Stroke

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Stroke

• EMS Week 2004
• Clear Lake Regional Medical Center
• May 19th 2004
• Russell K. Miller Jr. MD FACEP

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Stroke

• Definition
• Any vascular injury that reduces cerebral blood
  flow (CBF) to a specific region of the brain
  which causes neurologic impairment

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Stroke

• 700,000 patients per year
• 15 in-hospital mortality
• 20-25 30 day mortality

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Statistics

• 3rd leading cause of death in the U.S.
• First leading cause of disability in adults
• Once every minute
• One death every three minutes
• All ages, all walks of life
• 4 out of 5 families impacted
• (4,000,000 alive today)

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Stroke

• 50 of patients left with a disability
• 33 need assistance with daily lives

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Stroke

• 30 Billion a year
• 2 of all EMS calls
• 4 of all hospital admissions

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Stroke

• Morbidity
• Mortality
• Quality of life
• Economic 30 billion annually
• Direct costs 17 billion
• Mild stroke 8,000
• Moderate stroke 15,000
• Subarachnoid bleed 28,000
• TIA 4,000
• Fatal strokes only slightly cheaper
• Indirect costs 13 billion

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Pathophysiology of Stroke
The Ischemic Cascade and Secondary Injury
Clot
Area of core infarction

• Cells die quickly without reperfusion

Ischemic penumbra

• Cells at risk but not permanently
• 20-50 of perfusion from collateral
  circulation

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Cerebral Blood Flow

• Normal
• 40-60 ml/100gm of brain tissue

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Cerebral Blood Flow

• If lt 18 ml/100gm
• Tissue becomes electrically silent but function
  remains intact
• Clinically a neurological deficit exists

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Cerebral Blood Flow

• If lt 10 ml/100gm
• Membrane failure ensues
• Leads to tissue death
• Intracellular acidosis with failure of ATP pumps

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Ischemic Penumbra

• Ischemic tissue of 10-18 ml/100gm flow
• Electrically silent
• Recoverable tissue if flow restored

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Ischemic Penumbra

• This is partially reversible for up to 3 hours

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Stroke
Sudden disruption of normal blood flow to part
of the brain, producing cell damage

• Ischemic (blockage)
• Embolic
• Thrombotic
• Hemorrhagic (vessel rupture)
• Intracerebral
• Subarachnoid
• Stroke Syndromes

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Types of Stroke

• Ischemic 80
• Hemorrhagic 10

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Ischemic Stroke

• 430,000 per year
• 10-15 are TIAs
• Generally in peoplegt 60 years old

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Stroke

• 3 5 in patients 15-45 years old
• Migraines
• Drugs
• Cocaine
• Amphetamines
• Birth control pills
• Protein disorders

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Disorders that Mimic Stroke
Hypoglycemia Post-ictal phenomena (Todds
paralysis) Brain lesion (abscess or
tumor) Epidural or subdural hematoma Hypoxia (any
cause)
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Ischemic Stroke

• Embolic 25
• Thrombotic 33
• Unknown etiol. 36

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Embolic Stroke

• 25 of all strokes are Cardioembolic

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Embolic Stroke

• A-fib
• 5-17 times the likelihood of developing CVA

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Thrombotic Stroke

• 33 of all strokes arise from plaques

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Ischemic Stroke
Area of risk
Lodged blood clot
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Old CVA
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Hemorrhagic Stroke

• SAH
• 2 Rupture Berry Aneurysm in Circle of Wills
• ICH
• HTN
• AVMS

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Hemorrhagic Stroke

• Sub Arachnoid Hemorrhage (SAH)
• Intracranial Hemorrhage (ICH)

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Sub Arachnoid Hemorrhage
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Sub Arachnoid Hemorrhage
Middle cerebral artery
Ruptured Saccular aneurysm
Aneurysm
Saccular aneurysm
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Hemorrhagic Stroke
Cerebral hemorrhage
Middle cerebral artery
Internal carotid artery
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AV Malformation
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Intracranial Hemorrhage
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ICH Symptoms

• Headache
• Nausea / Vomiting
• Syncope
• Diaphoresis
• Hypertension

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Stroke Syndromes
Transient strokes stroke-like events

• Transient ischemic attack (TIA)
• Resembles a stroke
• Resolves in 30 minutes - 24 hours
• Should be regarded as a precursor to stroke
• Reversible ischemic neurologic deficit (RIND)
• Resolves in 1-3 days
• Lacunar stroke
• Weakness in one arm only
• Patients tend to be hypertensive

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Transient Ischemic Attack
Normal Blood Flow
Clot Forms
Clot Dissolves
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TIA

• Ischemic neurologic deficit
• lt 24 hours in duration
• Most lt 1 hour

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Stroke and MI

• 1 - 2 of MI patients will have a stroke within
  a month.
• ½ in the 1st 5 days
• ASA ? risk by 42
• Ischemic CVA ? cerebral autonomic dysfunction ?
  cardiac arrest

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Effects of Stroke
Effects depend on area(s) of brain affected
Right Hemisphere

• Left-sided paralysis
• Spatial misperception (falling, dropping
  things)
• Reading difficulty
• Impulsiveness
• Left-sided neglect
• Loss of short-term memory

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Effects of Stroke
Effects depend on area(s) of brain affected
Left Hemisphere

• Right-sided paralysis
• Speech/language impairment
• Inability to complete tasks without patient
  instruction
• Memory loss

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Effects of Stroke
Effects depend on area(s) of brain affected
Brain stem

• Disruption of breathing
• Loss of consciousness
• Variable effects on blood pressure
• Disruption of eye movements, swallowing,
  hearing, speech
• Bilateral paralysis likely

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Effects of Stroke
Effects depend on area(s) of brain affected
Cerebellum

• Balance
• Coordination
• Dizziness, nausea, vomiting
• Disruption of some reflexes, especially
  involving head neck

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Assessing Stroke
Presenting signs symptoms

• Unilateral weakness of face, arm or leg
• Facial droop
• Speech disorders (dysarthria, aphasia)
• Ataxia
• Dizziness
• Seizures
• Drooling/ dysphagia

• Changes in responsiveness
• Visual disturbances
• Severe headache of sudden onset

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Assessing Stroke

• Unable to walk
• Speech disorder
• Dizziness
• Numbness
• Seizure
• Found down
• Mental status change
• Heart attack

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NINDS Recommendations

• Door to Doctor 10 minutes
• Door to CT 25 minutes
• Door to CT reading 45 minutes
• Door to Rx 60 minutes
• Access to Neurology 15 minutes
• Access to Neurosurgery 1 hour

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EMS

• Assessment and support of cardiorespiratory
  function and serum glucose
• Determination of precise time of onset of signs
  and symptoms
• Rapid transport to ED
• Prearrival notification of ED
• Assessment of neurological function
• Rapid determination of essential medical
  information

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ER Priorities

• Assess ABCs, vital signs
• Provide oxygen by nasal cannula
• Obtain IV access (NS only) obtain blood
  samples(CBC, electrolytes, coagulation studies)
• Check blood sugar treat if indicated
• Perform general neurological screening assessment
• Alert Stroke Team neurologist, radiologist,CT
  technician

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Pronater Drift

• Have patient stretch arms out horizontally in
  front of him close eyes.
• Count to 10.
• Drop in either arm reveals unilateral weakness
  is considered positive.

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Pronater Drift
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Facial Droop
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National Institute of Neurologic Disorders and
Stroke (NINDS)

• June, 1996 FDA approved tPA for Rx of ischemic
  stroke (within 3 hours of onset)
• Must be preceded by CT to rule out bleeding
• Necessitates early assessment prompt,
  appropriate transport
• .9mg/kg up to 90 mg
• 10 as bolus
• Given within 3 hours

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Ischemic Penumbra

• This is partially reversible for up to 3 hours

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The Therapeutic Window

• Thrombolytics can limit size of ischemic
  core
• Neuroprotectants can mini- mize
  secondary injury to ischemic penumbra

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Inclusion Criteria

• 18 years or older
• Clinical diagnosis of ischemic stroke causing a
  measurable neurologic deficit
• Less than 180 minutes since symptom onset
• Non-hemorrhagic status confirmed by CT scan

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Exclusion Criteria

• Exclusion - Absolute
• Active internal bleed
• History of CVA
• Recent intracranial surgery
• Intracranial neoplasm
• Aneurysm
• Known bleeding disorder
• Severe hypertension

• Relative
• Age gt 75
• Recent major surgery
• Cerebrovascular disease
• GI/GU bleed
• Coagulation defect
• Pregnancy
• Diabetic retinopathy

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EMS

• Should transfer to facilities able to give tPA
  within one hour

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Prevention
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Work with your Dr

• Medication management is extremely important for
  stroke prevention
• Proper treatment of related conditions
  (hypertension, diabetes, heart disease, etc.)
  helps prevent stroke
• Surgery can sometimes lower risk

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Medications

• Antiplatelets
• a. Aspirin -- cheap effective
• b. Ticlid
• c. Plavix
• Anticoagulants
• a. Warfarin
• b. Heparin

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Medications Cont.

• Cholesterol Lowering Agents
• a. Statins
• b. Natural Substances
• Antidiabetic Agents
• a. Insulin
• b. Oral Hypoglycemic drugs
• c. Alpha-Glucosidase Inhibitors
• d. Thiazolidinediones

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Medications Cont.

• Antihypertensives
• Diuretics
• Angiotensin System Antagonists
• Calcium Channel Blockers
• Sympatholytics
• Beta Blockers
• Vasodilators

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Diet

• The most stroke resistant diet
• Low Fat (particularly in saturated fat)
• Low Sodium
• High Intake of Fruits and Vegetables (5-6
  servings daily)

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Diet Cont.

• High in Omega 3 fats
• Smaller Portions
• (4 oz. or less) of Meats
• High Fiber Intake

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Exercise

• Benefits
• Helps control blood pressure
• Helps relieve stress
• Helps body burn fats and lower obesity risk
• Reduces risk of cardio-vascular disease

Stroke survivors should consult doctor before
beginning program
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Exercise Cont.

• Other Benefits for Stroke Survivors
• Promotes rehabilitation
• Lessens depression
• Raises energy level
• Lessens risk of falling

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Quit Smoking!

• The health costs of smoking
• Contributes to atherosclerosis
• Raises blood pressure
• Reduces oxygen supply to the brain
• Makes blood thicker and more likely to clot
• Raises risks for stroke, heart disease, cancer,
  diabetes, hypertension and emphysema

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Manage Weight Stress

• Recent studies have proved that extra weight
  means extra stroke risk. Trim pounds and risk at
  the same time!
• Unrelieved stress is hard on all the body
  systems. By practicing stress reduction
  techniques, you help prevent many diseases.

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Warning Signs

• Sudden numbness, weakness or paralysis of the
  face, arm, or leg on one side of the body
• Loss of speech, trouble talking or trouble
  understanding speech
• Sudden dimness or loss of vision, particularly in
  only one eye
• Unexplained dizziness, unsteadiness or sudden
  falls
• Sudden severe headache with no apparent cause

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Conclusions

• Stroke is a medical emergency
• Additional education needed
• Prehospital caregivers must assess, stabilize
  and transport without delay
• Prehospital care may soon include neuroprotective
  agents

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Thanks!

• Your role is critical to all our patients, not
  just Stoke patients and we at Clear Lake Regional
  Medical Center thank you profoundly for your
  service and dedication to this noble art.
• RKM