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Stroke: An Introduction

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Title: Stroke: An Introduction


1
StrokeAn Introduction
  • Maarten Lansberg, MD, PhD
  • Neil Schwartz, MD, PhD
  • Stanford Stroke Center

2
Outline
  • Background
  • Stroke Diagnosis
  • Stroke Treatment
  • Stroke Prevention

3
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)

4
Types of Stroke
Mohr JP, Caplan LR, Melski JW, et al. Neurology
197828754-62
5
Anatomy
6
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7
MR Angiogram
8
What happens with cutoff of blood supply?
  • Oxygen deprivation to nerve cells in the affected
    area of the brain --gt
  • Nerve cells injured and die --gt
  • The part of the body controlled by those nerve
    cells cannot function.

9
What Causes Ischemic Stroke?
Thrombotic
Embolic
Thrombus
Embolus
10
Ischemic Stroke
11
(No Transcript)
12
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--gt
  • Nerve cells injured and die --gt
  • The part of the body controlled by those nerve
    cells cannot function.

13
Intracerebral Hemorrhage
14
(No Transcript)
15
(No Transcript)
16
Head CT Ischemic or Hemorrhagic Stroke?
17
Head CT Ischemic or Hemorrhagic Stroke?
18
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 302523-28.
  • 2. Hoyert DL, Kochanek KD, Murphy SL. National
    Vital Statistics Report 1999 4719.

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.

20
The Stroke Belt
Perry HM, Roccella EJ. Hypertension
199861206-15.
21
2. Stroke Diagnosis
22
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

23
Other Stroke Symptoms
  • Also common following stroke
  • Depression
  • Other emotional problems
  • Memory problems

24
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

25
Common Stroke Patterns (2)
  • Right (Nondominant) Hemisphere
  • Left hemiparesis
  • Left hemisensory loss
  • Left neglect
  • Left visual field defect
  • Right gaze preference
  • Dysarthria

26
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

27
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

28
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

29
3. Stroke Treatment
30
Time is Brain
31
EMS/ED evaluation of acute stroke
  • Assure adequate airway
  • Monitor vital signs
  • Conduct general assessment
  • Evidence of trauma to head or neck
  • Cardiovascular abnormalities

32
EMS/ED evaluation of acute stroke (cont.)
  • Conduct neurological examination
  • Level of consciousness (Glasgow Coma Scale)
  • Presence of seizure activity
  • NIH Stroke Scale

33
ED evaluation of acute stroke diagnostic tests
  • Non-contrast Head CT
  • EKG
  • Blood Glucose
  • CBC, platelets, PTT, PT/INR
  • Serum electrolytes

34
t-PA therapy
35
tPA therapy for acute stroke
  • Candidate for IV tPA?
  • Stroke onset lt 3 hours (When was the patient last
    seen at baseline ?)
  • Benefit 12 increased chance of good recovery
  • Risk bleeding (up to 6)

36
tPA exclusion criteria
  • Symptoms mild or rapidly resolving
  • SBP gt 180 or DBP gt 110
  • Blood on head CT
  • History of ICH
  • CNS tumor or vascular malformation
  • Bacterial endocarditis
  • Known bleeding disorder
  • PTT gt 40 PT gt 15 (INR gt 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 lt50 or gt400
  • Pregnant

37
Other therapies for acute stroke
  • IV t-Pa outside the three hour window
  • IA t-PA
  • IA mechanical thrombolysis/thrombectomy
  • Neuroprotective agents

38
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

39
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

40
4. Stroke Prevention
41
Stroke survivors greatest risk is another
stroke
16
Stroke
Heart Attack
14
14
13
13
12
10
10
Percent of patients with events
8
7
6
4
3
3
2
2
CATS
TASS
CAPRIE
ESPS 2
Stroke patient subgroup only (n 6,431)
Albers, G.W. Neurology. 20001454(5)1022-8.
42
Transient Ischemic Attack (TIA)
  • Stroke symptoms resolve in less than 24 hours
    (most resolve in lt 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

43
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 1997281507-17.

44
Stroke risk factors
Modifiable
  • Medical Conditions
  • Hypertension
  • Heart disease
  • Atrial fibrillation
  • High Cholesterol
  • Diabetes
  • Carotid stenosis
  • Prior stroke or TIA
  • Behaviors
  • Cigarette smoking
  • Alcohol abuse
  • Physical inactivity

Sacco RL. et al. Stroke. 1997281507-1517 Pancio
li AM et al. JAMA. 19982791288-1292
45
How many strokes can be prevented?
Adapted from Gorelick PB. Arch Neurol
199552347-55
Based on an estimated 731,000 strokes annually
46
HypertensionJNC VII Guidelines
47
Lower blood pressure Lower Risk
48
PROGRESS Trial
Blood pressure reduction following stroke
20
28 relative risk reduction
14
15
Stroke Rate ()
10
10
Placebo
Active
5
0 1 2 3 4
Follow-up time (years)
Progress, Lancet. 20013581033-41
49
Risk factor modificationsfor blood
lipidsNational Cholesterol Education Program
(NCEP) Guidelines
  • Condition
  • Hyperlipidemia or
  • atherosclerotic disease
  • (LDL gt100 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 19932693015-23.
50
Risk factor modifications for DMADA
Recommendations to Reduce Microvascular
Complications
  • Average pre-prandial glucose lt120 mg/dL
  • Average bedtime glucose 100 to 140 mg/dL
  • HbA1c lt7
  • 1. Lukovitis TG, Mazzone T, Gorelick PB.
    Neuroepidemiology 1999181-14.
  • 2. Diabetes Care 199821 (Suppl 1)1-200

51
Lifestyle Risk Factor Modifications
  • Lifestyle Factor
  • Cigarette Smoking
  • Alcohol use
  • Physical activity
  • Diet
  • Recommendation
  • Counseling
  • Nicotine replacement therapy
  • Bupropion
  • Up to 2 drinks/day for men, 1 drink/day for
    women, or lighter individuals
  • Brisk activity (30 to 60 min/day)
  • 5 servings/day fruit and vegetables
  • Limit saturated fat (lt30 total energy)

Gorelick PB, Sacco RL, Smith DB, eet al. JAMA
19992811112-1120.
52
Prevention of Blood Clot Formation
Müller, 1997
53
Medications that prevent strokeBlood thinners
  • Anticoagulants
  • Coumadin (warfarin)
  • Exanta
  • Heparins
  • Antiplatelet Agents
  • Aspirin
  • Aspirin/extended release dipyridamole (Aggrenox)
  • Clopidogril (Plavix)
  • Ticlopidine (Ticlid)

54
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 199953(suppl.
4)S25-S38 FDA. Federal Register.
19986356802. Albers GW, et al. Chest 2001, 119
300S-320S.
55
Choice of medication for stroke prevention
What is the cause of the stroke?
Atherosclerosis
Unknown
Heart
Warfarin (Coumadin)
Antiplatelet therapy
Albers GW, et al. Chest 1998114683S-698S Barnett
HJ et al. N Engl J Med. 19983391415-1425
56
Prevention of recurrent stroke Stroke caused by
atrial fibrillation
Relative Risk Reduction
80
66
Benefit of aspirin
60
Benefit of warfarin
40
20
15
0
EAFT Study Group Lancet 1993, 342 1255-62
57
How to prevent a stroke
  • Control treatable risk factors
  • Take an anti-platelet agent or an anti-coagulant
  • Surgical therapy for carotid stenosis

58
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

59
Stroke Websites
  • American Stroke Association
  • www.strokeassociation.org
  • National Stroke Association
  • www.stroke.org
  • Stanford Stroke Center
  • www.stanford.edu/group/neurology/stroke/
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