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Stroke: An Introduction Maarten Lansberg, MD, PhD Neil Schwartz, MD, PhD Stanford Stroke Center Outline • Background • Stroke Diagnosis • Stroke Treatment • Stroke Prevention What is a Stroke? (Brain Attack) Disruption of blood flow to part of the brain caused by: • Occlusion of a blood vessel (ischemic stroke) OR • Rupture of a blood vessel (hemorrhagic stroke) Types of Stroke 84% Total Ischemic 53% Thrombotic 31% Embolic Intracerebral Subarachnoid 0% Ischemic Hemorrhagic 10% 6% 20% 40% 60% Mohr JP, Caplan LR, Melski JW, et al. Neurology 1978;28:754-62 80% 100% Anatomy MR Angiogram What happens with cutoff of blood supply? Oxygen deprivation to nerve cells in the affected area of the brain --> Nerve cells injured and die --> The part of the body controlled by those nerve cells cannot function. What Causes Ischemic Stroke? Thrombotic Embolic Thrombus Embolus Ischemic Stroke What happens with rupture of a blood vessel? Oxygen deprivation to nerve cells in the affected area of the brain and local destruction of nerve cells--> Nerve cells injured and die --> The part of the body controlled by those nerve cells cannot function. Intracerebral Hemorrhage Head CT: Ischemic or Hemorrhagic Stroke? Head CT: Ischemic or Hemorrhagic Stroke? Stroke Impact • 750,000 strokes per year • Third leading cause of death (1st: heart disease, 2nd: all cancers) – Over 160,000 deaths per year • Over 4 million stroke survivors 1. Williams GR, Jiang JG, Matchar DB, et al. Stroke 1999; 30:2523-28. 2. Hoyert DL, Kochanek KD, Murphy SL. National Vital Statistics Report 1999; 47:19. Stroke Impact (2) • Leading cause of adult disability – Of those who survive, 90% have deficit • Half of all patients hospitalized for acute neurological disease. • Stroke costs the U.S. $30 to $40 billion per year. The Stroke Belt Perry HM, Roccella EJ. Hypertension 1998;6:1206-15. 2. Stroke Diagnosis Symptoms of Stroke • Sudden numbness or weakness of face, arm or leg, especially on one side of the body • Sudden confusion, trouble speaking or understanding • Sudden trouble seeing from one or both eyes • Sudden unsteadiness, dizziness, loss of balance or coordination • Sudden severe headache with no known cause Other Stroke Symptoms • Also common following stroke – Depression – Other emotional problems – Memory problems Common Stroke Patterns • Left (Dominant) Hemisphere: – Aphasia – Right hemiparesis – Right hemisensory loss – Right visual field defect – Left gaze preference – Dysarthria – Difficulty reading, writing, or calculating Common Stroke Patterns (2) • Right (Nondominant) Hemisphere: – Left hemiparesis – Left hemisensory loss – Left neglect – Left visual field defect – Right gaze preference – Dysarthria Common Stroke Patterns (3) • Brainstem/Cerebellum/Posterior Circulation – Motor or sensory loss in all 4 limbs – Crossed signs (face vs. body) – Limb or gait ataxia – Dysarthria – Dysconjugate gaze – Nystagmus – Amnesia – Cortical blindness Common Stroke Patterns (4) • Small Vessel (Lacunar) Strokes (Subcortical or Brain Stem) – Pure Motor • Weakness of face, arm, leg – Pure Sensory • Decreased sensation of face, arm, leg Differential Diagnosis • Stroke (ischemic; hemorrhagic) • Intracranial mass – Tumor – Subdural hematoma • Seizure with persistent neurological signs • Migraine with persistent neurological signs • Metabolic – Hyper/Hypoglycemia • Infectious – Meningitis / Encephalitis / Cerebral abscess – Systemic 3. Stroke Treatment Time is Brain EMS/ED evaluation of acute stroke • Assure adequate airway • Monitor vital signs • Conduct general assessment – Evidence of trauma to head or neck – Cardiovascular abnormalities EMS/ED evaluation of acute stroke (cont.) • Conduct neurological examination – Level of consciousness (Glasgow Coma Scale) – Presence of seizure activity – NIH Stroke Scale ED evaluation of acute stroke: diagnostic tests • • • • • Non-contrast Head CT EKG Blood Glucose CBC, platelets, PTT, PT/INR Serum electrolytes t-PA therapy tPA therapy for acute stroke • Candidate for IV tPA? – Stroke onset < 3 hours (When was the patient last seen at baseline ?) • Benefit: 12 % increased chance of good recovery • Risk: bleeding (up to 6%) tPA exclusion criteria – – – – – – – – – – – – – – – – Symptoms mild or rapidly resolving SBP > 180 or DBP > 110 Blood on head CT History of ICH CNS tumor or vascular malformation Bacterial endocarditis Known bleeding disorder PTT > 40; PT > 15 (INR > 1.7) Stroke within 3 months Significant trauma in last 3 months GI/GU/Resp hemorrhage within 21 days Major surgery within 14 days / minor surgery within 10 days Peritoneal dialysis or hemodialysis Seizure at onset of stroke Glucose <50 or >400 Pregnant Other therapies for acute stroke • IV t-Pa outside the three hour window • IA t-PA • IA mechanical thrombolysis/thrombectomy • Neuroprotective agents Stroke Management If not a candidate for acute intervention, then focus on: – Prevention of recurrent stroke • Diagnostic evaluation for stroke etiology • Risk factor assessment – Rehabilitation (PT/OT/SLP) – Prevention of Complications • DVT, aspiration PNA, decubitus ulcers, falls Diagnostic stroke evaluation • Purpose: Identify location, size, and cause of stroke • Tests may include: – – – – – – – – Follow-up head CT Brain MRI/MRA Carotid ultrasound Cardiac echo (transthoracic or transesophageal) Cerebral angiogram or CT angiogram Lipid panel Hemoglobin A1c Hypercoagulable tests: antiphospholipid antibodies, Protein C & S, Antithrombin III, Factor V Leiden mutation, Prothrombin 20210A mutation… 4. Stroke Prevention Percent of patients with events Stroke survivor’s greatest risk is another stroke 16 14 Stroke 14% Heart Attack 13% 13% 12 10% 10 8 7% 6 4 3% 3% 2% 2 CATS TASS CAPRIE* ESPS 2 * Stroke patient subgroup only (n = 6,431) Albers, G.W. Neurology. 2000;14;54(5):1022-8. Transient Ischemic Attack (TIA) • Stroke symptoms resolve in less than 24 hours (most resolve in < 1 hour) • Warning sign for stroke and heart attack – One third go on to have a stroke within 5 years • Stroke risk can be reduced • Opportunity to prevent full stroke Stroke risk factors Non - Modifiable • Age • Gender (men) • Heredity: family history of stroke, hypercoagulable states • Race/ethnicity (e.g. African Americans) Sacco RL, Benjamin EJ, Broderick JP, et al. Stroke: 1997;28:1507-17. Stroke risk factors Modifiable Behaviors Cigarette smoking Alcohol abuse Physical inactivity Sacco RL. et al. Stroke. 1997;28:1507-1517 1998;279:1288-1292 Medical Conditions • Hypertension • Heart disease • Atrial fibrillation • High Cholesterol • Diabetes • Carotid stenosis • Prior stroke or TIA Pancioli AM et al. JAMA. How many strokes can be prevented?* 360,000 HTN 146,000 Cholesterol 90,000 Smoking 69,000 AF 34,000 Heavy Alcohol Use 0 100,000 200,000 Adapted from Gorelick PB. Arch Neurol 1995;52:347-55 *Based on an estimated 731,000 strokes annually 300,000 400,000 Hypertension JNC VII Guidelines Events Cardiovascular Cardiovascular Events (%) Lower blood pressure = Lower Risk <<140/90 140/90 < 130/85 < 130/85 < 120/80 < 120/80 Vasan RS et al N Engl J Med 345; 1291-7, 2001 PROGRESS Trial Blood pressure reduction following stroke Stroke Rate (%) 20 28% relative risk reduction 15 10 14% 10% Placebo Active 5 0 1 2 3 Follow-up time (years) Progress, Lancet. 2001;358:1033-41 4 Risk factor modifications for blood lipids National Cholesterol Education Program (NCEP) Guidelines Condition Hyperlipidemia or atherosclerotic disease (LDL >100 mg/dL) Recommendation • Diet: decrease fat and cholesterol • Exercise • Add pharmacologic therapy: statin agents Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 1993;269:3015-23. Risk factor modifications for DM ADA Recommendations to Reduce Microvascular Complications • Average pre-prandial glucose <120 mg/dL • Average bedtime glucose 100 to 140 mg/dL • HbA1c <7% 1. Lukovitis TG, Mazzone T, Gorelick PB. Neuroepidemiology 1999;18:1-14. 2. Diabetes Care 1998;21 (Suppl 1):1-200 Lifestyle Risk Factor Modifications Lifestyle Factor • Cigarette Smoking Recommendation • Counseling • Nicotine replacement therapy • Bupropion • Alcohol use • Up to 2 drinks/day for men, 1 drink/day for women, or lighter individuals • Physical activity • Brisk activity (30 to 60 min/day) • Diet • 5 servings/day fruit and vegetables • Limit saturated fat (<30% total energy) Gorelick PB, Sacco RL, Smith DB, eet al. JAMA 1999;281:1112-1120. Prevention of Blood Clot Formation Müller, 1997 Medications that prevent stroke “Blood thinners” Anticoagulants Antiplatelet Agents •Coumadin (warfarin) •Aspirin •Exanta •Aspirin/extended release dipyridamole (Aggrenox) •Heparins •Clopidogril (Plavix) •Ticlopidine (Ticlid) Aspirin for prevention of stroke •Aspirin benefit independent of dose and gender •FDA, AHA & ACCP all recommend – an aspirin dose between 50 and 325 mg/day Albers GW at al Neurology 1999;53(suppl. 4):S25-S38 FDA. Federal Register. 1998;63:56802. Albers GW, et al. Chest 2001, 119: 300S-320S. Choice of medication for stroke prevention What is the cause of the stroke? Atherosclerosis Unknown Antiplatelet therapy Heart Warfarin (Coumadin) Albers GW, et al. Chest 1998;114:683S-698S Barnett HJ et al. N Engl J Med. 1998;339:1415-1425 Prevention of recurrent stroke Stroke caused by atrial fibrillation Relative Risk Reduction 80% 66% 60% Benefit of aspirin Benefit of warfarin 40% 20% 15% 0% EAFT Study Group Lancet 1993, 342: 1255-62 How to prevent a stroke • Control treatable risk factors • Take an anti-platelet agent or an anti-coagulant • Surgical therapy for carotid stenosis Changing the perception of stroke MYTH • Stroke is unpreventable • Cannot be treated • Strikes only the elderly • Recovery ends 6 months after a stroke REALITY • Stroke is largely preventable • Requires urgent treatment • Can happen to anyone • Stroke recovery can continue throughout life Stroke Websites American Stroke Association: www.strokeassociation.org National Stroke Association: www.stroke.org Stanford Stroke Center www.stanford.edu/group/neurology/stroke/