Neurovascular Emergencies

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Neurovascular Emergencies

• Victor Politi, M.D., FACP
• Medical Director, SVCMC, School of Allied Health,
  Physician Assistant Program

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Brain Injury - Hypoxia

• Ischemia
• mismatch between needed cerebral blood flow and
  the amount of perfusion supplied
• Injury
• After a period of ischemia, the brain becomes
  damaged
• Infarction
• Irreversible death of brain tissue

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Neurological Changes

• Reasons for increased ICP (pressure)
• Bleeding
• Edema
• Inflammation
• Tumor

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Neurological Changes - Bleeding

• Bleeding
• aneurysm
• trauma
• CVA
• subdural (SDH) - bleeding below the Dura
• Epidural- bleeding above the Dura
• Subarachnoid (SAH)
• Intracerebral- bleeding within the brain

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Neurological Changes-EDEMA

• Edema -
• general swelling of brain tissue in response to
• trauma (injury)
• hypoxia (cellular death)

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Neurological Changes -

• Inflammation -
• infection of brain tissue
• Tumor -
• cancer
• arteriovenous malformation (AVM)

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Assessment of Neurological Function

• Level of consciousness
• Glasgow Coma Scale (GCS) the standard measure
  used to quantify level of consciousness in head
  injury patients
• Widely used in scoring systems, treatment
  protocols and general clinical decision-making in
  critically ill patients

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Glasgow Coma Score

• The GCS is scored between 3 and 15, 3 being the
  worst, 15 the best
• GCS is composed of 3 parameters Best Eye
  Response, Best Verbal Response, Best Motor
  Response
• A GCS of 13 or higher correlates with a mild
  brain injury, 9-12 is moderate injury and 8 or
  less a severe brain injury

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Glasgow Coma Scale

• E (eye) M (motor) V (verbal) 3 to 15
• 90 less than or equal to 8 are in coma
• Greater than or equal to 9 not in coma
• 8 is the critical score
• Less than or equal to 8 at 6 hours - 50 die
• 9-11 moderate severity
• Greater than or equal to 12 minor injury
• Coma is defined as (1) not opening eyes, (2) not
  obeying commands, and (3) not uttering
  understandable words.

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Glasgow Coma Scale (GCS)

• Measures best response
• Eyes scaled 1-4
• Verbal scaled 1-5
• Motor scaled 1-6
• Total 3-15

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Glasgow Coma Scale (GCS)- Eyes
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Glasgow Coma Scale (GCS)-Verbal
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Glasgow Coma Scale (GCS)-Motor
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Assessment of Neurological FunctionDecorticate
Posturing

• Seen when there is lesion of corticospinal tract
  superior to level of brainstem
• indicated in comatose patient who responds to
  sternal rub by full flexion of the elbows,
  wrists, fingers, as well as plantar flexion of
  feet with extension and internal rotation of legs

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Assessment of Neurological Function - Decerebrate
posturing

• Seen in patients with lesions of brainstem
• patients exhibit extension of the arms, flexion
  of the wrists, jaw-clenching, back-arching,
  plantar flexion, neck extension, either
  spontaneously or in response to sternal rub

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Cushing Triad

• Increased BP Decreased HR
• Irregular Respirations

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Cushing Triad

• Increase in BP to overcome the increase of
  pressure inside the skull
• Brain trying to prevent infarct
• Decreased HR to allow the heart to pump more
  effectively and increase BP
• Cheyne-Stokes respirations to try to blow off CO2
• CO2 is a potent vasodilator

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Cushing Triad

• CO2 is a potent vasodilator
• Increase of CO2 in the blood
• Causes increase in blood volume intracranially
• Decrease in CO2 in the blood
• Causes decrease in blood volume intracranially

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Herniation

• The increased ICP is forcing the brain through
  the Foramen Magnum
• Signs and Symptoms
• worsening GCS
• sudden change in pupil response (dilation or no
  responsiveness)
• Change in VS indicating Cushing's response
• General demise of patient

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Treatment

• Airway
• Increased ICP may diminish or paralyze the gag
  reflex
• - allowing aspiration
• Suction
• Positioning
• - C Spine ?

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Treatment

• Breathing
• severe brain injury may interfere with breathing
  center of the brain
• be ready to BVM patient if necessary
• High flow oxygen (10-15 lpm)

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Treatment

• Circulation
• Treat for shock
• prevent hypotension - hypoxia and infarct of
  brain tissue
• IV initiate
• assist with BP control
• med line if seizure

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Treatment

• Positioning
• What can be done to assist flow into the skull
• maintain blood pressure
• What can be done to assist flow out of the skull
• HOB elevated to 30
• C-collar removed

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Treatment

• Communicate with the patient
• whether they respond or not
• They may be awake and cannot communicate

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Neurovascular Emergencies

• TIA (transient ischemic attack)
• Stroke
• Hemorrhage
• Aneurysm
• Headache (worst of life)

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Headache
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Danger signals

• First or worst headaches
• Headache on exertion, early morning, or nocturnal
• Progressive headache
• New onset headache in adult gt50 years old
• Abnormal physical or neurological findings
  (fever, stiff neck)

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Secondary Headache DDx

• Subarachnoid Hemorrhage (SAH)
• first or worst headache
• physicians consistently misdiagnose SAH
• pts with the greatest potential tx benefits are
  most often misdiagnosed
• early complications develop in patients with an
  incorrect dx
• Meningitis
• associated with fever, neck stiffness, confusion
  

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Secondary Headache DDx

• Subdural hematoma
• recent trauma (/-)
• Stroke (Ischemic or Hemorrhagic)
• occurs with focal neurologic sx
• Cervicocephalic arterial dissection
• trauma hx (/-), neck pain, ipsilateral Horners
• Giant cell arteritis
• gt 50 yrs, visual loss, temporal pain, ? ESR

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Secondary Headache DDx

• Dental abscesses/TMJ
• oral or jaw pain initially
• Sinusitis
• overdiagnosed, dx more likely with fever/purulent
  nasal discharge
• Trigeminal neuralgia
• sharp unilateral pain usually over maxillary
  distribution
• Low CSF pressure headache
• sx resolve in supine position and recur when
  upright
• Acute Glaucoma
• periorbital pain, conjuntival injection, lens
  clouding

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Subhyaloid hemorrhage
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CT versus MRI

• Preferred in SAHICH

• Posterior fossa lesions
• CVT
• Meningeal disease
• Cerebritis and abscess
• Pituitary pathology

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SAH
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L.P in evaluation of headache

• Suspected SAH if CT is negative
• (Deterioration after LP in patients with clots
  on CT or a dilated pupil)
• Start antibiotics in patients with suspected
  meningitis, while waiting for CT
• CSF pressure should be measured
• Distinguish traumatic tap from true hemorrhage

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Probability of detecting xanthochromia in CSF
with spectrophotometry after SAH

• 12 hours 100
• 1 week 100
• 2 weeks 100
• 3 weeks gt70
• 4 weeks gt40

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Angiography

• In proven SAH- 4 vessel angio to identify source
  and r/o multiple aneurysms
• Initial arteriogram negative in up to 16 of SAH
• MRA detects 90 of saccular aneurysms of gt5mm
• Spiral CT angio detects 85 of saccular aneurysms

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Cerebral Aneurysm
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Cerebral aneurysm

• The brain has many arterial blood vessels that
  supply blood pumped by the heart. When the wall
  of a blood vessel becomes weak and/or thin, it
  forms a bulge or a bubble. This bulge or bubble
  is called an aneurysm.
• Aneurysms may also rupture, causing bleeding in
  the brain. This bleeding results in Subarachnoid
  Hemorrhage

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Causes

• Genetic predisposition in persons with polycystic
  kidney disease or coarctation of the aorta
• Cause often unknown

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Treatment

• Unruptured aneurysms
• Large Aneurysms are surgically clipped at their
  bases to prevent rupture.
• Small (less than 1/2 centimeter) ones without
  symptoms are usually followed with repeated
  cerebral angiographies

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Treatment

• Ruptured aneurysms
• Surgical clip placed at the base of the aneurysm
• Aminocaproic acid may be considered, but has
  complications
• Calcium channel blockers such as Nimodipine may
  prevent spasm of the artery where the aneurysm
  ruptured

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STROKE
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Stroke

• 3rd Leading cause of death in the United States
• The mortality from the acute event is about 20
• Leading cause of disability

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Three Types of Stroke

• Temporary or partially occluded blood flow (TIA)
• Hemorrhagic stroke
• Ischemic (infarct) stroke

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Stroke - Type 1

• Temporary partial occlusion of blood flow
• TIA or Transient ischemic attack
• nonpermanent deficits
• 30 will have a stroke

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Management of TIA

• ASA
• Dipyridamole (Persantine)
• Ticlid
• Plavix
• Carotid Endarterectomy

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Stroke - Type 2

• Hemorrhage Stroke
• bleeding in skull or brain (subarachnoid or
  intracerebral)
• blood must be removed
• burst aneurysm
• (the worst headache of my life)

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Hemorrhagic Stroke

• Only 1 out of every 5 strokes
• 30-day mortality of 30-50
• Occur in younger patient population
• Two major categories -
• intracerebral
• subarachnoid hemorrhage

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ICH

• Majority of hemorrhagic strokes
• Leading risk factors - increasing age,hx of prior
  stroke
• Associated with
• Chronic HTN
• Amyloidosis
• Other causes -
• bleeding diathesis due to iatrogenic
  anticoagulation, vascular malformation and
  cocaine use

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SAH

• Half as common as ICH
• Half of all SAH due to berry aneurysm rupture
  most commonly occurring at arterial bifurcations
  or branchings
• Arteriovenous malformations make up another 6 of
  all SAH

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Stroke - Type 3

• Ischemic (infarct) stroke
• 70-80 of all strokes
• can be reversed with clot busters
• occlusion or blockage
• embolization (primarily from the carotid artery
  or the heart)
• thrombosis
• low flow state

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Ischemic Stroke

• Three Major Categories
• Thrombotic
• Embolic
• Hypoperfusion

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Ischemic Stroke
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Stroke

• Arteriosclerosis -
• what occurs in the heart can occur in the brain
  as well...

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T.P.A. - Thrombolytics for CVA

• When to Use
• Time to Drug From Onset of Symptoms
• Exclusion Criteria

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Tissue Plasminogen Activator (TPA)

• Medication approved by FDA for acute treatment of
  stroke
• Must be given within 3 hours of neurologic
  symptoms(numbness, tingling, weakness, speech
  problems, language difficulties), while awake

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Tissue Plasminogen Activator (TPA)

• IV r-TPA given in a dose of 0.9mg/kg up to a
  maximum of 90mg - 10 of the dose in a bolus and
  the remainder infused over one hour
• improves outcome after stroke when given very
  early and within 3 hours on onset of stroke in
  carefully selected persons.
• The benefit persists over the long term (3
  months)

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Tissue Plasminogen Activator (TPA)
Contraindications

• Patient selection and timing of symptoms are
  critical!
• Symptoms not rapidly improving or resolved
• No currently active internal bleeding
• No illness predisposing to an increased risk of
  bleed

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Tissue Plasminogen Activator (TPA)
Contraindications

• No history of prior brain hemorrhage
• No significant GI or GU bleeding in past 3 months
• No known stroke, serious head trauma, or brain
  surgery in past 3 months
• No lumbar puncture or arterial puncture in past
  week

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Tissue Plasminogen Activator (TPA) -
Contraindications

• No pregnancy
• Diastolic BP lt or 110 and systolic BP of lt or
  185
• Platelet count less than 100,000/mm3
• No Major surgery within preceding 14 days
• Blood glucose lt50mg/dl or gt 400mg/dl
• recent MI

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QUESTIONS ??