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Stroke

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Title: Stroke


1
Stroke
  • Laura Lewis Mason RN, MS, ANP-C
  • University at Buffalo Neurosurgery
  • State University of New York

2
Definition of Stroke
  • Sudden loss of circulation to an area of the
    brain
  • Ischemic strokes are caused by a brain embolism
    intracranial athererosclerosis and/or
    liopohyalinosis of small penetrating vessels.
    Ischemic strokes accounts for 80 of all strokes
  • Hemorrhagic strokes are caused by ruptured
    aneurysms, AVMs, severe hypertension bleeding
    diathesis (malignancies) and trauma. Hemmorhagic
    stroke accounts for 20 of all strokes2
  • Flow limitation (vessel dissection)

3
Epidemiology
  • In United States estimated 600,000 to 750,000
    strokes occur annually
  • Ranks third among causes of death and first among
    causes of long term disability

4
Diagnosis
Yearly Incidence in the US
5
Projected number of strokes in US2002 - 2025
30,000 Aneurysms
Source Stroke, January 2004 J. P. Broderick, MD
6
Epidemiology
  • 1/3 recover
  • 1/3 die
  • 1/3 destroyed

7
  • Stroke Facts

8
  • Direct cost of stroke
  • 60 Billion

9
Cost
  • Measured in loss of work, hospitalization,
    rehabilitation, and care of survivors in nursing
    homes
  • Major cost or impact of a stroke is the loss of
    independence that occurs in 30 of survivors

10
Stroke
  • Most prevalent neurologic condition
  • Most common discharge diagnosis to nursing homes
  • Most common diagnosis treated in rehab
  • LEADING CAUSE OF ADULT DISABILITY

11
Stroke Survivors
  • NIH study of survivors of ischemic stroke age 65
    and older
  • 50 had partial paralysis
  • 30 were unable to walk without assistance
  • 19 had cognitive impairment
  • 35 had depressive symptoms
  • 26 were institutionalized in a nursing home

12
Stroke IgnoranceGallup Survey
  • 97 cant name stroke symptoms
  • 44 had suffered CVA or had family with CVA
  • lt50 identified brain as organ of insult
  • Most fear CVA more than MI

13
Acute Stroke Patients
  • 25 correctly identified symptoms
  • 24 seek medical help within 3 hours
  • Patients with previous stroke not more inclined
    to seek medical help

14
Why Dont CVA Patients Seek Treatment?
  • Dont recognize symptoms
  • Think symptoms will subside
  • Think nothing can be done
  • Worried about cost
  • Denial - dont want fears confirmed
  • Fear of hospitals

15
Stroke
  • 80 think their symptoms are not serious!!

16
Symptoms of Stroke
  • Sudden.
  • Loss of vision in one eye or the other
  • Weakness of the face, arm, or leg especially on
    one side of the body
  • Sudden confusion or inability to speak
  • Sudden loss of balance or incoordination
  • Sudden severe headache

17
  • Stroke Awareness!!

18
Risk Factors of a Stroke
  • Unmodifiable factors
  • Age Increase risk of stroke with increase in
    age. For every decade after 55 risk of stroke
    doubles. 2/3 of all strokes ocurr in people gt65
  • Gender Mengt risk for stroke (1.25xs) but more
    women die from stroke
  • Race/Ethnicity African Americans have double
    the risk than caucasian. AA between ages of 45-55
    have 4-5xs the stroke death rate than caucasian
  • Family history genetic tendency for stroke risk
    factors, lifestyle, htn, diabetes

19
Risk Factors for a Stroke
  • Modifiable-
  • Hypertension People with hypertension have a
    risk for stroke that is 4-6xs higher than the
    risk for those without htn.
  • Heart Disease Atrial fibrillation- increases
    risk 4-6. Valve disease.
  • Diabetes Three times the risk of stroke than
    those without diabetes
  • Cholesterol High Cholesterol gt150
  • Smoking doubles persons risk for ischemic stroke
    and increases persons risk for SAH by up to 3.5
  • Alcohol Consumption
  • Inactivity
  • Blood dyscrasias/Malignancies
  • Head and Neck Injuries May damage the
    cerebrovascular system, ie spontaneous carotid
    dissections
  • Infections viral and bacterial infections
    combined with other risk factors add a small risk

20
  • Stroke Belt

21
U.S. Stroke Belt
Source US Census Bureau Postcensal Population
Estimates (IDC9 430-438.9) (1991-1995)
22
Stroke Risk
  • Previous CVA
  • TIA

10-fold increase
23
  • Management of risk factors can reduce stroke
    incidence by
  • 50

24
Risk Factor Modification
  • Lipid reduction
  • Blood pressure control
  • Antiplatelet/anticoagulation therapy
  • Smoking cessation
  • Physical activity counseling
  • Beta blockers post MI
  • ACE inhibitors in CHF
  • Hormone replacement counseling

25
Acute Stroke
  • Requires multidisciplinary care
  • EMS involved in confirming signs and symptoms of
    stroke
  • EMS initiates call to stroke center and
    transportation of patient to the ER

26
Time is Brain
27
Rapid Triage and Assessment
  • Time is Brain
  • Is the etiology of the neurological deficit
    ischemic, hemorrhagic or other system
    abnormalities?
  • Determination of the etiology of stroke as well
    as time frame of when symptoms first occurred
    determines our treatment plan

28
NIHSS
  • 42 point scale comprised of 13 items that grade
    orientation, language, hemi-attention, motor,
    sensory, coordination, and visual deficits
  • Rapidly determines severity and possible location
    of a stroke
  • Score is associated with clinical outcome
  • NIHSS 0 no deficit
  • 5 is minor
  • Helps identify those that are likely to respond
    to thrombolytic therapy and those at risk ( gt20)
  • Is formally incorporated in the guidelines for
    thrombolytic therapy by the America Stroke
    Association

29
Radiographic Evaluation
  • CT head
  • CT perfusion
  • MRI diffusion/perfusion
  • CT angiogram/MR angiogram
  • Cerebral Angiography

30
Aquilion One
  • 320 x 0.5 mm detector rows with 16cm of coverage
  • Table with 200cm scan range and 660 lb. maximum
    load

31
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32
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33
Current Strategies For the Endovascular
Management of Acute Stroke
  • Mechanical (Pull the clot out)
  • Pharmacological (Dissolve the clot)
  • Endovascular Bypass (Stent the vessel open)

34
War on Stroke Tools
  • Thrombolysis
  • Intravenous
  • Intra-arterial
  • wire, snare, cage etc
  • Angioplasty
  • Stent
  • Suction thrombectomy
  • Ultrasound (IA / external)
  • Other

35
IV Thrombolysis
  • marginally effective/limitations
  • Large branch occlusions
  • may cause intracerebral hemorrhage
  • time window 3 hours
  • mild to moderate stroke
  • not much better than placebo
  • NIHSS gt10 gt 75 decrease odds of recovery
    (STARS study)
  • NINDS Trial Recanalization rates 26-40 (based
    on iv TPA data)
  • Mortality 21

NIH Trial NEJM 95 3331581 MAST Trial Lancet
95 3461509 ECASS Trial JAMA 95
2741017 ECASS II Trial Lancet 98 3521245
36
Intra-arterial ThrombolysisAdvantages
  • Angiographic visualization of thrombus
  • patients without thrombus dont get treated
  • High concentration of lytic drugs locally in
    thrombus and lower systemic doses
  • Improved titration of medication dose with
    angiographic visualization
  • dissections can be treated

37
Concentric Multi-Merci
  • Multi-Merci Recanalization Rates
  • 54.1 (60/111) Retriever alone
  • 69.4 (77/111) Post Procedure

38
PenumbraThrombus Perturbation and Aspiration
39
Penumbra
  • NIHSSgt8 and less than 8h from onset
  • 81.6 revascularization to TIMI 2 or 3
  • ICH symptomatic 11.2,
  • asymptomatic 16.8
  • NIHSS improved by gt/4 57.8
  • Mortality at 30d 26.4

40
Angioplasty/ StentLessons From the Heart
  • Useful for underlying atheroma
  • Occlusions refractory to reopening with other
    means
  • Worthwhile to perform stenting to restore flow
    early
  • Recanalization vs. sidebranch occlusion

Maverick OTW Balloon Catheter (Boston Scientific)
41
  • Case example
  • 83 yo male
  • acute RMCA stroke
  • left plegic, R gaze preference, L facial droop,
    dysarthric
  • NIHSS gt 10
  • onset gt 14 hrs
  • PMH paroxysmal afib (discovered on this
    admission)

42
Initial CT perfusion relative CBV preservation
suggests ischemia rather than infarct, ie
salvageable!!
43
Combo micro guidecath run demonstrates clot
location/size, distal patency
44
After MERCI, integrilin, retavase, MERCI again ?
TIMI-II inferior division
clot still present
45
s/p Gateway balloon angioplasty ? TIMI-III
inferior division, TIMI-II superior division
clot, no sup. M2
46
Pre
Post
47
preop CBF
preop TTP
postop TTP
area of infarct
area at risk
48
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49
  • 76 year old woman with prior history of multiple
    brain
  • Aneurysms clipped
  • Unknown onset over 12 hours ago
  • NIHSS 30
  • History of atrial fibrillation off Coumadin for
    GI bleed

50
CT perfusion bilateral PCA ischemia
51
CTA shows midbasilar artery occlusion
52
CTA shows tortous access
53
Solution R radial artery access Initial angiogram
confirms mid-basilar occlusion
54
MERCI retriever deployed
55
Clot retrieved
56
  • Post intervention improvement
  • from NIHSS 30 down to 4
  • Discharge to rehab,
  • Home in 2 weeks

57
Acute Implantation of Intracranial Stents
Endovascular Bypass
  • Advantages
  • Time Immediate restoration of flow
  • Success High recanalization rates (maybe 100)
  • Currently only used in setting of previous device
    failure
  • Could potentially do this earlier
  • Technically straight forward for experienced
    operator

58
Wingspan Stent
  • Balloon angioplasty
  • Stent placement
  • Self-expanding
  • Flexible
  • Microcatheter delivery system

SUNY Buffalo FDA Sponsored IDE 9/07
59
  • Illustrative Cases

60
Stent Assisted Revascularization for Stroke
  • 26 year old female presents 3 hours out with R
    hemiparesis and aphasia
  • NIHSS 9

61
CT Perfusion shows established infarct in insula
with at risk L hemisphere
62
Initial CTP, immediate post intervention and
delayed Head CT Post intervention NIHSS 1
Follow-up CT 48 hours later
Pre-Stent CT perfusion TTP
63
Stent Assisted Revascularization in Stroke (SARIS)
  • FDA approved IDE registry to evaluate safety of
    primary (no ia or iv thrombolysis or mechanical
    retrieval)wingspan stenting for acute stroke at
  • University at Buffalo Barrow Neurological
    Institute

64
SARIS Recanalization
  • All patients achieved recanalization
  • TIMI 2 40
  • TIMI 3 60
  • Plt0.0001 compared to presenting TIMI scores

65
SARIS Clinical Improvement
  • 65 improved 4 NIHSS points during
    hospitalization

66
Are stents the answer?
  • We dont know

67
Are stents the answer?
  • We dont know
  • BUT..
  • It sure looks promising!

68
  • Intra-arterial Treatment of Acute Stroke is
    beneficial
  • Algorithms are for guidance must individualize
    treatment!
  • Selection based on physiological imaging!
  • Need technology designed for the brain!

69
Thank you!
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