STROKE SYNDROMES: RAPID RECOGNITION & TRIAGE

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1 STROKE SYNDROMES: RAPID RECOGNITION & TRIAGE David Lee Gordon, M.D., FAAN, FANA, FAHA Professor and Chair Department of Neurology The University of Oklahoma Health Sciences Center

2 STROKE SYNDROMES: RAPID RECOGNITION & TRIAGE DISCLOSURES Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months. David Lee Gordon, M.D. I have no relevant financial relationships or affiliations with commercial interests to disclose.

3 STROKE SYNDROMES: RAPID RECOGNITION & TRIAGE LEARNING OBJECTIVES At the end of this session, the attendee will be able to: Describe the three major types of stroke Identify the five major stroke syndromes Relate clinical presentation (stroke syndrome) to appropriate triage of patients with acute stroke

4 STROKE DEFINITION & 3 TYPES Sudden brain dysfunction due to artery problem Focal Brain Dysfunction Ischemic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage 85% 10% 5% Clot blocking artery Bleeding into brain Bleeding around brain Diffuse Brain Dysfunction Primary Stroke Centers manage ischemic strokes. Comprehensive Stroke Centers manage all three stroke types.

5 STROKE CENTER LEVELS Parallel Trauma Levels Level 1 = Comprehensive Stroke Center (TJC certification) Comprehensive management of AIS, ICH, & SAH including all therapeutic options and levels of care, including ED, ASU, NSICU, neurointervention, surgery Level 2 = Primary Stroke Center (TJC certification) ED & ASU management of AIS drip & keep Level 3 = Acute Stroke-Ready Hospital (TJC certification) ED management of AIS drip & ship Level 4 Not prepared to manage acute stroke patients Drip refers to administration of IV tpa; TJC = The Joint Commission; AIS = acute ischemic stroke; ICH = intracerebral hemorrhage; SAH = subarachnoid hemorrhage; ED = emergency department; ASU = acute stroke unit; NSICU = Neurosciences Intensive Care Unit

6 ISCHEMIC STROKE & TIA Both are usually caused by a traveling blood clot Acute ischemic stroke (AIS) Focal brain ischemia with infarction, usually with sequelae, because clot did not dissolve in time Equivalent term is cerebral infarction Transient ischemic attack (TIA) Focal brain ischemia with transient episode of neurologic dysfunction but NO infarction or sequelae, because clot dissolved in time Signals that patient is at risk for an ischemic stroke in the near future next time, the clot may not dissolve in time Partial seizures and migraines can mimic TIAs

7 ISCHEMIC STROKE & TIA PATHOPHYSIOLOGY Ischemia to focal area of brain CLOT INFARCT Usually due to thromboembolus Thrombus = blood clot Embolus = floating plug Blood clot forms in vascular system (arteries or heart), travels downstream, plugs a brain artery Blood clots form for 1 of 2 reasons: Platelets (Velcro) stick to bumpy pipes (white clot) Clotting factors (Jello) clump when blood stagnant (red clot) Blood clots come from 1 of 3 locations: Artery esp. hardening of artery wall (atherosclerosis) Heart esp. irregular heart rhythm (atrial fibrillation) Blood blood too sticky (hypercoagulable state)

8 CLOT ISCHEMIC STROKE TREATMENT Treat current stroke, prevent future strokes INFARCT Acute therapy Time is Brain, Save the Penumbra! Thrombolysis (IV tpa) within 3 or 4.5 hours Thrombectomy After IV tpa With distal ICA or proximal MCA occlusion Do NOT lower blood pressure Avoid aspiration & IV glucose/dextrose Secondary prevention Same for AIS & TIA Vascular risk factor therapy (hypertension, DM, cholesterol, etc.) Antithrombotic therapy (blood thinners) Antiplatelet agent(s) or anticoagulant Carotid revascularization procedure (for ICA stenosis in neck) Carotid endarterectomy (CEA) or carotid angioplasty & stenting (CAS) MCA = middle cerebral artery; ICA = internal carotid artery

9 CEREBRAL ARTERY ANATOMY R MCA ACA L Anterior Circulation ICA = internal carotid a. MCA = middle cerebral a. ACA = anterior cerebral a. PCA Proximal MCA = M1 segment Posterior Circulation VA = vertebral a. BA = basilar a. ICA VA BA PCA = posterior cerebral a. a. = artery Distal ICA/proximal MCA occlusion may be eligible for mechanical thrombectomy and time is brain. Obtain CT angiography (CTA) of head in all Stroke Alert patients. Normal MRA, coronal view (looking at patient s face)

10 ACUTE ISCHEMIC STROKE PATHOPHYSIOLOGY: THE PENUMBRA & CORE Penumbra is zone of reversible ischemia around core of irreversible infarction during first few hours after ischemic stroke onset Penumbra is damaged by: Low BP hypoperfusion Hyperglycemia lactic acidosis Fever metabolic demand Seizure metabolic demand Penumbra Core Note: Low BP & high blood glucose hurt the penumbra! pen (paene) = almost umbra = shadow

11 AIS EMERGENCY THERAPIES Time is brain, save the penumbra! Tissue plasminogen activator (tpa) IV Thrombolytic (specifically fibrinolytic) agent Lyses clot & reperfuses penumbra Saves penumbra neurons & improves patient outcome if administered within hours of stroke onset Different criteria for 3- and 4.5-h windows May cause fatal intracranial bleeding if given too late but excellent safety if given early Endovascular/IA therapy = Neurointervention Mechanical thrombectomy Proven benefit with IV tpa & in pts Clot in Artery w/ distal ICA or proximal MCA (M1) occlusion & evidence of salvageable penumbra Maximum benefit & safety w/in 6 h of onset Penumbra Core pen (paene) = almost umbra = shadow

12 AIS EMERGENCY THERAPY IV tissue plasminogen activator (tpa) Stroke onset = last time known to be without symptoms FDA-approved < 3 h, consensus guidelines < 4.5 h, but: The earlier you give IV tpa, the better the outcome Do NOT give if BP > 185/110 or blood glucose < 50 Disability risk 30% despite ~5% symptomatic ICH risk Lawsuits for not giving >>> lawsuits for giving < 3.0 Hours No upper age limit No limit on stroke size Can give if taking warfarin & INR < Hours Do NOT give if: Pt > 80 yo Stroke too large (NIHSS > 25) Ischemia > 1/3 MCA on scan Taking warfarin at all DM w/ previous stroke

13 AIS EMERGENCY THERAPY Neurointervention / IA treatment Intra-arterial (IA) mechanical thrombectomy using stent retriever device improves outcomes in acute ischemic stroke patients if: Imaging modality (e.g., CT angiography) demonstrates distal ICA or proximal MCA (M1) occlusion Performed in addition to IV tpa administration Performed w/in 6 h of stroke onset (onset-to-groin puncture time) Patient prestroke neurologic function was good (mrs 0-1) Patient s deficit is severe (NIHSS score > 6) & brain imaging shows minimal infarction/gray-matter blurring (ASPECTS > 6) Using IA stent retrievers as described above results in: mortality morbidity ( likelihood of functional independence)

14 BRAIN ANATOMY BASICS View from the side CEREBRAL CORTEX gray matter computer center front motor back sensory left language right attention CEREBELLUM coordination center CEREBRAL SUBCORTEX deep white matter wires gray matter balls motor modifier (basal ganglia) sensory relay (thalamus) BRAINSTEM funnel/connector between cerebrum and spinal cord nerves to face/head (cranial nerves) primitive centers

15 BRAIN ANATOMY BASICS View from the front Cerebral cortex (LEG) Cerebral cortex (ARM) Cerebral cortex (FACE) Cerebral Cortex Deep white matter Thalamus Basal ganglia Cerebral Subcortex Brainstem Cerebellum

16 BRAIN ANATOMY BASICS View from the front with cerebral artery territories MCA ACA Cerebral cortex (LEG) Cerebral cortex (ARM) Cerebral cortex (FACE) Cerebral Cortex Deep white matter Thalamus Basal ganglia Cerebral Subcortex PCA Brainstem Cerebellum ACA = anterior cerebral artery MCA = middle cerebral artery PCA = posterior cerebral artery

17 BRAIN ANATOMY BASICS MCA infarction also involves leg if blockage at beginning of M1 MCA F A L MCA supplies: Cortex for face & arm AND Subcortex for face, arm, leg Blockage of: End of M1 segment causes only face &/or arm symptoms Beginning of M1 segment causes face, arm, & leg symptoms

18 5 MAJOR STROKE SYNDROMES 1. Left hemisphere 2. Right hemisphere 3. Brainstem Cerebellum 5. Possible hemorrhage 4 3

19 5 MAJOR STROKE SYNDROMES And Correlation w/ Ischemic Stroke Arteries & Intracerebral Hemorrhage Locations Stroke Syndrome 1. Left Hemisphere 2. Right Hemisphere 3. Brainstem Ischemic Stroke Main Arteries Involved L MCA R MCA BA 4. Cerebellum BA or VA branches Intracerebral Hemorrhage Common Locations L basal ganglia L thalamus R basal ganglia R thalamus Pons L/R cerebellum 5. Possible Hemorrhage MCA = middle cerebral artery BA = basilar artery VA = vertebral artery

20 LEFT (DOMINANT) HEMISPHERE Typical signs: Right body deficits (visual, motor, sensory), aphasia Right Visual Field Deficit Right Hemiparesis Right Hemisensory Loss Aphasia (Expressive &/or Receptive)* Left Gaze Deviation (Preference) M1 OCCLUSION MORE LIKELY IF ALL FINDINGS ARE PRESENT: Aphasia Visual field deficit Gaze preference Hemiparesis (at least F & A) Hemisensory loss (at least F & A) *Expressive (motor) aphasia: Assoc w/ paresis (weakness) Receptive (sensory) aphasia: Assoc w/ sensory, visual field loss

21 LEFT HEMISPHERE SYNDROMES L MCA infarctions w/ CT-exam correlations Small-artery occlusion Unlikely thrombectomy End-of-M1 Occlusion Possible thrombectomy Beginning-of-M1 Occlusion Possible thrombectomy Subcortex infarction R hemiparesis (F, A, L) R hemisensory loss (F, A, L) Cortex infarction Aphasia L gaze preference R visual field deficit R hemiparesis (F, A) R hemisensory loss (F, A) Subcortex + cortex infarction Aphasia L gaze preference R visual field deficit R hemiparesis (F, A, L) R hemisensory loss (F, A, L) F = face, A = arm, L = leg MCA ACA PCA infarction

22 RIGHT (NONDOMINANT) HEMISPHERE Typical signs: Left body deficits (visual, motor, sensory), neglect Left Hemi-inattention (Neglect) Right Gaze Deviation (Preference) M1 OCCLUSION MORE LIKELY IF ALL FINDINGS ARE PRESENT: Neglect Visual field deficit Gaze preference Hemiparesis (at least F & A) Hemisensory loss (at least F & A) Left Visual Field Deficit Left Hemiparesis Left Hemisensory Loss

23 RIGHT HEMISPHERE SYNDROMES R MCA infarctions w/ CT-exam correlations Small-artery occlusion Unlikely thrombectomy End-of-M1 Occlusion Possible thrombectomy Beginning-of-M1 Occlusion Possible thrombectomy Subcortex infarction L hemiparesis (F, A, L) L hemisensory loss (F, A, L) Cortex infarction Neglect R gaze preference L visual field deficit L hemiparesis (F, A) L hemisensory loss (F, A) Subcortex + cortex infarction Neglect R gaze preference L visual field deficit L hemiparesis (F, A, L) L hemisensory loss (F, A, L) F = face, A = arm, L = leg MCA ACA PCA infarction

24 BRAINSTEM Typical signs: Bilateral long-tract signs or crossed signs Bilateral Long-tract Signs Quadriparesis Sensory Loss in All 4 Limbs Crossed Signs One side of face & contralateral body Hemiparesis Hemisensory Loss

25 BRAINSTEM Typical signs: Primitive center deficits, cranial nerve deficits Primitive Center Deficits Consciousness Nausea, Vomiting Hiccups, Abnormal Respirations Cranial Nerve Deficits Oropharyngeal Weakness: Dysarthria, Dysphagia Cranial Nerve Deficits Vertigo, Tinnitus Eye Movement Abnormalities: Diplopia Dysconjugate Gaze Gaze Deviation (Palsy) Dysarthria = poor articulation when speaking Dysphagia = difficulty swallowing Vertigo = hallucination of movement Tinnitus = ringing in the ears Diplopia = double vision Dysconjugate = not conjoined

26 CEREBELLUM Typical signs: Dyscoordination (= ataxia) of limb(s), trunk Ipsilateral Limb Ataxia (dyscoordination) Truncal or Gait Ataxia (imbalance w/ wide-based gait) Note: Cerebellum controls same side of body because cerebral cortex controls opposite side of cerebellum

27 HEMORRHAGE & THE BRAIN COVERINGS Cranium (skull): hard container enclosing brain Meninges: 3-layered sack surrounding brain and spinal cord, lined with pain nerves Both ICH & SAH: suddenly increase intracranial pressure (ICP) SAH: irritates meninges Two Types of Spontaneous (nontraumatic) Intracranial Hemorrhage Intracerebral Hemorrhage (ICH) Bleeding into brain Subarachnoid Hemorrhage (SAH) Bleeding around brain

28 FINDINGS CONSISTENT WITH INTRACRANIAL HEMORRHAGE Both Subarachnoid and Intracerebral Hemorrhage: Headache Nausea, vomiting Consciousness (due to ICP) Subarachnoid Hemorrhage: Intolerance to light Neck stiffness / pain (due to meningeal irritation) Intracerebral Hemorrhage: Focal signs such as hemiparesis (due to focal lesion)

29 ISCHEMIC STROKE MIMICS Differential diagnosis of sudden onset focal neurologic deficit Intracerebral hemorrhage CT Tumor with bleed or partial seizure CT Abscess with partial seizure CT Subdural hematoma (esp. acute on chronic) CT Hypoglycemia labs (fingerstick glucose) Toxic-metabolic insult w/ old cerebral lesion labs/normal MRI (DWI) Partial seizure w/ postictal state History Migraine History/normal MRI (DWI) Conversion reaction (rare) History/normal MRI (DWI) If patient s symptoms completely resolve, the differential diagnosis of transient neurologic deficits is TIA, seizure, migraine

30 HEMISPHERE STROKE SYNDROMES ISCHEMIC STROKE CT Correlations INTRACEREBRAL HEMORRHAGE Basal Ganglia Thalamus Normal sulcus Blurring of gray-white junction Sulcal effacement Hemiparesis + aphasia/neglect, VF deficit, gaze preference, hemisensory loss Hemiparesis + Hemiparesis + Depending on size of ICH, may be associated w/ all hemisphere signs + ICP signs

31 BRAINSTEM STROKE SYNDROMES ISCHEMIC STROKE Basilar artery occlusion CT Correlations INTRACEREBRAL HEMORRHAGE Pontine ICH Vertigo, dysarthria, dysphagia, nausea, quadriparesis, abnormal eye movements, LOC Case courtesy of Dr Donna D'Souza, Radiopaedia.org, rid: 3829 Coma w/ abnormal eye movements

32 CEREBELLUM STROKE SYNDROMES CT Correlations ISCHEMIC STROKE INTRACEREBRAL HEMORRHAGE Right Cerebellum Right Cerebellum plus ICP plus brainstem compression Right hemiataxia, can t walk, +/- nausea Posterior headache, nausea, vomiting, right hemiataxia, can t walk coma +

33 STROKE SYNDROMES: RAPID RECOGNITION & TRIAGE LEARNING OBJECTIVES At the end of this session, the attendee will be able to: Describe the three major types of stroke Identify the five major stroke syndromes Relate clinical presentation (stroke syndrome) to appropriate triage of patients with acute stroke

34 THE END

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