Download Acute Care of the Ischemic Stroke Patient - Dartmouth

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Smart!
Neurology
Migraine ALS
Parkinson’s Headache
Seizures Neuropathy
Cardiology
Stroke
Heart attack Arrhythmias
Heart failure Valvular disease
Everything you ever
wanted to know about stroke
(but were afraid to ask)
Timothy Lukovits, M.D.
Objectives


Highlight some important differences and
similarities between heart attack and
stroke
Motivate you to prevent a stroke
How is a stroke different from a
heart attack?


A stroke is a sudden neurological deficit
caused by a blood vessel problem
2 types



Ischemic strokes
Hemorrhagic strokes
The effects of a stroke are extremely
varied
Why is heart attack easier to
recognize than stroke ?

Painful



Public and health
care providers
commonly
recognize
symptoms and
need for action

Often painless
the stroke itself often
affects awareness of
symptoms
Poor recognition of
symptoms and need
for action
Respondents unable to name
1 warning sign or risk factor for stroke
Pancioli, A. M. et al. JAMA 1998;279:1288-1292.
Copyright restrictions may apply.
Which of the following are
warning signs of stroke?
A.
B.
Sudden weakness or numbness of the face, arm or
leg, especially on one side of the body
Sudden confusion, trouble speaking
or understanding
C.
Sudden chest pain
D.
Sudden trouble seeing in one or both eyes
E.
F.
Sudden trouble walking, dizziness, loss of balance
or coordination
Sudden, severe headache with no known cause
A.
B.
Sudden weakness or numbness of the face, arm or
leg, especially on one side of the body
Sudden confusion, trouble speaking
or understanding
C.
Sudden chest pain
D.
Sudden trouble seeing in one or both eyes
E.
F.
Sudden trouble walking, dizziness, loss of balance
or coordination
Sudden, severe headache with no known cause
Is heart attack easier to diagnose
than stroke?

Diagnosis is
relatively easy.
EKG and cardiac
enzymes readily
available.

Diagnosis is
difficult. Many
things can mimic
stroke. There is
no blood test for
stroke. MRI not
readily available.
MRI with diffusion weighted
imaging
Isolated weakness right index finger
JS Kim, Neurology, 2002
Where is the stroke?
CT scan of arteries of
neck and head
Are the causes of heart attack and
stroke different?


Cause is usually
rupture of a plaque
within a coronary
artery
So the diagnostic and
treatment strategy is
fairly straightforward
(find the blockage
and open it up!)


Atherosclerosis is
important, but there
are many other
causes
Determining the
cause in an individual
is often a deductive
process
There are many potential
causes of stroke
Stroke is not just a brain disease
and often the brain is just an
innocent bystander


Usually caused by diseases that are affect
the entire vascular system
(atherosclerosis)
Material blocking brain arteries usually
comes from outside the brain (atrial
fibrillation, carotid artery disease)
How is a Cardiologist different
than a Neurologist

Basically a plumber or
electrician



Diagnostician
Detective
Daredevil
Case



Healthy 61 year-old man developed
confused speech 1 day after falling out of
a tree.
August 11th, topping a tree, fell and
sustained a left collar bone fracture and
small puncture of the lung.
Next night suddenly developed confused
speech.




Trauma (fall out of a tree)
Vascular problem (leg vein injury)
Blood disorder (hypercoagulability)
Congenital heart anomaly (patent foramen
ovale)
How are heart attack and stroke
SIMILAR?
Time is critical
 The first priority is to save tissue at
risk

Kidwell 2004
You need to call 911 ASAP for both
heart attack and stroke!




There is a 3 hour time limit for the medication tPA, and the sooner it’s given the better!
Future strokes may be prevented if we identify
the cause of stroke ASAP
People brought by ambulance are treated faster
Neurological deterioration and other
complications may be prevented if a patient is
hospitalized earlier


June 2006 7AM: A 75 year-old
woman collapsed at home, brought
to her local emergency room. She
cannot move her right side or speak.
The doctors there are not
comfortable using t-PA so transfer to
DHMC is requested.
1:02 PM: Arrival DHMC ED.
4:49 PM artery is opened

The system needs to be very
coordinated
PREPARED
RAPID EVALUATION
INDIVIDUALIZED
CARE
Improving Stroke Care
at DHMC
A TEAM APPROACH
PROTOCOLS TO DECREASE ERRORS
Ways everyone here
can prevent a stroke


Identify and control risk factors
If a warning sign of stroke occurs, get
attention
10y risk 88% !
10y risk 13% !

Preventing a heart attack or stroke is
MUCH more effective (and safer) than
a procedure!
HJM Barnett 1999
The medical and surgical 5-year Kaplan-Meier curves of freedom from ipsilateral stroke and
perioperative stroke and death indicate a 5.9% difference favoring endarterectomy at 5 years in
the Asymptomatic Carotid Atherosclerosis Study (ACAS)
Barnett, H. J. M. et al. Arch Neurol 2000;57:40-45.
Copyright restrictions may apply.
Kaplan-Meier 5-year risks of ipsilateral ischemic stroke for NASCET patients according to
gender and degree of internal carotid artery stenosis in the medical and surgical groups
Alamowitch, S. et al. Stroke 2005;36:27-31
Copyright ©2005 American Heart Association
2004: 144 pts Rx t-PA
50% had t-PA started at 1 of
47 referring hospitals
>50% of these have <60 beds
Meyer 2005
MGH TeleStroke
Effectiveness of Stroke Prevention
Absolute risk reduction in a year:
Strategy






Warfarin for atrial fibrillation
Carotid endarterctomy for symptomatic dz
Smoking cessation
Antihypertensive therapy if BP elevated
Cholesterol lowering medications
Aspirin
ARR (%)
8
4
2
2
2
1-2
Schaebitz W-R, 2000
anticoag
RG Hart 2003
Stroke Diagnosis 40 years ago
Stroke Warning Signs

Sudden weakness or numbness of the face,
arm or leg, especially on one side of the
body

Sudden confusion, trouble speaking
or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of
balance or coordination

Sudden, severe headache with no known
cause
What is a TIA ?




Transient Ischemic Attack=Stroke
symptoms that resolve with a short time.
Can be a warning sign of impending
stroke.
The highest risk period of stroke following
a TIA is the first 2 weeks.
The risk of stroke soon after a TIA can
now be estimated.
ABCD2 Tool
risk of stroke following TIA
A
Age> or = 60
1
B
Blood pressure >140/90
1
C
Clinical features
D2
unilateral weakness
2
speech impairment
1
Duration
> 60 min
2
10-59 min
1
Diabetes
1
Estimated 10-Year Rate (%)
30
27
25
22.4
Men
20
W omen
19.1
14.8
15
8.4
10
5
2.6
5.4
4
2
1.1
6.3
3.5
0
A
Systolic BP*
Diabetes
Cigarettes
Prior Atrial Fib.
Prior CVD
B
A
95-105
No
No
No
No
C
B
130-148
No
No
No
No
D
C
130-148
Yes
No
No
No
D
130-148
Yes
Yes
No
No
E
E
130-148
Yes
Yes
Yes
No
F
F
130-148
Yes
Yes
Yes
Yes
*BP in millimeters of mercury (mmHg)
Estimated 10-year stroke risk in 55-year-old adults according to levels
of various risk factors (FHS).
Source: Wolf et al., Stroke.1991;22:312-318.
Which action would you take if you
thought someone was having a
heart or stroke?
A.
B.
C.
D.
E.
take the person a hospital
advise the person to call a doctor
call 911
call a spouse or family member
do something else
Which action would you take if you
thought someone was having a
heart or stroke?
A.
B.
C.
D.
E.
take the person a hospital
advise the person to call a doctor
call 911
call a spouse or family member
do something else

Bleeding into the
heart doesn’t
occur

Brain
hemorrhage is
common
CT scan: ischemic stroke
Intracerebral hemorrhage
at 1 hour and 6 hours
Intra-arterial thrombolysis
Time window=6 hours

You need to open the artery
Like with heart disease, the
treatment and prevention of stroke
needs to be individualized!

A 65 yo man attends a vascular disease
prevention fair and an ultrasound shows a
blockage of his left carotid artery. He is
told to speak to his doctor ASAP and he
becomes worried that there is a “time
bomb” ticking in his neck.
11/30/06