Download Robert T - Trinity Health

CVA
SAMIR TURK, M.D.
SYMPTOMS OF STROKES AND TIA
•
•
•
•
•
•
PARALYSIS
NUMBNESS
LANGUAGE
VISUAL
ATAXIA
VERTIGO
CLINICAL PRESENTATION
• CORRELATES WITH OCCLUDED ARTERY
• KNOWLEDGE OF BLOOD SUPPLY ALLOWS
LOCALIZATION
• RADIOLOGICAL TESTING CONFIRMS
LOCALIZATION
MOTOR/SENSORY RULE
• BRAIN MEDIATES OPPOSITE SIDEMOTOR/SENSORY
• BRAIN STEM – SAME SIDE OF FACE
MOTOR/SENSATION
• CEREBELLUM –SAME SIDE FINE MOTOR
BLOOD SUPPLY
• 2 MAJOR TERRITORIES :
1- ANTERIOR CIRCULATION – ICA/MCA/ACA
2-POSTERIOR CIRCULATION –
VERTEBRALS/BASILAR/POSTERIORCEREBRAL
MCA OCCLUSION
LEFT DOMINANT - 90%
LANGUAGE –
RIGHT FACE AND ARM MOTOR AND SENSORY
RIGHT SIDE NEGLECT
EYES DEVIATE TO LEFT
LEFT ACA
• RIGHT LEG-- MOTOR AND SENSORY
• BEHAVIOR : ANGER/HOSTILITY
RIGHT MCA
•
•
•
•
APROXIA
LEFT SIDED FACE/ARM MOTOR AND SENSORY
LEFT SIDED NEGLECT AND VISION LOSS
EYES DEVIATE TO RIGHT
RIGHT ACA
• LEFT LEG MOTOR AND SENSORY
• BEHAVIOUR : ANXIETY AND DEPRESSION
ICA OCCLUSON
• BOTH ACA AND MCA OCCLUSION
• MONONUCLEAR BLINDNESS –OPTHALMIC
ARTERY OCCLUSION
• PARTIAL HORNER SYNDROME : PTOSIS/MIOSIS
BUT ANHYDROSIS IS ABSENT
POSTERIOR CIRCULATION
•
•
•
•
•
•
REMEMBER THE 5 D’s
1-dizziness
2-diplopia
3-dysarthria
4-dysphagia
5-dystaxia
POSTERIOR CIRCULATION
• CROSSED FINDINGS :
CRANIAL NERVES DEFICIT- IPSILATERAL
MOTOR/SENSORY DEFICIT- CONTRALATERAL
VERTEBRAL OCCLUSION
• PRODUCES OCCLUSION IN PICA
• LEADS TO LATERAL MEDULLARY SYNDROME
LATERAL MEDULLARY SYNDROME
• 1- SPINOTHALAMIC TRACT- CONTRALATERAL DECREASE IN TEMP
AND PAIN
• 2- 5TH CRANIAL NERVE PALSY –IPSILAT EYE PAIN,NUMB FACE AND
DECREASE CORNEAL REFLEX
• 3- VESTIBULAR NUCLEUS – DIZZINESS/VOMITTING AND
NYSTAGMUS
• 4- INFERIOR CERBELLAR PEDUNCLE –IPSILAT.ATAXIA
• 5- IPSILATERAL HORNER- LABILE BP AND TACHY
• 6- HOARSNESS AND DYSPHAGIA
• 7-ABNORMAL RESPIRATION
STROKE MIMICKS
•
•
•
•
•
•
•
HYPOGLYEMIA
MASS LESIONS
SEIZURES
MIGRAINE
ENCEPHALOPATHIES
CONVERSION DISORDERS
PERIPHERAL VESTIBULOPATHIES
CHAMLEONS
•
•
•
•
•
CONFUSION STATES
VIT DEF
MS
MOVEMENT DISORDERS
TRANSIENT GLOBAL AMNESIA
TREATMENT
•
•
•
•
TRADITIONAL : SUPPORTIVE
THROMBOLYSIS : IV
THROMBOLYSIS : INTRAARTERIAL IN SITU
RETRIEVAL DEVICES
TREATMENT
• IV THROMBOLYSIS.
• TPA FOR TREATMENT OF CVA APPROVED IN
1996
• NINDS TRIAL
IV THROMBOLYSIS
• 31% OF THOSE WHO RECEIVED TPA HAD
EXCELLENT OUTCOME
• 20% OF THOSE WHO DID NOT RECEIVE IV TPA
HAD EXCELLENT RECOVERY
• 11% ABSPLUTE IMPROVEMENT
IV THROMBOLYSIS
TPA
HEMORRHAGE 6.4%
DEATH 11%
NO TPA
HEMORRHAGE <1%
DEATH 20%
INDICATION FOR IV TPA
•
•
•
•
•
AGE >18
DEFINED TIME OF ONSET
WITHIN <3 HOURS
MEASURABLE NIHSS
NO CONTRAINDICATION
CONTRAINDICATION FOR IV
THROMBOLYSIS
•
•
•
•
•
•
•
MINOR SYMPTOMS OR IMPROVING
SEIZURE AT ONSET
STROKE OR HEAD TRAUMA < 3 MONTHS
ANY HX OF ICH
GI/GU HEMORRAGE < 3 WEEKS
MAJOR SURGERY < 3 WEEKS
NONCOMPRESSIBLE ARTERIAL PUNCTURE<7
DAYS
CONTRAINDICATION OF IV
THROMBOLYSIS
• RECEIVED HEPARIN WITHIN 48 HRS AND PTT
IS ABNORMAL
• BP > 185/100
• INR >1.7
• PLTS <100K
• GLUCOSE <50 OR >400
IV TPA 3-4.5 HOURS
• SOME BENEFIT IN SELECTED PATIENTS
• NOT FDA APPROVED
• ADDITIONAL EXCLUSION CRITERIA :
AGE>80
ON ORAL ANTICOAGULATION REGARDLESS
OF INR
NIH SCORE >25
HX OF STROKE AND DM
OTHER CONSIDERATIONS
• IF THERE IS CONTRAINDICATION TO IV LYSIS
THEN CONSIDER :
1- INTRAARTERIAL LYSIS – LESS TPA
2- MECHANICAL RETRIEVAL DEVICES
PENUMBRA SYSTEM OR MERCI DEVICE
SHOULD CONSIDER FOR ALL CASES OF NIHSS OF
>10 AS THE CHANCE OF OPENING AN MCA
OCCLUSION WITH IV LYSIS IS ONLY 15%
LIMITATIONS OF IV TPA
• ONLY 4% OF CVA PTS RECEIVE TPA
• 22% PRESENT WITHIN 3 HRS
• 51% OF THOSE PRESENTING WITHIN 2 HRS ARE
INELIGIBLE
• POOR RECANALISATION RATES- M1 SEGMENT
ONLY 13%
INTRAARTERIAL THROMBOLYSIS
• SAME AS IV THROMBOLYSIS – THE RISK OF
BLEEDING IS HIGHEST WITH LAERGER
STROKES
• RISK OF DISSECTION,PERFORATION AND
DISTAL EMBOLISATION
• TECHNICALLY VERY DEMANDING AND
CHALLENGING
• CEREBRAL VESSELS ARE VERY TORTUROUS
INTAARTERIAL THROMBOLYSIS
• ONLY FEW MG OF TPA IS NEEDED
• MAY NEED AN HOUR OR MORE TO LYSE THE
CLOT
• BEST TO DO WITHOUT INTUBATIONS IF
POSSIBLE
• LARGER VESSELS MAY BE IMPOSSIBLE TO
OPEN WITH LYSIS ALONE
MEDICAL TREATMENT
• IS AS IMPORTANT AS LYSIS
• BP MEDICATIONS SHOULD BE WITHHELD
UNLESS SBP >220 OR DBP>120
• TREAT HYPOTENSION WITH SALINE AND
PRESSORS IF NEEDED
• TREAT CARDIAC ARRYTHMIAS
MEDICAL TX
• TREAT HIGH BP BEFORE IV LYSIS IF SBP>185
OR DBP>110.
• USE IV LABETOLOL OR NICARDIPINE
• AFTER LYSIS MAINTAIN SBP <180 OR DBP<100
MEDICAL TX
• HYPGLYCEMIA MAY MIMIC STROKES
• HYPERGLYEMIA WITH BS > 140 HAS WORSE
OUTCOME
Dr. Turk
Basilar Intervention
May 2011
PRESENTATION
• 50 YEAR OLD MAN LIVES ALONE
• WOKE UP FROM SLEEP WITH DIZZINESS AND
SEVERE NAUSEA AND ATAXIA
• CALLED AMBULANCE
• COLLAPSED . INTUBATED AND BROUGHT TO
ER COMATOSE
BASILAR ARTERY INTERVENTION
• IN ER FOUND TO BE TOTALLY UNRESPONSIVE
• EMERGENCY MRA SHOWED TOTAL
OCCLUSION OF BASILAR ARTERY
ARCH ANGIO
BRACHIOCEPHALIC ARTERY
RIGHT ICA
RT VERTEBRAL
INFUSION CATHETER IN BASILAR
ARTERY
REESTABLISHMENT OF FLOW
STENT ADVANCED TO BASILAR ARTERY
BASILAR ARETERY STENTED TO KEEP
OPENED
LEFT CAROTID OCCLUSION
• 54 YEAR OLD MAN AT GRANDCHILD BIRTHDAY
COLLAPSED
• PRESENTED TO ER WITHIN 30 MINUTES.
• LEFT HEMIPARESIS WITH APHASIA
• STUDIES SHOWED ACUTE RIGHT CEREBRAL
INFARCT
• IV THROMBOLYSIS GIVEN 9O MG TPA
• RECOVERED FULLY
L CAROTID OCCLUSION
• STUDIES SHOWED SEVERE STENOSIS OF LEFT
CAROTID AND A SMALL INFARCT ON MRI/MRA
• STARTED ON PLAVIX AND ASPIRIN AND WAS
PLANNED TO COME BACK FOR CEA WITHIN A
WEEK OR TWO
• WHILE GETTING READY FOR DISCHARGE
COLLAPSED AGAIN AND WAS COMATOSE
• DENSE RIGHT HEMIPARESIS AND APHASIA
INTERVENTION
• TAKEN PROMPTLY TO CATH LAB
• ANGIO DONE
OCCLUDED LEFT ICA
OCCLUDED LEFT ACA AND PART OF MCA
Post PTA
Third patient
77 year old with sudden aphasia
• WAS FOUND TO HAVE NEW ONSET ATRIAL
FIBRILLATION
OCCLUDED MCA
FLOW REESTABLISHED WITH 5 MG OF TPA