Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Sheital Bavishi, DO Assistant Professor University of Cincinnati Department of Physical Medicine and Rehabilitation Director Brain Injury Program University of Cincinnati UC Neuroscience Institute UC Neuroscience Institute • Affects more than 700,000 people in the US annually • Third leading cause of death • One of the most common causes of longterm disability, certainly one of the most serious and life-changing UC Neuroscience Institute SAH, 5% ICH, 10% Ischemic, 85% UC Neuroscience Institute • Stroke: focal neurologic deficit caused by cerebrovascular event lasting at least 24 hours; usually of sudden onset – ischemia: 80% (thrombosis, embolism, hypotension) – hemorrhage: 20% (subarachnoid, intracerebral) • TIA (transient ischemic attack): same as above, caused by transient ischemia and resolving completely within 24 hours UC Neuroscience Institute • Non-modifiable: • Age, Race, Gender, Family history • Modifiable/Treatable: – – – – – – – Hypertension Diabetes TIA’s/previous strokes Cardiac disease (?PFO) Atrial fibrillation Hypercholesterolemia Hypercoagulable states UC Neuroscience Institute --obesity --alcohol/drug consumption --oral contraceptives --migraine headaches --cigarette smoking --autoimmune/inflammatory disease --homocysteine • Carotid arteries – Internal: brain – External: face “anterior circulation” • Vertebral arteries “posterior circulation” UC Neuroscience Institute • Catheter angiography • CT angiography • MR angiography Contrast dye injected in blood stream makes vessels show up UC Neuroscience Institute UC Neuroscience Institute blockage Aneurysm AVM Artery stenosis UC Neuroscience Institute Stroke Tumor • Limiting cellular injury • Reperfusion • Preventing Systemic Complications • Preventing Neurologic Complications • Rehabilitation UC Neuroscience Institute • Maintain cerebral perfusion– autoregulation/adequate blood pressure (BP) • Maintain cerebral oxygenation --(allow increased oxygen extraction as compensatory mechanism for altered perfusion) • Maintain normothermia -- (increased temp = increased oxygen metabolism/demand) • Maintain euglycemia -- (hyperglycemia exacerbates ischemic damage) UC Neuroscience Institute • Acute stroke – Clot dissolve (tPA) – Clot retrieval • Aneurysm – Coil – Glue • Artery stenosis – Angioplasty & stent • AVMs and tumors – Glue (embolization) UC Neuroscience Institute Onyx glue Clot-buster (tPA) • Drug dissolves clot • Give within 4.5 hours UC Neuroscience Institute Clot retrieval • Device grabs and pulls clot out • Suction catheter aspirates clot • A clot-busting drug called t-PA (tissue plasminogen activator) given within 3 hours after stroke onset • New data suggest time window out to 4 ½ hours UC Neuroscience Institute • BOTTOM LINE: Appropriate patients without contraindications should be treated at 0-3 hours, as per the NINDS study protocol. • TIME IS BRAIN: the sooner treatment is started, the greater the odds ratio of favorable outcome UC Neuroscience Institute blockage UC Neuroscience Institute t-PA restores blood flow UC Neuroscience Institute Inflate balloon and inject for 2 minutes, let Onyx solidify for 3 minutes then re-perfuse UC Neuroscience Institute • Bypass reroutes an artery from outside of skull into a brain artery to protect blood supply to brain before clipping the bypass aneurysm UC Neuroscience Institute UC Neuroscience Institute Medications – Blood thinner – Cholesterol reduction – Blood pressure control Endarterectomy – Surgery removes plaque Angioplasty & stenting – Balloon compresses plaque and stent holds artery open UC Neuroscience Institute • Angioplasty & stenting – Restores vessel diameter – Reduces clot risk UC Neuroscience Institute UC Neuroscience Institute UC Neuroscience Institute UC Neuroscience Institute Dilated arteries and veins with no capillary bed UC Neuroscience Institute • Goal is to reduce size of nidus and to occlude arterial feeders difficult to access surgically • Surgical dissection and control of fragile deep feeding arteries significantly improved • Embolization alone will not cure UC Neuroscience Institute • Prevent medical and neurological complications • Risk factor modification – Especially treatments for hypertension, diabetes, high cholesterol and smoking cessation • Appropriate medical or surgical therapy – must know mechanism of stroke – Echo to look for cardiac source – Imaging to look for carotid source – Otherwise, staged anti-platelet therapy UC Neuroscience Institute • Aspiration (feeding tube, intubation) • DVT (subQ Heparin) • Infection (leading cause of late death) • Skin Breakdown UC Neuroscience Institute • Increased intracranial pressure – hemorrhagic transformation – cytotoxic edema • Edema maximal at 36-72 hours, usually manifests as decline in level of consciousness • Herniation is leading cause of death in acute setting (fatal arrhythmia is second) UC Neuroscience Institute • Seizures – Approximately 4% of patients – recur in 20-80% cases – treat with anticonvulsants • Depression – As high as 75% incidence after stroke – TREAT IT!! – New study suggests that early SSRI might improve outcome even if depression not yet present UC Neuroscience Institute • Benefit is well established • Mechanism by which this facilitates recovery is unclear • Begin Occupational Therapy, Physical Therapy, Speech Therapy immediately • Recovery maximal in first weeks, months; can continue --DON’T GIVE UP! --Recovery is the next great frontier for stroke and brain injury UC Neuroscience Institute • • • • Spasticity Management Neurogenic bowel and bladder Constraint-Induced therapy Body-weight supported treadmill training • Splints and bracing • Pain Syndromes • Psychosocial Considerations UC Neuroscience Institute • • • • • • • Acute hospital therapies Acute Inpatient rehabilitation Short-term skilled rehabilitation Transitional Rehabilitation programs Day Rehabilitation programs Outpatient therapy Home Health therapy UC Neuroscience Institute The Stroke Recovery Center at Drake is a multi-disciplinary evaluation and treatment program for those individuals with physical and cognitive deficits from a previous CVA, designed to maximize independence and function. UC Neuroscience Institute • Stroke Recovery Center: – refers now to the full spectrum of services-from acute rehab on • START – Stroke Team Assessment and Recovery Treatment (START) Program – The START program is the outpatient multidisciplinary team evaluation UC Neuroscience Institute The therapeutic plan may be developed around: • out patient rehabilitation services, • research programs, or • a combination of both UC Neuroscience Institute The Stroke Recovery Center was only one of five programs of this type identified in the United States (as of July 2008) UC Neuroscience Institute To provide collaborative care that improves the function and quality of life of people with strokes while scientifically advancing the field of stroke recovery. UC Neuroscience Institute To be the premier destination for the most innovative, aggressive and comprehensive treatment for people with stroke. UC Neuroscience Institute Dr. Brett Kissela Dr. Mark Goddard Professor Co-Director, Neurology Residency Program Vice-Chair of Education and Clinical Services Department of Neurology University of Cincinnati Associate Professor Chairman, Department of Physical Medicine and Rehabilitation University of Cincinnati Rehabilitation Medical Director – Drake Center UC Neuroscience Institute Questions? UC Neuroscience Institute