Treatment of Ischemic Stroke in the Neuro-ICU

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1 Treatment of Ischemic Stroke in the Neuro-ICU Gary L. Bernardini, MD, PhD Professor of Neurology Director, Stroke and Neurocritical Care Departments of Neurology and Neurosurgery Albany Medical Center Albany, NY

2 Treatment of Ischemic Stroke in the Neuro-ICU Nothing to disclose

3 Overview What type of strokes treated in NICU Specific monitoring available in NICU Presentation of 2 cases

4 Which strokes need the Neuro-ICU? Ischemic Strokes space occupying lesion, e.g., malignant MCA infarct depressed level of consciousness post IV rt-pa post neuroendovascular procedures (IA rt-pa, MERCI, Penumbra, Solitaire) Intracerebral hemorrhage (ICH) ICP management Acute blood pressure control S/P evacuation Subarachnoid hemorrhage (SAH) Need for intubation Any ICP issues Significant medical co-morbidities Help define Comprehensive Stroke Centers

5 Diagnostic and Treatment Modalities Specific to Neurocritical Care Intracranial pressure (ICP) monitoring Ventricular and spinal drainage Continuous EEG monitoring Induced hypothermia Brain tissue oxygen monitoring Brain tissue perfusion Jugular venous oxygen monitoring Licox Hemedex Perfusion Monitor

6 LICOX monitor

7 Diagnostic and Treatment Modalities Specific to Neurocritical Care Transcranial Doppler monitoring Cerebral perfusion imaging SPECT CT Perfusion MR PI Barbituate-induced coma Hemostatic therapy Thrombolytic reperfusion therapy Cerebral microdialysis Hyperosmotic therapy Multimodality data acquisition and analysis

8 Temperature regulation: Normothermia and Therapeutic Hypothermia ZOLL Alsius Cathethers IVTM

9 Case 1 Patient is 60-year-old left-handed man with h/o stroke 10 years ago, left CEA 2 months PTA, right CEA 1 month PTA, DM-2, HTN, smokes 1-pk/day for 30 years, dyslipidemia, last seen normal at 1630 on June 23, 2013 Awoke from nap at 1810 and wife found him lying in kitchen with left hand weakness, left facial droop and slurred speech. EMS called BP 159/104, HR 80 Taken to AMC Neuro exam: awake, dysarthric, right gaze preference, left facial droop, left UE 0/5 and LE 3/5 strength, 5/5 strength on right, sensory intact no extinction NIHSS= 12 Within window and received IV rt-pa

10 Case 1 Initial head CT: old right frontal stroke Hyperdense MCA sign CTA (not shown): Right M1 MCA occlusion

11 CTP shows significant decreased rcbf and increased MTT in right hemisphere Case 1: CT Perfusion

12 Case 1 Angio: right M1 MCA occlusion Solitaire stent retriever device in place Post Solitaire with reperfusion thru right M1 MCA Lateral view with distal M3, M4 brs with continued slowed flow

13 Case 1 Post Solitaire Rx head CT: Significant hemorrhage right subcortical frontal lobe

14 Case 1 Underwent surgical evacuation with hemicraniectomy

15 Case 1 MRI DWI right fronto-parietal stroke with residual hemorrhage on MRI T2*

16 Case 1 Head CT post craniectomy day#3

17 Case 1 Discharged to acute rehab facility with NIHSS=11 Follow-up 4 months later Participating in PT, OT, and progressing very well in rehab Neuro exam: Sensory: Motor: Awake, alert, oriented, mild dysarthria CN II-XII: Left lower quadrantanopsia, mild left facial weakness Motor: Left UE 2/5 and LE 3/5 strength, mild increased tone on left Decreased light touch left arm and leg Left UE flaccid, left LE 4+/5 strength Gait/station: Able to walk independently with quad cane Modified Rankin (mrs) score of 3

18

19 Case 2 62 year-old right-handed man with h/o HTN, hyperlipidemia, smoker 2-packs cigarettes per day, OSA, at club with his friends developed sudden onset dysarthria and left hemiparesis Initial BP 160/92, HR=60 reg, F/S 92 Medflighted to AMC Neuro exam: somnolent, dysarthric, followed all commands, right gaze preference, no blink to threat on right, left facial droop, left UE 3/5, left LE 4-/5, right side full strength, absent LT/PP left UE & LE NIHSS score=12 Initial head CT: negative except hyperdense right MCA sign CTA: occlusion of right ICA at bifurcation; trace filling in right petrous and supraclinoid segments; right MCA occluded CT Perfusion: poor injection, inconclusive study

20 Case 2 Initial head CT: negative except hyperdense MCA sign CTA neck: right ICA occlusion CTA head: proximal right MCA occlusion

21 Case 2 Door to Drug time for receiving IV rt-pa: 58 minutes Developed pruritic rash after receiving about ½ dose rt-pa IV rt-pa infusion stopped Transferred to Neuro-ICU for close observation due to impending large stroke

22 Case 2 Head CT hospital Day#2: significant intracerebral edema with right-to-left shift ( Malignant MCA Infarct )

23 Case 2 S/P Right hemicraniectomy Note hemorrhage: right sylvian, temporal, and lateral frontal regions MRI DWI showing near-complete right MCA stroke

24 Case 2 Head CT 4 days later: sinking skin flap syndrome Note: enlarged ventricles

25 Case 2 S/P cranioplasty 7 months later

26 Case 2 Follow-up: Patient seen in clinic 1-year after admission Neuro exam: Awake, alert, mostly fluent. Dysarthria but able to constuct fairly complex sentences CN II-XII: left visual neglect, decreased sensation to LT left V3 on face, left central mild-to-moderate facial droop. Motor: Right UE/LE full 5/5 strength. Left UE 2/5, left LE 4/5 with foot drop Sensory: No sensation in left arm or leg Gait/station: Wheelchair bound Continues with PT/OT 2-3x/week Memory is good except for common sense not so good Appetite good, no dysphagia Recently took cruise with wife to Bahamas

27 Case 2 May we have the video please

28 Thank you! Any questions?? Rome, Italy The CODES Putnam Den Saratoga Springs

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