 882 0.95 675 2.91 207 0.30    No 91 914 99.05 22524 97.09 69390 99.70    Crude HR (95% CI) … 10.20* (8.71–11.93) 1.00

    Adjusted HR (95% CI)

… 10.21* (8.71–11.96) 1.00

1-Y follow-up    Yes 1637 1.76 968 4.17 669 0.96    No 91 159 98.24 22231 95.83 68928 99.04    Crude HR (95% CI) … 4.61* (4.17–5.11) 1.00

    Adjusted HR (95% CI)

… 4.61* (4.16–5.11) 1.00

5-Y follow-up    Yes 4611 4.97 1901 8.20 2710 3.89    No 88 185 95.03 21298 91.8 66887 96.11    Crude HR (95% CI) … 2.34* (2.20–2.50) 1.00

    Adjusted HR (95% CI)

… 2.32* (2.17–2.47) 1.00

Crude and Adjusted Hazard Ratios of Stroke Among Sampled Patients During the 3-Month, 1-Year, and 5-Year Follow-Up Periods From Index Health Care Utilization (N=92 796)

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Stroke Occurrence

Comparison Cohort Patients With TBI With Skull Fracture

Patients With TBI Without Skull Fracture

No. % No. % No. %

3-Mo follow-up    Yes 207 0.30 58 4.22 617 2.83    No 69390 99.70 1315 95.78 21209 97.17    Crude HR (95% CI) 1.00 19.44* (14.35–26.34) 9.76* (8.32–11.44)

    Adjusted HR (95% CI)

1.00 19.98* (14.73–27.22) 9.75* (8.31–11.45)

1-Y follow-up    Yes 669 0.96 73 5.32 895 4.10    No 68928 99.04 1300 94.68 20931 95.90    Crude HR (95% CI) 1.00 8.12* (6.27–10.51) 4.45* (4.02–4.94)

    Adjusted HR (95% CI)

1.00 8.39* (7.47–10.89) 4.44* (4.00–4.93)

5-Y follow-up    Yes 2710 3.89 115 8.38 1786 8.18    No 66887 96.11 1258 91.62 20040 91.82    Crude HR (95% CI) 1.00 3.47* (2.81–4.28) 2.29* (2.15–2.45)

    Adjusted HR (95% CI)

1.00 3.54* (2.86–4.37) 2.26* (2.12–2.42)

Crude and Adjusted Hazard Ratios of Stroke Among Sampled Patients During 3-Month, 1-Year, and 5-Year Follow-Up Periods From Index Health Care Utilization According to TBI Subtype (N=92 796)

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Stroke OccurrenceTotal n=92 796 Patients With TBI n=23 199 Comparison Cohort n=69 597

No. % No. % No. %Subarachnoid hemorrhage    Yes 155 0.17 94 0.41 61 0.09

    Crude HR (95% CI) 4.83* (3.82–7.17) 1.00

    Adjusted HR (95% CI) 4.89* (3.81–7.19) 1.00

Intra-cerebral hemorrhage    Yes 664 0.72 457 1.92 207 0.30

    Crude HR (95% CI) 6.28* (5.58–7.77) 1.00

    Adjusted HR (95% CI) 6.33* (5.60–7.83) 1.00

Ischemic stroke

    Yes 2617 2.82 857 3.69 1760 2.53

    Crude HR (95% CI) 1.46* (1.34–1.60) 1.00

    Adjusted HR (95% CI) 1.43* (1.31–1.56) 1.00

Unspecified stroke

    Yes 1175 1.27 493 2.13 682 0.98

    Crude HR (95% CI) 2.23* (2.02–2.47) 1.00

    Adjusted HR (95% CI) 2.21* (1.99–2.44) 1.00

Crude and Adjusted Hazard Ratios of Stroke by Stroke Subtype Among Sampled Patients During 5-Year Follow-Up From Index Health Care Utilization

Traumatic brain injury may be an independent risk factor for stroke

• James F. Burke, MD, MS, Jessica L. Stulc, MD, MPH, Lesli E. Skolarus, MD, MS, Erika D. Sears, MD, MS, Darin B. Zahuranec, MD, MS and Lewis B. Morgenstern, MD- Neurology July 2, 2013 vol. 81 no. 1 33-39

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Traumatic brain injury may be an independent risk factor for stroke

• Results and Conclusion:

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Results: The cohort included a total of 1,173,353 trauma subjects, 436,630 (37%) with TBI. The patients with TBI were slightly younger than the controls (mean age 49.2 vs 50.3 years), less likely to be female (46.8% vs 49.3%), and had a higher mean injury severity score (4.6 vs 4.1). Subsequent stroke was identified in 1.1% of the TBI group and 0.9% of the control group over a median follow-up period of 28 months (interquartile range 14–44). After adjustment, TBI was independently associated with subsequent ischemic stroke (hazard ratio 1.31, 95% confidence interval 1.25–1.36).

Conclusions: In this large cohort, TBI is associated with ischemic stroke, independent of other major predictors.

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Normal human brain anatomy and physiology

• Lobes

• Meninges

• Functions

• Humonculus

• Circulation18

Brain anatomy

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Regions of the Brain

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Broca’s Area: Receptive Aphasia

Wernicke’s Area: Expressive

Aphasia

Brain anatomy: Meninges

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Homonculus

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MCA – Face & Arm Affected

> LegACA – Leg

> Arm

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Major Vessels

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Circle of Willis

• Carotid arteries and the basilar artery feed into the Circle of Willis

• Circle creates a “backup” system

• Communicating arteries connect the major brain arteries; blood can flow both ways and shift blood from other arteries to compensate for blockages if necessary

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Stroke - disruption of normal blood flow to the brain

Blockage Breakage

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Thrombosis vs. Embolism in Ischemic Strokes

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Thrombosis vs. Embolism in Ischemic Strokes

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Area of damage/specific deficit

Basilar arteryBalance

Basic Body Function

• Links both vertebral arteries– Bilateral sensory loss– Bilateral paralysis– Coma– Changes in muscle tone– Cranial nerve involvement

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Posterior Cerebral Artery

• 5-10% of strokes• Feeds the back of the brain• Supplies midbrain, basal

ganglia, thalamus, occipital lobe, hippocampus and lower temporal and parietal lobes

– Loss of contra-lateral sensation– Contra-lateral paralysis– Dysconjugate eye movements– Nystagmus– Other cranial nerve involvement

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Opposite Side motor & sensoryCranial Nerves

www.finr.net (2012)

Middle Cerebral Artery

• 90% of all strokes• Largest of the brains arteries• Supplies most of the outer

surface of the frontal, parietal and temporal lobes. Supplies blood to basal ganglia– Contra-lateral weakness– Sensory loss– Homonymous hemianopia – Left – aphasic– Right- neglect, poor motivation

37 www.finr.net (2012)

Anterior Cerebral Artery• Less common stroke• Feeds the interior part, deep

brain structures, frontal and parietal lobes, corpus callosum, bottom of cerebrum– Weakness and sensory loss

contra-lateral leg– Clumsy– Slow to initiate response– Apathy– Mute– Short term memory loss– Impulsivity– Lack of concentration– Incontinence

38 www.finr.net (2012)

Ischemic Penumbra

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Ischemic Penumbra

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Ischemic vs Hemorrhagic Strokes

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Hemorrhagic Stroke

Hemorrhagic Stroke

Intracerebral (Intraparenchymal) Hemorrhage• Mortality rate: 35 – 55%

Subarachnoid Hemorrhage• Approximately 15% of non-traumatic SAH

cause death prior to reaching medical attention

• Mortality rate is approximately 50% overall

Intracerebral Hemorrhage

Traumatic Brain Injury

Increased risk possibly due to weakened vessels from TBI

Hypertension (most common cause)• Prolonged (20+ years), poorly controlled HTN• Small vessels deep w/in brain most susceptible

Substance Abuse• Younger population• Cocaine, meth• Other Rx and OTC stimulants

(pseudoephedrine, Ritalin, Viagra, diet aids)• Small vessels most susceptible

Intracerebral Hemorrhage

Subarachnoid Hemorrhage (Non-traumatic)

• 80% caused by ruptured aneurysm

• Other 20% due to AVM, HTN, vasculitis, tumors, clotting abnormalities, etc.

• Note – this is referring to DIRECT SAH from trauma – as noted earlier, prior TBI also increases risk of SAH

Subarachnoid Hemorrhage

Normal SAH

Hemorrhagic Stroke: Common Symptoms

• Altered LOC

• Sudden onset of severe HA - “Worst headache of my life” (SAH)

• Photophobia (sensitivity to light)

• Focal neuro deficits- Symptoms depend upon where the bleeding occurs (i.e. weakness or slurred speech)

Signs of Increased Intracranial Pressure

• Headache• Altered LOC • Nausea / Vomiting

Late signs of Increased ICP

• Cushing’s Triad

- Elevated SBP / widening pulse pressure

- Bradycardia

- Respiratory irregularity

• Pupil change in size or response

- Very late response

- Indication of herniation

Challenge of stroke

• Delay in presentation- Denial- Does not hurt- Wake up strokes

• Stroke mimics- Postictal- Complex migraine- Hypo/hyperglycemia- Bells palsy (in Bells Palsy – inability to raise eyebrow)- Transient global amnesia- Tumors/abscess- Syncope/hypotension/hypoxia

Risk Factors

Cannot Control• Hypertension• Smoking• Cholesterol• Diabetes• Atrial Fibrillation

Can Control

• Age• Heredity & Race• Gender

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Stroke Signs & Symptoms

• Weakness and/or numbness of face, arm and/or leg (most often on the same side of body)

• Expressive aphasia (may appear as confusion)

• Receptive aphasia (may appear as confusion)

• Dysarthria (slurred speech)

• Confusion

Stroke Signs & Symptoms

• Visual deficits: blurry, double-vision, or loss of vision

• Dysconjugate gaze

• Dizziness

• Nausea / vomiting

• Difficulty walking

Stroke Signs & Symptoms

• Ataxia

• Difficulty swallowing

• Neglect (or inattention) to one side of body

• Decreased LOC (particularly with hemorrhagic strokes)

• Severe HA (hemorrhagic stroke)

Community Education – Think FAST!

= FACE: Ask the person to smile

= ARM: Raise both arms

= SPEECH: Ask the person to speak

= TIME: Call 911

F

A

S

T

Last Known Well

• TIME is the key to treatment options

• Establish last known well- Information from family

• Expedite transport to the nearest “stroke ready” facility (able to give IV tPA)

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TIME IS BRAIN- ISCHEMIC STROKE TREATMENT

• 0-4.5 hours - IV- alteplase (tPA)- Clot busting drug

• 0-8 hours - Endovascular treatment options (may be done in

addition to IV tPA)- IA tPA- IA thrombectomy

• > 8 hours- unknown- Secondary prevention/consult Neuro specialists

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IV Thrombolytic Therapy (Alteplase)

• IV rtPA (alteplase) can be given if the patient meets criteria and the drug can be started within 4.5 hours of onset of symptoms.- 0 – 3 hours approved by FDA (for stroke)- 3 – 4.5 hours recommended by American

Stroke Association based on a European research study

• Because it takes approximately 1 hour to complete the necessary work-up, patients who present within 3 hours of “last known well” should be considered IV rtPA candidates

Outside the window

Stroke

is still an EMERGENCY

Within 9 hrs LKW

Last Known well- 4.5-10 hours

• Treatment options still available!

• Advanced Imaging required- CTA or diffusion weighted MRI- Large vessel clot/salvageable pneumbra

• Intra-arterial treatment- IA tPA- IA mechanical clot retrieval

Pneumbra

Before & After

Solitaire

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Aneurysm Coiling v. Clipping

Coiling (endovascular)

Clipping (surgery)

Questions? And Contact Information

• Tim Hehr RN MA- Timothy.Hehr@allina.com

• Amy Castle RN- Amy.Castle@allina.com

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