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8/9/2012 1 MICHAEL OPONG-KUSI, DO MBA MORTON CLINIC, TULSA, OK, USA CEREBRO VASCULAR ACCIDENTS
8/9/2012 1
MICHAEL OPONG-KUSI, DO MBA
MORTON CLINIC, TULSA, OK, USA
CEREBRO VASCULAR
ACCIDENTS
8/9/2012 2
Cerebrovascular Accident
Third Leading cause of deaths (USA)
750,000 strokes in USA per year.
150,000 deaths in USA per year
Statistics for Ghana ???
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TRANSIENT ISCHEMIC ATTACKS
TIA: focal neurological deficit with abrupt onset resolves within 24 hours.
Up to 50% will show acute infarction on MRI.
If symptoms persists > 1 hr 14% will resolve in 24hours.
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TRANSIENT ISCHEMIC ATTACKS
Carotid distribution TIA resolves within 14 minutes.
Vertebral artery distribution TIA resolves within 8 minutes.
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TRANSIENT ISCHEMIC ATTACK
TIA precursor for ischemic stroke
Cardio embolic disease stroke
Lacuna stroke
Hemorrhagic stroke
TIA proceed to CVA @ 10% in 3 mo
@ 13% in 1 yr
@ 30% in 5 yrs
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TRANSIENT ISCHEMIC ATTACK
Differential diagnosis:
Aortic dissection
Drugs
Venous thrombosis
Paroxysmal arrhythmias
Complicated migraines
Arterial vasculitis
Todd’s paralysis
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TRANSIENT ISCHEMIC ATTACK
Todd’s Paralysis
Transient hemi paresis in post ictal period after a grand mal seizure. Can last half hour to 36 hours.
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TRANSIENT ISCHEMIC ATTACK
Evaluation:
Clinical history!!
Determine carotid vs. vertebral history per exam
CT of head without contrast to rule out hemorrhage.
Carotid duplex ultrasound
Cerebral arterial angiography or MRI
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TRANSIENT ISCHEMIC ATTACK
Therapy:
Ischemic etiology
Platelet agent
Statin agent
Modification of risk factors
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TRANSIENT ISCHEMIC ATTACK
Therapy:
Aspirin first drug of choice
81mg to 325mg po q daily
18% risk reduction by cyclooxygenase inhibition.
Clopidogrel (plavix) 75mg po q daily blocks platelet ADP inhibition.
Dipyridamole 200 mg BID
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TRANSIENT ISCHEMIC ATTACK
Cardio embolic etiology:
Atrial fibrillation multiple stroke sites,
Mitral stenosis, mechanical valves, recent MI, tumor, estrogen BCPs
Therapy
IV heparin and initiate warfarin therapy to attain INR 2-3
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TRANSIENT ISCHEMIC ATTACK
Endarterectomy
If >70 stenosis is documented by carotid imaging studies and pt. symptomatic
Endarterectomy is beneficial.
Symptomatic patients with <50% stenosis no surgical benefit over medical therapy
Surgical mortality <6% in experienced centers.
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CEREBROVASCULAR
ACCIDENT
85% Ischemic Stroke
Thrombolic or embolic; cardiac to artery or artery to artery.
15% Hemorrhagic stroke
Intracerebral, subarachnoid, subdural or epidural
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CEREBROVASCULAR
ACCIDENT
Lacuna CVA 20% of all CVA
80% present as completed defect
20% present in hours or days.
Etiology
Thrombosis of penetrating branches cerebral arteries.
Major risk factor Hypertension, dyslipidemia
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CEREBROVASCULAR
ACCIDENT
Embolic etiology
Sudden onset of symptoms
No loss of consciousness
Accurate documentation of time of onset key in determining thrombolytic therapy.
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CEREBROVASCULAR
ACCIDENT
Internal Carotid Artery
Ipsilateral monocular blindness.
Contralateral weakness
Contralateral sensory loss
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CEREBROVASCULAR
ACCIDENT
Anterior Cerebral Artery
Contralateral weakness
Contralateral sensory loss
Deficit leg > arm and face
Personality changes.
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CEREBROVASCULAR
ACCIDENT
Posterior Circulation
Cortical blindness
Ataxia
Ipsilateral cranial nerve defect
Diplopia
Dysarthria (aphasia)
Altered level of consciousness.
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CEREBROVASCULAR
ACCIDENT
Hemorrhagic stroke:
Sudden onset of severe headaches
(the worst headache of my life!)
Loss of consciousness imply brain stem involvement.
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CEREBROVASCULAR
ACCIDENT
Onset of stroke at young age
AV malformation
Cerebral aneurysm
Endocarditis
Vasculitis
Traumatic carotid disease
Hypercuagable state
Drugs
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CEREBROVASCULAR
ACCIDENT
Onset of stroke at young age
Hypercouagulable states
Test at least 2 months post stroke
No wafarin at least 2 weeks
Protein C & S, Leiden Factor V, antiphospholipid antibody syndrome
Lupus anticoagulant
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CEREBROVASCULAR
ACCIDENT
Evaluation:
Transesophageal echo (TEE)
Invaluable in evaluating atrial septal defects, patent foramen ovale, cardiac clot, valvular disease, endocarditis.
Aortic arch atheroma
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CEREBROVASCULAR
ACCIDENT
Evaluation:
History, History, History!!!
Stat CT of the head WITHOUT CONTRAST media (contrast will obliterate intracranial bleed.)
CT may be normal for 6-24 hours post ischemic stroke!
CT may miss posterior fossa defects.
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CEREBROVASCULAR
ACCIDENT
Evaluation:
MRI head scan indicates:
Early defects
Vertebral basilar CVA
Occlusion of venous sinus
Small infarctions
MRI does not show bleeding well
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CEREBROVASCULAR
ACCIDENT
MRI angiography
Overestimates degree of vascular stenosis
Less helpful in the carotid siphon or middle cerebral artery
Gold Standard
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CEREBROVASCULAR
ACCIDENT
Primary Risk Factors:
Hypertension
Smoking
Diabetes Milletus
Hyperlipidemia
Physical Inactivity
Obesity / oral contraceptives
Advanced age.
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CEREBROVASCULAR
ACCIDENT
Medical Therapy
Aspirin 50-325 mg daily first choice!
Reduces relative risk by 18%
Decreases acute mortality and recurrent CVA in thrombotic strokes
Clopidogrel (Plavix) 75 mg daily
Alternative to aspirin less GI bleeding symptoms than aspirin.
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CEREBROVASCULAR
ACCIDENT
Medical Therapy
Antiplatelet agents
Dipyridamole 200mg + Aspirin 25mg BID
Heparin
Use in stroke in evolution 12mic gm/kg/hr
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CEREBROVASCULAR
ACCIDENT
Medical Therapy
Stat CT of the head to exclude bleed.
If stroke large by clinical exam and by CT hold heparin for one week
Low risk for recurrent bleed.
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CEREBROVASCULAR
ACCIDENT
Medical Therapy
Cardioembolic stroke
If endocarditis on native valves do not give heparin.
If endocarditis on mechanical valves wait 72 hours and repeat head CT if no bleed start heparin.
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CEREBROVASCULAR
ACCIDENT
Medical Therapy
Intravenous thrombolysis
r-TPA (approved drug for thrombolysis)
Inclusion Criteria
Age > 18 yrs ;
Treatment within 3 hours of CVA
Head CT does not show bleed
Neurological defect not too big
Keep BP<185/110
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CEREBROVASCULAR
ACCIDENT
Medical Therapy
Intravenous thrombolysis
Exclusion Criteria
Small CVA
CT scan show bleed
Hx. Recent CVA, surgery or trauma
Uncontrolled HTN, DM, coagulation defects.
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CEREBROVASCULAR
ACCIDENT
Medical Therapy
Intravenous thrombolysis
Results
10 fold increase in symptomatic intracerebral hemorrhage
30% decrease in disability @ 3 months
No change in mortality in 1 year
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CEREBROVASCULAR
ACCIDENT
Surgical therapy
Angioplasty and stent therapy
Problems with artery dissection, distal embolization,re-stenosis,
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CEREBROVASCULAR
ACCIDENT
Complications of Stroke
Seizures
Follow Glucose and Na levels.
Diazepam, phenytoin
Cerebyx (very expensive!!)
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CEREBROVASCULAR
ACCIDENT
Complications of Stroke
SIADH Syndrome
Low serum Na+ with high urine Na+
Decreased mental status
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CEREBROVASCULAR
ACCIDENT
Complications of Stroke
Cerebral Edema
Maximal day 3-5 persist for 10 days
Intubate and hyperventilate pCO2 to 35
Mannitol
Surgical decompression
CNS drainage
Steroids no benefits except tumor related
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CEREBROVASCULAR
ACCIDENT
Complications of Stroke
Hypertension
Ischemic Stroke treat if BP> 210/120
Avoid ischemia for 10 days
Hemorrhagic stroke
Acute bleed maintain SBP 140-160 to prevent further bleeding
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CEREBROVASCULAR
ACCIDENT
Complications of Stroke
DO NOT FORGET THE COMMOM COMPLICATIONS!
Pneumonia, UTI, Pulmonary emboli,
DVT prophylaxis, Sepsis, treat other co morbidities!
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CASE PRESENTATIONS
45 Year old male presented to the ER with difficulty speaking when he woke in the morning. He could not move his right leg and arm. He has otherwise been “healthy”
