stroke ceu
Post on 21-Jan-2018
64 Views
Preview:
TRANSCRIPT
GOALS & OBJECTIVES
• REVIEW CLINICALLY RELEVANT NEUROANATOMY
• ANATOMY INVOLVED IN STROKE SYNDROMES
• DISCUSS PRE-HOSPITAL AND HOSPITAL EVALUATION OF PATIENTS SUSPECTED OF STROKE
• ENHANCE PERSPECTIVE FOR PRE-HOSPITAL PROVIDERS
• CLINICAL PEARLS TO OPTIMIZE PATIENT CARE
• PROVIDE CASE-BASED CLINICAL SCENARIOS FOR KNOWLEDGE ASSESSMENT AND TUTORIAL
• IMPROVE PRE-HOSPITAL PROVIDER AWARENESS OF STROKE/MIMICS
STROKE PATHOLOGY & EPIDEMIOLOGY • STROKE IS AN INFARCT OF THE BRAIN
• A CLOTTED BLOOD VESSEL CUTS OFF BLOOD SUPPLY CAUSING DEATH OF THE TISSUE THAT VESSEL SUPPLIES
• RISK FACTORS: HYPERTENSION, DM, SMOKING, AGE, ATRIAL FIBRILLATION
• DISTINCT FROM INTRACRANIAL HEMORRHAGE
• NATIONALLY, EACH YEAR:
• 795,000 PEOPLE HAVE A STROKE
• 5TH LEADING CAUSE OF DEATH
• LOCALLLY:
• >350 PATIENTS SUSPECTED OF STROKE PRESENTED TO UF HEALTH-JACKSONVILLE IN 2016
• APPROXIMATELY 60% AS PRE-HOSPITAL STROKE ALERTS AND 40% STROKE ALERTED IN ED
NEUROANATOMY
• CENTRAL NERVOUS SYSTEMCerebellummovement, balance,
speech
Cranial Nerves
MOTORHOMONCULUS• ACA=ANTERIOR CEREBRAL ARTERY
• MCA=MIDDLE CEREBRAL ARTERY
• EXTREMITY WEAKNESS IS EVIDENT IN THE
OPPOSITE SIDE THAN THE BRAIN AFFECTED
• THIS IS BECAUSE NERVES THAT CONTROL
EXTREMITY MOVEMENT CROSS SIDES IN
THE BRAIN STEM AS CONNECTS WITH
SPINAL CORD
ACA
MCA
VASCULAR DISTRIBUTION
ANTERIOR
CIRCULATION
POSTERIOR
CIRCULATION
1
2
3 4
56 789
101112
Pons
Medulla
Midbrain
• MIDBRAIN
• CN3-4
• PONS
• CN5-8
• MEDULLA
• CN9-12
1
2
34
56 789
101112
Midbrain
CRANIAL NERVESLooks down
Looks lateral
All other directions
CNS LESION BY VASCULAR DISTRIBUTIONANTERIOR CIRCULATION LESION• ANTERIOR AND MIDDLE CEREBRAL ARTERIES ARISE FROM CAROTID ARTERY—ANTERIOR CIRCULATION
• MCA—CORTEX, UPPER LIMB AND FACE, WERNICKE’S/BROCA’S AREA (LEFT BRAIN)
• WEAKNESS OF OPPOSITE SIDE, LOSS OF SENSATION
• APHASIA (DIFFICULTY SPEAKING)
• ACA—CORTEX, LOWER LIMB
• WEAKNESS OF OPPOSITE SIDE, LOSS OF SENSATION
• LATERAL STRIATE ARTERY—INTERNAL CAPSULE
• WEAKNESS OF OPPOSITE SIDE, SENSATION INTACT
• INFARCT DUE TO UNMANAGED HYPERTENSION
PUTTING IT TOGETHERPOSTERIOR CIRCULATION LESION• POSTERIOR CEREBRAL ARTERY ARISES FROM VERTEBRAL ARTERY—POSTERIOR CIRCULATION
• “CEREBELLAR SIGNS” AND CRANIAL NERVE INVOLVEMENT CAN HELP IN DETERMINING IF “DIZZINESS” OR VERTIGO IS
SIGNIFYING A POSTERIOR CIRCULATION STROKE
• PICA—CN 8, 9, 10, SYMPATHETIC ANS FIBERS, CEREBELLUM, LATERAL SPINOTHALAMIC TRACT
• VERTIGO (DIZZINESS), VOMITING, NYSTAGMUS (ABNORMAL EYE MOVEMENT), DYSPHAGIA (DIFFICULTY SWALLOWING),
HOARSENESS, DECREASED GAG REFLEX
• HORNER’S SYNDROME ON SAME SIDE—EYELID DROOP, SMALL PUPIL, LACK OF SWEAT
• ATAXIA—UNSTEADY GAIT, DYSMETRIA—CANNOT COORDINATE FINGER-TO-NOSE
• DECREASED PAIN/TEMP SENSATION AT LIMBS OF OPPOSITE SIDE
• AKA--LATERAL MEDULLARY SYNDROME
PUTTING IT TOGETHERPOSTERIOR CIRCULATION LESION• AICA—CN 5,7,8, ANS SYMPATHETIC FIBERS, CEREBELLUM, SPINOTHALAMIC TRACT
• DECREASE IN TASTE, SALIVATION, LACRIMATION, CORNEAL REFLEX
• FACIAL PARALYSIS OF SAME SIDE
• VERTIGO, VOMITING, NYSTAGMUS, DECREASED HEARING
• HORNER’S SYNDROME OF SAME SIDE
• ATAXIA, DYSMETRIA
• DECREASED PAIN AND TEMP SENSATION OF SAME SIDE
• AKA--LATERAL PONTINE SYNDROME
APHASIA VS. DYSARTHRIA• APHASIA– CLEAR SPEECH, DIFFICULTY COMMUNICATING
• ASSOCIATED WITH LEFT MCA DISTRIBUTION
• ANTERIOR CIRCULATION
• DIFFERENT TYPES:
• BROCA’S, WERNICKE’S, GLOBAL, CONDUCTION
• DYSARTHRIA– SLURRED SPEECH
• ASSOCIATED WITH CEREBELLAR OR CRANIAL NERVE DYSFUNCTION
• POSTERIOR CIRCULATION
CASE—YOU ARRIVE ON SCENE
• 59 YO M W/ HX HTN, P/W RIGHT FACIAL DROOP AND RIGHT UPPER EXTREMITY WEAKNESS, SPEECH
DIFFICULTY. CO-WORKERS CALLED 911 AFTER NOTICING HE WASN’T ACTING RIGHT WHEN ARRIVING AT
WORK. LAST SEEN NORMAL AT 4 AM AFTER WAKING UP (4.5 HOURS AGO), PER WIFE WHO IS ALSO
PRESENT ON SCENE. WIFE STATES NORMAL STATE OF HEALTH PRIOR. DENIES OTHER COMPLAINTS. NO
CP/ABDOMINAL PAIN/SOB/FEVER/CHILLS/TRAUMA. HX PROVIDED BY WIFE AND CO-WORKERS, LIMITED
BY CONDITION.
CASE—FIELD ASSESSMENT
• VS:
• 98.7F ORAL, HR 102, BP 142/88, RR 14, O2 96% RA, ACCUCHECK 119
• EXAM:
• ALERT, NO DISTRESS, A&O X1 (TO SELF ONLY), SPEAKS IN 1 WORD SENTENCES, CLEAR SPEECH BUT
CONFUSED RESPONSE, + RIGHT FACIAL DROOP, RIGHT UPPER EXTREMITY WEAKNESS. LEFT UPPER
EXTREMITY AND BOTH LOWER EXTREMITIES HAVE FULL STRENGTH. NO EYE/TONGUE DEVIATION.
• STROKE ALERT PAGED FROM FIELD
EVALUATION—PRE-HOSPITAL
• LAMS score >4 correlates with NIHSS, and
is highly predictive of large artery
Anterior Circulation stroke
• ACA and MCA arterial distributions
previously discussed
EVALUATION—PRE-HOSPITAL
EVALUATION—PRE-HOSPITAL
EVALUATION—ED• NIHSS/MNIHSS
• ASSESSES SEVERITY OF STROKE
• ALSO AT THIS POINT
• VITALS
• LIKELY HYPERTENSIVE
• POSSIBLY MILD FEVER
• POCT GLUCOSE, EKG, CXR, CT HEAD
• LABS:
• CBC, BMP, PT/INR, PTT
1
0
2
0
2
2
0
000
1
2
0
111
0
EVALUATION—ED
• COOPERATIVE EFFORT WITH ED,
NEUROLOGY, AND
INTERVENTIONAL RADIOLOGY
• WITHIN 6.5 HOURS OF ONSET,
PAGE STROKE ALERT
• NIHSS 4 OR MORE:
• CT HEAD
• CONSIDER TPA
• NIHSS 6 OR MORE:
• CTA HEAD/NECK
• CONSIDER IR
IV TPA• ALTEPLASE—TISSUE PLASMINOGEN ACTIVATOR
• “CLOT BUSTER”, THROMBOLYSIS, ACTIVELY DISSOLVES CLOT
• RISK OF BLEEDING
EVALUATION—INTERVENTIONAL RADIOLOGY
• WINDOW ABOUT 8 HRS
• VOLUME <90 CC ON DWI MRI
• ASPECTS SCORE
• INTERVENTIONAL METHODS:
• CATHETER DIRECTED THROMBOLYSIS WITH INTRA-ARTERIAL TPA
DIRECTLY TO CLOT
• CLOT EXTRACTION
• LESS BLEEDING RISK AND MORE LIBERAL TIME WINDOW THAN IV TPA
• LIMITED TO LARGE VESSEL OCCLUSION AND SMALL INFARCT SIZE
EVALUATION—NEUROLOGY
EVALUATION—NEUROLOGY
• MRS
TIA?ED EVALUATION
BACK TO OUR PATIENT
• NON-CONTRAST CT HEAD
• NO HEMORRHAGE (HEMORRHAGE SHOWS UP WHITE--HYPER DENSITY)
• + LEFT MCA DISTRIBUTION HYPO DENSITY (DARK AREA)
• ACUTE STROKE
• CAN BE SUBTLE
• CT CAN BE COMPLETELY NORMAL STROKE IS EARLY
ACA
MCA
INTRACRANIAL HEMORRHAGE• SUBARACHNOID
• HEADACHE—SUDDEN, MAXIMAL, DIFFERENT FROM USUAL
• STROKE-LIKE SX OR SIGNS, MENINGISMUS (STIFF NECK)
• NON-TRAUMATIC: COMMONLY ANTERIOR COMMUNICATING ARTERY ANEURYSM RUPTURE
• TRAUMA
• SUBDURAL
• BRIDGING VEINS, ELDERLY, TRAUMA
• EPIDURAL
• TEMPORAL BONE TRAUMA, MIDDLE MENINGEAL ARTERY
• LUCID INTERVAL
• INTRAPARENCHYMAL
• TRAUMA, INVOLVES CORTEX
SAH
SDHEDH
CASE CONTINUED
• PATIENT IS OUTSIDE OF TPA TIME WINDOW
• >4.5 HOURS SINCE ONSET
• INTERVENTIONAL RADIOLOGY CONSIDERING INTERVENTION, PENDING MRI
• THROUGH ED COURSE
• PATIENT BECOMES LESS RESPONSIVE, MORE CONFUSED/AGITATED, ELEVATED CORE TEMP—102F
• INTERVAL DECLINE IN MENTAL STATUS MEANS MORE LIKELY EVOLVING PROCESS, SUCH AS EXPANSION OF PENUMBRA
(AREA OF BRAIN AFFECTED BY INFARCT), INFECTION, OR HEMORRHAGE (PATIENT HAD A NEGATIVE CT FOR HEMORRHAGE)
• INTUBATED FOR AIRWAY PROTECTION/ANTICIPATED COURSE
CASE CONTINUED– FINAL DX: MENINGITIS
• DEFINITIVE DX/TX AND HOSPITAL COURSE
• LUMBAR PUNCTURE—CSF TESTING: GRAM POSITIVE DIPLOCOCCI SUGGESTIVE OF PNEUMOCOCCUS
• MRI
• LEFT TEMPORAL MENINGITIS/ENCEPHALITIS W/ ASSOCIATED MIDDLE EAR INFECTION C/W CHOLESTEATOMA
• NO ACUTE INFARCT OR HEMORRHAGE
• S/P LEFT TYMPANOMASTOIDECTOMY, INFRATEMPORAL MIDDLE POSTAURICULAR CRANIAL FOSSA
CRANIOPLASTY
• EXTUBATED, DISCHARGED 12 DAYS LATER, NO RESIDUAL DEFICITS TO DATE
MANY PATHOLOGIES MIMIC STROKE • STROKE MIMICS—METABOLIC, INFECTIOUS, AUTOIMMUNE, VASCULAR, ONCOLOGIC, PSYCHIATRIC
• ICH, COMPLICATED MIGRAINE, HTN ENCEPHALOPATHY
• BLOOD SUGAR ABNORMALITIES, HYPOKALEMIA/HYPONATUREMIA
• LABRYNTHITIS/MENIERE’S (INNER EAR PROBLEMS), DEMYELINATING DISEASE, GUILLAIN-BARRE SYNDROME
• MENINGITIS/ENCEPHALITIS, BOTULISM, BELL’S PALSY
• TODD’S PARALYSIS/SEIZURE, WERNICKE’S ENCEPHALOPATHY
• CAROTID/VERTEBRAL/AORTIC DISSECTION, CAVERNOUS SINUS THROMBOSIS
• MASS/EDEMA, HYDROCEPHALUS, TRAUMA
• DRUG TOXICITY, CONVERSION DISORDER
PRE-HOSPITAL STROKE ALERT PEARLS• TIME LAST SEEN AT NORMAL---ASK PATIENT, ASK FAMILY, ASK AGAIN
• WAS IT A ‘WAKE-UP’ STROKE?
• WHAT IS BASELINE, PROGRESSION OF SX?
• GET YOUR ACCUCHECK BEFORE PAGING STROKE ALERT
• HX—DRUGS/INGESTIONS/MEDS? AMS STATIC OR DYNAMIC/HEADACHE/CHEST PAIN?
• LOW GRADE FEVER MAY BE PRESENT WITH STROKE BUT ALSO MAY FOREBODE INFECTIOUS PROCESS
• PATIENT MAY PRESENT AS SEEMINGLY ONLY CONFUSED OR APHASIC
• SEIZURES:
• CAN RESULT FROM STROKE
• CAN CAUSE STROKE-LIKE SYNDROME, NOT A REAL STROKE (TODD’S PARALYSIS)
• IN PATIENT’S WITH ELEVATED ICP, EKG CAN LOOK LIKE CARDIAC STRAIN
• CAN ALSO BE HAVING A CARDIAC EVENT
• AVOID HYPOTENSION AND HYPOXEMIA
EKG in patient with elevated ICP
PRE-HOSPITAL STROKE ALERT PEARLS• ACCUCHECK BEFORE PAGING STROKE ALERT,
• LISTEN TO YOUR PATIENT—ATTENTION TO SYMPTOMS/SIGNS/VITALS!
• USE PRE-HOSPITAL SHORTENED NIHSS TO ASSESS SEVERITY
• HAS BEEN FOUND TO BE ACCURATE AND USEFUL
• COMMUNICATE LAMS SCORE ON ARRIVAL TO ED
• MAY BE DYNAMIC, WILL HELP GUIDE HOSPITAL CARE
CONCLUSIONS• STROKE CAN HAVE MANY FORMS AND MANY MIMICS
• DIFFICULT TO DISCERN PRE-HOSPITAL
• HISTORY, PHYSICAL, VITALS ARE INTEGRAL
• LOW THRESHOLD FOR STROKE ALERT, EXPEDITE CARE FOR DEFINITIVE DX/TX
• MAY BE END UP BEING A DIFFERENT DX, BUT EQUALLY OR MORE LIFE THREATENING PATHOLOGY
• KNOWING UNDERLYING ANATOMY AND PEARLS AND PITFALLS CAN HELP WITH STROKE ASSESSMENT
• PRE-HOSPITAL ASSESSMENT AND CARE IS CRUCIAL TO ED AND INPATIENT MANAGEMENT
• STROKE ALERTS FROM THE FIELD EXPEDITE HOSPITAL CARE
• WHAT YOU DO MATTERS!
THANKS & REFERENCES• JOSEPH SABATO, M.D.
• ANDREW SCHMIDT, D.O.
• CLINICAL NEUROANATOMY MADE RIDICULOUSLY SIMPLE, 3RD ED
• ATLAS OF HUMAN ANATOMY 5TH ED
• TINTINALLI’S EMERGENCY MEDICINE MANUAL, 7TH ED
• EMERGENCY DEPARTMENT RESUSCITATION OF THE CRITICALLY ILL
• LIFE IN THE FAST LANE
• BOARD REVIEW SERIES-GROSS ANATOMY, 5TH ED
• GRAY’S ANATOMY FOR STUDENTS
• USMLE FIRST AID
• MDCALC
• CENTER FOR DISEASE CONTROL
• AMERICAN HEART ASSOCIATION
top related