Different Strokes for Different Folks

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Different Strokes for Different Folks

• Barb Bancroft, RN, MSN, PNP
• CPP Associates, Inc.
• www.barbbancroft.com

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The usual first slide with statistics

• 3rd leading cause of death in U.S.
• 1st leading cause of disability in U.S.
• 795,000 new cases per year
• Broadly divided into ischemic (87) and
  hemorrhagic strokes (13)
• 46 of all ischemic strokes (320,000)are caused
  by sudden occlusion of a large cerebral vessel
• One large vessel ischemic stroke occurs every 90
• Worse prognosis vs. small-vessel ischemic stroke
• (Roger VL, et al. and Smith WS)

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The second usual slide with more startling
numbers

• In the first minute of a stroke, your brain loses
  an estimated 1.9 million cells, resulting in the
  loss of 14 billion synapses and 7.5 miles of
  pathwayswhat you would lose in three weeks of
  normal aging. (January 2006 Stroke)
• But the loss continues every minute the stroke is
  left untreated. If a stroke runs its usual
  10-hour course, it can kill 1.2 billion nerve
  cellswhat a normal brain loses over the course
  of 36 years. (UCLA neurologist Jeffrey Saver)
  (Interview) 200734(2).
• TIME IS BRAIN!!

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Is neurogenesis possible?

• Prior to 1998 the answer was NOall you could do
  was KILL neuronsbooze, trauma, strokes, stress
• Dr. Spickerman
• Gerd Kemperman and Fred Gage discovered
  neurogenesis
• BUT only in 2 areas of the brain
• The hippocampus and the olfactory bulb
• How can you stimulate neurogenesis?

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Say YES to drugs

• Antidepressants
• Statin drugs
• Lithium

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Exercise

• One of the best ways to stimulate the growth of
  new neurons is to EXERCISE!

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Meditationand the monks

• Find a nice quiet environment
• Close your eyes
• Deep breaths
• Relax muscles
• oingy-boingy, oingy-boingy, oingy-boingy

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Does the brain have the capability of forming new
synapses?

• Yes
• Its called plasticity
• Use it! Range of motion, start PT and OT within
  24 to 48 hours if possible
• Exerciserecruitment of pathways
• Mirror neuronsmonkey see, monkey do LOOK in the
  mirror, move the right arm and the paralyzed arm
  will also move

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Brain boosters

• Challenge your powers of navigationturn off the
  GPS and use a map vary your routinewalking,
  driving home from work
• Math on the flyadd shopping purchases, calculate
  miles when driving
• Mind gamesmemorize phone numbers, CCs, spell
  cities and states forward and backward
• Ballroom dancinglearning stepsspatial, planning
  movements, balance

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Brain boosters

• New recipesfollowing steps, directions, planning
• Tai chiplanning, sequence of movements
• Assemble furniturefix things at home
• Musical instrumentfine motor, auditory,
  processing, procedural thinking
• Drawing, painting , sculpture classvisual
  memory, creative imagination
• Read the news actively every dayactivates
  attention centers remembering scores of sports
  events

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A review of neuroanatomy

• The lobes
• The brainstem
• The blood supplyanterior supply, posterior
  supply
• REMEMBER THE WORD SYMMETRY

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Orientation to the 3D brain--Lateral viewboxing
glove

• ANTERIOR
• Lobesfrontal, parietal, temporal, occipital
• Sulci
• Gyri
• Lateral fissure (Fissure of Sylvius)
• Central sulcusprecentral and postcentral gyrus
• POSTERIOR
• Cerebellum
• Brainstem

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Sagittal (medial) sectionlocation of brainstem

• Dura
• Tentorium cerebelli
• Infratentorial
• Supratentorial

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Meningeal layers

• Epidural (between bone and dura)arteries from
  the external carotid branch across the top of the
  dura (epidural hematoma)
• Dura
• Subdural spacebridging veins (subdural hematoma)
• Arachnoid
• Subarachnoid spacethis is the space where all of
  the cerebral arteries are locatedanterior and
  posterior blood supplies meet at the base of the
  brain in the Circle of Willis (subarachnoid
  hemorrhage
• Pia
• brain

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Lateral and coronal view
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Homunculus (motor and sensory)
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Corticospinal tract
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Inferior surfacebrainstem view
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NIH STROKE SCALE (NIHSS)

• NIHSS score is a measure of stroke severity rated
  from 1 to 42 based on findings on physical exam
  when the patient is evaluated at baseline, 2
  hours, 24 hours, 7-10 days and 3 months, and then
  time varies
• The higher the number, the greater the impairment
• 1-7 mild impairment
• 8-15 moderate impairment
• Over 15 severe impairment
• NIHSS score greater than or equal to 12 has a 91
  predictive positive value of a central
  large-vessel stroke
• EMERGENCY! Actions taken during first few hours
  have a significant impact on the extent of future
  disability

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THE FRONTAL LOBES

• Prime real estate of the brain
• Comprises one-third of the cerebral cortex
• Pre-frontal lobe--this is your Mother
• No, negative, dont, stop She is inhibitory
• Gamma-amino-butyric-acid (GABA)
• Judgment, insight, forward planning, following
  steps, directions, procedural thinking,
  socialization (you need bilateral frontal lobe
  disease to lose socialization)

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Abstraction

• Textbooks tell you to interpret proverbsWhat
  does a rolling stone gathers no moss mean?
• HUH? Abstract (conceptual thinking vs. concrete
  thinking)
• How are a car, plane and boat alike?
• Cow, horse, and pig?

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Frontal lobes

• Voluntary speech center (left frontal operculum)
• Dr. Pierre Paul Broca
• Brocas aphasia (aphasia--communication
  disorder)
• Non-fluent aphasiatelegraphic, staccato speech
• 20 of strokes present with some type of
  aphasia
• Kids and strokes
• Left-handed people and strokes

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Frontal lobes

• Pre-central gyrus the motor cortexupper motor
  neurons)
• Voluntary movement center of brain
• Send message through the Corticospinal tract
  through the internal capsule of cortex through
  the midbrain to brainstem where it crosses at the
  medulla (pyramids)
• Contralateral symptoms (opposite side, below
  where it crosses)
• FAT leg

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Corticospinal Tract
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Upper Motor Neurons/CS tract

• Contralateral hemiparesis
• (70 of anterior strokes present with
  hemiparesis)

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NIH STROKE SCALE--5 and 6 testing motor
function of arms and legs

• Extend the arms (palms down) 90 degrees (if
  sitting) or 45 degrees (if supine) and the leg 30
  degrees (always tested supine)
• Drift is scored if the arm falls before 10
  seconds or the leg before 5 seconds)
• Each arm is tested, in turn, beginning with the
  non-paretic arm.

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Scoring

• 0no drift 1drifts before 10 seconds but does
  not hit bed 2some effort against gravity,
  cannot get to or maintain 90 (or 45) degrees
  some effort against gravity 3no effort against
  gravity, limb falls 4no movement at all
• Do same with legshold the leg supine at 30
  degrees, drift is scored if the leg falls before
  5 seconds (scored as above)

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Motor function

• The initial shock of the strokethe patient may
  not be able to even hold the arm up
• Reflexes may be absent
• But as the nervous system recovers and the shock
  of the stroke is over
• Motor function may begin to recover, but will
  recover without a normal MOM or inhibitory input

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Upper Motor Neurons/CS tract

• No MOM?
• Hemiparalysis (spastic paralysis)
• Hyperreflexia
• Babinski reflex present or absent? (dont use
  terms positive or negativeconfusing)

• And thats why we always stand to the side when
  we check reflexes

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Josef Francois Felix Babinski

• The Babinski reflex
• Babinski, Josef Francois Felix, (1857-1932), a
  Parisian of Polish origin, described the famous
  abnormality of the extensor plantar response seen
  in disorders involving the corticospinal tracts
  in a series of short articles beginning in 1896.
• English physicians used their Rolls Royce key

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Upper vs. Lower Motor Neuron damage
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Reflex Chartnormal vs. stroke

• Achilles, patellar, biceps, triceps (S1,2 L3,4
  C5,6 C7,8)
• Normal--2 to 3
• REMEMBER SYMMETRY is the word of the day.

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Reflex Chartnormal vs. stroke

• Areflexia may be present on the opposite side due
  to the shock of the stroke)0
• As the brain recovers, and theres no mother
  (inhibition), the reflexes are uncontrolled
• Hyperreflexia 4 in the limbs involved (more
  later)
• TOES up

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Corticobulbar tract

• BULB means brainstem
• FACE upper motor neurons synapse in brainstem
  (bulb) on the SAME side
• Ipsalateral
• So a stroke patient can have IPSALATERAL lower
  facial weakness and CONTRALATERAL hemiparalysis

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TEMPORAL LOBES

• Wernickes area (superior temporal
  gyrus)reception of speech
• Do you hear me? (Cranial nerve VIII, the acoustic
  nerve primary sensory modality)
• Do you understand what I am telling you? Higher
  cortical function (hearing and coma)
• Interpretation of speech and sounds (superior
  temporal gyrus)
• Coins jingling in pocket
• Auditory agnosia

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Best language (9 on stroke scale)

• In the NIHSS there is a picture attached as part
  of the evaluation the patient is asked to
  describe what is happening in the picture, to
  name the items on the attached naming sheet, and
  to read from the attached list of sentences.
• Comprehension is judged from the responses as
  well as to all of the commands on stroke scale
  questions 1-8.

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Scoring 9

• 0 no aphasia
• 1 mild to moderate aphasiasome obvious loss of
  fluency or facility of comprehension
• 2 severe aphasiaall communication is through
  fragmentary expression listener carries the
  burden of communication
• 3 mute, global aphasiano usable speech or
  auditory comprehension coma patients

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TEMPORAL LOBES

• Recent memory (hippocampus)
• Remember 3 items
• Red ball, clock, tennis shoe
• Repeat them after meimmediate recall
• Red ball, clock, tennis shoe
• Continue with exam for 10 minutes and ask them to
  repeat those 3 items
• Only two areas of the brain are capable of
  neurogenesisthe olfactory bulb and the
  hippocampus (CN I connected to the uncus
  connected to the hippocampussmell and memory)

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PARIETAL LOBES

• Postcentral gyrus (somatosensory cortex)
• Right parietal lobe interprets left side of your
  body and the left side of your world
• Damage to the parietal lobes results in
  difficulty recognizing body parts and
  acknowledging the opposite side of your world
• Contralateral hemisensory loss
• Integration of tactile sensationstouch,
  pressure, vibration, and proprioception (do you
  know where your body parts are? Did you have to
  look for them?)

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PARIETAL LOBES..testing

• Double simultaneous stimulikids vs. adults
• Touch two areas at the same time..
• The neglect syndrome in adults (non-dominant
  parietal lobe)
• Kids will always neglect their body and will
  recognize touch on the face

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Stroke scale 11

• Extinction and inattention (formerly Neglect)
• See scale
• 0 no abnormality
• 1 visual, tactile, auditory, spatial or
  personal inattention or extinction to bilateral
  simultaneous stimulation in one of the sensory
  modalities
• 2 profound hemi-inattention or extinction to
  more than one modality does not recognize own
  hand or orients to only one side of space

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PARIETAL LOBES..testing

• Ability to localize stimuli
• Sharp vs. dull
• Tests for proprioceptionwhats proprioception?
• Graphesthesia/agraphesthesia
• Stereognosis/astereognosis
• Anosognosia (unawareness of illness, denial of
  hemiplegia)nondominant hemisphere
• Apraxiaexample a dressing apraxia
  ideomotor apraxia
  constructional apraxia

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OCCIPITAL LOBES

• Do you see this object?
• If they can see it, CN2 (the optic nerve)
• What is it? The occipital cortex
  (interpretationhigher cortical function)
• Visual integrationproblems manifest as cortical
  blindness (visual agnosia)
• Optic radiations via temporal and parietal
  lobes--homonymous hemianopia
• Visual field testing (3 on the NIH STROKE SCALE)

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Homonymous hemianopia
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Loss of visionoptic tract and optic radiations

• Right parietal lobe sees the Left LOWER visual
  field in both eyes
• Right temporal lobe sees the left UPPER visual
  field in both eyes
• Stroke in parietal and temporal optic radiations
  homonymous (same) hemianopsia (half loss of
  vision)

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Brainstem (bulb)midbrain, pons, medulla, and
cerebellum (sits on top of brainstem)

• Cranial nerve assessment
• MidbrainopticII oculomotorIII
• PonsAscending Reticular Activating System
  pupils (pontine pupils)(coma)
• CN V, VI, VII, VIII
• MedullaCV/respiratory center
• CN IX, X, XI, XII
• Cerebellumcoordination, synergy, equilibrium
  (dysmetria, dysarthria, dyssynergia)

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The light reflex tests two cranial nervesCNII
and CNIIIsensory via II, and motor via III

• PERRLA (pupils equal, round, reactive to light
  and accommodation)
• Located just beneath the tentorium
• As the uncus herniates over the tentorium it puts
  pressure on the CNIII (severe cerebral edema, or
  a large intracranial bleed)
• Dilated pupil on the side of the herniation

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The BRAINSTEM(the bulb)

• The optic disk (also known as the optic papilla)
• Papilledema (swelling of the optic disk due to
  increased intracranial pressure)

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The BRAINSTEM

• CN III, IV, VIfollow my finger (extraocular
  movements)
• CNIII also elevates the eyelid (levator palpebre)
• diplopia

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NIH STROKE SCALE--2best gaze

• Only horizontal eye movements will be tested
• CN III and VI
• If the patient has a conjugate deviation that can
  be overcome by voluntary or reflexive activity
  (oculocephalic testing or Dolls eye maneuver)
  the score will be 1
• Patients with forced deviation, or total gaze
  paresis not overcome by the oculocephalic
  maneuver will score a 2

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The BRAINSTEM

• CN V supplies sensation to the facedo you feel
  this? this? this? Check all 3 roots
• CN V supplies motor to the masseter and
  temporalisclench your teeth
• V (Trigeminal) and VII (Facial) work together
• Corneal reflextouch cornea with a cotton wisp
  and the patient blinks

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Facial Nerve--VII

• Muscle of facial expressionsmile, frown,
  surprise, close eyes
• Checking for symmetry
• Show me your teeth
• BBBBB

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NIH STROKE SCALE -- 4

• Facial palsy ask, or use pantomime to encourage
  the patient to show teeth or raise eyebrows and
  close eyes. Score symmetry of grimace in response
  to noxious stimuli in the poorly responsive or
  non-comprehending patient
• 0 normal
• 1 minor paralysis )flattened nasolabial fold,
  asymmetry on smiling
• 2 partial paralysis (total or near total
  paralysis on lower face)
• 3 complete paralysis of one or both sidesupper
  and lower

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The BRAINSTEM

• VIII (acoustic)(dizziness)
• IX (Glossopharyngeal) and X (Vagus)
• Swallowing (dysphagia)
• The gag reflex
• The uvula

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The BRAINSTEM

• CN XII (Hypoglossal)tongue movement and strength
• LaLaLaLa
• Stick tongue out
• Push tongue against cheek

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Cerebral circulationanterior circulation

• Aorta, common carotids (CCA), internal carotids
  (ICA), ophthalmic arteries, middle cerebral
  arteries (MCA), and anterior cerebral arteries
  (ACA)
• Middle cerebral arteries (MCA and the lateral
  aspects of the frontal, temporal lobes and
  parietal lobesexits at the lateral fissure
• The lenticulostriate arteries branch off the MCA
  (fragile and tend to rupture with hypertension)
  and extend into the brain parenchyma
• Anterior cerebral arteries go straight up the
  middle between both lobesconnected by the
  anterior communicating artery of the Circle of
  Willis (subarachnoid space)

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Anterior blood supply
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The anterior circulation

• Supplies the frontal lobes, parietal lobes, most
  of the temporal lobes, the basal ganglia, and the
  internal capsule
• Major signs of a vascular event affecting the
  anterior circulation include hemiparesis and
  aphasia (dominant hemisphere)
• Face and arm more than leg? Cortical distribution
• Face arm leginternal capsule (subcortical)

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Face, arm, and leginternal capsule, subcortical
hemorrhage

• Lenticulostriate artery rupture and hemorrhage

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Anterior ischemic symptoms and signs (cerebral
hemispheresfrontal- temporal- parietal)

• Contralateral hemiparesis of extremities
• Sensory deficits of contralateral extremities
• Loss of vision in ipsilateral eye (if the
  ophthalmic artery is involved)
• Homonymous hemianopia
• AphasiaBrocas, Wernickes, global

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Cerebral circulationposterior circulationvertebr
obasilar system

• Subclavian arteries to the vertebral arteries to
  the basilar artery to the posterior cerebral
  arteries (with a few other tributaries to the
  cerebellum and pons)

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Posterior circulation

• Supplies the brainstem, thalamus, cerebellum,
  occipital lobe and a portion of the medial and
  inferior temporal lobes
• The anterior circulation and posterior
  circulation meet at the base of the brainthe
  Circle of Willis aneurysms are most common at
  the Circle of Willis (more later)
• Dont forget that all of these LARGE, major
  arteries are running through the subarachnoid
  spacewith a rupture, subarachnoid hemorrhage

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Posterior circulationvertebro-basilar (brainstem)
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Signs suggesting posterior circulation
localization

• The Dsdiplopia, dysphagia, dysarthria,
  dizziness(dizziness has to be found with one of
  the other Ds)signify a posterior circulation
  problem

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Posterior ischemic symptoms and signs (brainstem
and occipital lobes and cerebellum)

• Motor dysfunction of ipsilateral face and or
  extremities
• Ataxia, vertigo
• The Dsdiplopia, dysphagia, dysarthrias,
  disequilibrium/dizziness
• These TIAs are more likely than those with
  anterior symptomatology to lead to ischemic
  stroke

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Posterior circulationvertebro-basilar (brainstem)
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One last reminder

• Large vessel artery strokes are most common
• Large vessels mean any greater than 2 mm in
  diameter and include the internal carotid, middle
  cerebral artery, anterior cerebral artery,
  vertebral artery, and basilar arteries

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Part 2

• Types of stroke
• Risk factors for stroke

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Principle stroke types

• Thrombotic stroke
• Embolic stroke
• Lacunar stroke
• (the first 3 are ischemic strokes)
• Hemorrhagic stroke

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What is the clinical profile of a thrombotic
stroke?

• The rupture of an atherosclerotic plaque in one
  of the large cerebral arteries leads to sudden
  clot or thrombus formation
• The presentation can be gradual, stuttering, or
  in a stepwise progression
• Carotid distribution usually

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Thrombotic strokes (40)

• Older population with history high cholesterol
  and atherosclerosis
• May have hypertension
• Onset may be gradual
• 50 of the time there is a preceding TIA
• 5 with mental status changes
• MRI/CT shows ischemic infarction
• May hear a carotid bruit
• Stroke during sleep, wake up with a stroke in
  progresswhen was the patient last observed as
  normal? last known normal

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What is the clinical profile of an embolic stroke?

• Sudden onset, often during usual daily activity
• Deficit is generally maximal at onset, often with
  improvement shortly afterward as the embolus
  breaks up and portions travel farther out into
  more distal branches of the affected arteryMCA
  territory
• The heart is usually the source and atrial
  fibrillation is a big offender, as are mechanical
  valves, or endocarditis
• Onset may be associated with palpitations,
  initiation of a cardiac arrhythmia, or following
  the Valsalva maneuver, heavy lifting or voiding

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Embolic strokes (30)

• Sudden onset, older population
• 10 with preceding TIAs
• 1 with altered mental status
• MRI/CT shows superficial/cortical infarction
• Underlying heart disease, atrial fib, peripheral
  emboli, strokes in different vascular territories

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What is the clinical profile of a lacunar stroke?

• 4 classic lacunar stroke syndromes 1st two are
  most common
• 1) pure motor hemiparesisFAT leg equally
  affected
• 2) pure hemisensory stroke
• 3) clumsy hand-dysarthria, in which there is
  significant disuse of the affected arm out of
  proportion to the amount of weakness evident
• 4) ataxia with paresis
• Associated with hypertension resulting from
  vasoconstriction/occlusion of the small
  perforating arterioles

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Lacunar strokes (20)

• May be gradual
• 30 with preceding TIAs
• 0 with altered mental status
• Small, deep infarction
• Pure motor, or pure sensory stroke

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What is the clinical profile of a hemorrhagic
stroke?

• Sudden onset, along with a prominent decrease in
  consciousness early in the course fluctuation of
  mental status is a common feature. Hypertension
  often occurs with bradycardia (Cushing reflex)
  along with other signs of increased ICP
• Ruptured cerebral aneurysms w/ subarachnoid
  hemorrhage (Circle of Willis), ruptured AV
  malformation, ruptured penetrating arteries (such
  as the lenticulostriate arteries w/ HBP)

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Hemorrhagic strokes (10)

• Sudden onset, worst headache EVER
• 30-60 may have less severe HA if aneurysm leaks
• 5 with preceding TIAs
• 25 with altered mental status
• MRI
• CT with hyperdense area (white area)
• Nausea, vomiting, coma, stiff neck, photophobia

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Aneurysm location

• Anterior Communicating artery30-35
• Internal carotid/posterior communicating
  artery29 35
• Middle cerebral artery20
• Basilar apex 5
• Vertebrobasilar junction (2)
• Superior cerebellar artery (3)
• Posterior inferior cerebellar artery (3)

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Incidence of aneurysms

• Aneurysmal SAH 6-8 of strokes
• Women greater than men
• 50 rupture
• 50 mortality rate with rupture
• 15 increase with a first degree relative with one

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AVManother cause of SAH

• Arteriovenous malformation
• 2-17 hemorrhagic strokes
• 8.6 of SAH
• 64 diagnosed before age 64
• 29 mortality
• S and Sspontaneous intracranial hemorrhage
  (50), seizure (30), headache (11-14), evolving
  neurologic symptoms

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Subarachnoid hemorrhageHunt-Hess grading scale

• Grade 1alert, mild headache, stiff neck
• Grade 2alert, vision problems, moderate to
  severe headache, stiff neck
• Grade 3lethargy or confusion, weakness or
  partial paralysis on one side of body
• Grade 4stupor, moderate to severe paralysis on
  one side of body
• Grade 5comatose

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Survival rates based on SAH severity

• Grade 1 70 survival
• Grade 2 60 survival
• Grade 3 50 survival
• Grade 4 20 survival
• Grade 5 10 survival
• Overall mortality rate for SAH is 50 at 1 year
  25 of survivors have persistent neuro deficits

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KNOW your risk factors--Some you cant
modifysome you can

• The number one risk factor you cant modify is
  AGEthe older you are, the higher the risk
• 2/3 of all strokes occur over the age of 65
• Blood vessels age

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Some risk factors you cant modify

• Genderin any given year more women than men will
  suffer a stroke, and women account for more than
  60 of all stroke deaths in the US
• Mens stroke incidence rates are greater than
  womens at younger ages but not at older ages.
  The male/female incidence ratio is 1.25 at ages
  55-64 1.50 for ages 65-74 1.07 at 75-84 and
  0.76 at 85 and older

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Some you cant modify

• Family History influences your risk for
  cardiovascular disease of any natureparent,
  grandparent, sister, brother
• Especially if they had a stroke before the age of
  65

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Risk Factors you cant modify

• Ethnicity--American Indian, people of African or
  South Asian descent are more likely to have
  hypertension and diabetes and therefore an
  increased risk of stroke

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Risk factors you cant modify

• Previous TIA or stroke
• Currently a TIA lasts no longer than 24 hours
  however, this definition is currently being
  revised to focus on manifestations that last for
  no more than one hour
• The majority of TIAs last 10 to 60 minutes

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TIAs (transient ischemic attacks) or
mini-strokes

• 15 to 19 of ischemic strokes are preceded by a
  TIA
• 4 to 5 will experience a progression to stroke
  within 48 hours
• Front-loadedhalf of the strokes that occur
  within 90 days happen within the first 48 hours
  after a TIA
• (Rothwell PM and Warlow CP. Timing of TIAs
  preceding stroke Time window for prevention is
  very short. Neurology 2005 Mar 864817-20)

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Most common symptoms

• Temporary loss of vision (amaurosis fugaxa
  transient monocular blindness) (Feels like a
  curtain was pulled down over my eye)
• Aphasia
• Hemiparesis
• Paresthesias (unilateral)

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Treatment of TIAs

• Early intervention after thorough evaluation by
  PCP or neurologist
• Antiplatelet and anticoagulant therapy has been
  found to reduce risk for early TIA recurrence or
  ischemic stroke by 80
• Initial treatment with antiplatelet
  therapyaspirin 50 to 325 mg/d

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Treatment of TIAs

• 2nd lineASA dipyramidole (Aggrenox)
  substantial benefit in using this combo to reduce
  BP and prevent secondary progression to stroke
• 3rd lineclopidogrel (Plavix) in patients who
  cannot tolerate ASA
• Warfarin for patients with AF (INR target 2-3,
  2.5), valvular heart disease (INR 2.5-3.5),
  crescendo TIAs
• Carotid endarterectomy for patients with greater
  than 70 stenosis or high-dose ASA and
  clopidogrel (Plavix)

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Treatment of TIAs

• Long-term management addresses the patients risk
  factors
• Lower BP with prils gradually
• Statins for atherosclerosis
• Antiplatelet drugs

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Hypertension a modifiable risk factor

• Ideal BP 120/80
• Acceptable BP with treatment is 130/80
• 140/90 is TOO HIGH

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Hypertension

• Hypertension is the most important risk factor
  for ischemic and hemorrhagic stroke. The
  incidence of stroke increases directly in
  relation to the degree of elevation of systolic
  and diastolic blood pressure. More important,
  there has been conclusive evidence for more than
  30 years that control of hypertension prevents
  strokes. Meta-analyses of randomized controlled
  trials confirm an approximate 30 to 40 reduction
  in stroke risk with lowering of blood pressure.

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Hypertension in the elderly

• Depending on co-morbidities it maybe kept
  slightly higher in the elderly to avoid
  hypotension, falls, and a broken hip
• But not TOO high66 of all strokes are due to
  hypertension
• Keeping the blood pressure BELOW 140/90 prevents
  strokes, acute coronary syndromes, chronic heart
  failure, dementia, and renal failure
• Is your patient hypertensive? Check HbA1ctype 2
  diabetes is 2.5x more likely to develop in
  patients with hypertension

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Hypertension

• Decreasing diastolic blood pressure by 5-6 mmHg
  or decreasing systolic blood pressure by 10-12
  mmHg over 2-3 years decreases the risk of stroke
  by 38
• So, what can we do to reduce blood pressure and
  thus, reduce stroke risk?

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Treatment of high blood pressure

• Weight loss
• (excess weight is also a risk factor for stroke)

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The DASH diet to lower BP

• Dietary Approaches to Stopping Hypertension
• Increase potassium-containing foods
• 4,700 mg of potassium per day
• People who are potassium deficient are 1.5 to 2.5
  times more likely to have a stroke

102
DASH dietK containing foods (mg)

• Oranges (260 mg)
• Raisins (1/2 cup) (543 mg)
• Halibut (654 mg)
• Potato (926 mg)
• Canteloupe (1 cup)(547)
• Banana (451mg)
• Milk (1 cup) (290 mg)
• Before adding K
• containing foods
• Are they on ACE inhibitors?
• Spironolactone? Both?

103
DASH diet

• Limit sodium intake to 2.4 g per day (slightly
  more than one teaspoon)
• Say no to processed foods
• Say no to Lean Cuisine
• Say no to other processed foods (bacon, bologna,
  ham)

104
DASH dietcalcium containing foods

• Increase calcium-containing foods (low-fat dairy
  products)
• Got low-fat milk?
• Lowfat yogurt?
• 320 mg of calcium per 8 ounces of skim milk

105
Say YES to drugs to reduce blood pressure

• Thiazide diuretics
• ACE inhibitors the prils
• ARBsthe sartans
• Calcium channel blockers the dipines
• Beta blockers olols, alols, ilols

106
PrilsThe ACE inhibitors (Brazilian pit viper)

• Captopril (Capoten)
• Enalapril (Vasotec)
• Lisinopril (Prinivil, Zestril)
• Perindopril (Aceon)
• Moxepril (Univasc)
• Benazepril (Lotensin)
• Quinapril (Accupril)
• Trandolapril (Mavik)
• Ramipril (Altace)
• Etc

107
The prils against stroke

• Perindopril (Aceon) Protection Against Recurrent
  Stroke Study (PROGRESS)decreased stroke by 28
• Ramipril (Altace) in the HOPE (Heart Outcomes
  Prevention Evaluation) showed ramipril decreased
  the risk of stroke even if the patients were not
  hypertensive

108
Risk factors that can be modifiedsmoking

• Accelerates atherosclerosis
• Accelerates aging
• Vasoconstricts cerebral vessels
• Current smokers who smoke 20 or more per day have
  a 2 to 4x greater stroke risk

109
Smokinga modifiable risk factor

• Even passive smoke elevates the risk

110
How can you stop smoking?

• Cold turkey?
• Nicotine replacement patches or gum
• Bupropion (Zyban)
• Varenicline (Chantix)
• Psychotherapy

111
READ my LIPIDSHypercholesterolemia

• Fat plaques in all of the major arteries
  including the precerebral arteries--aorta and the
  carotids and the vertebral arteries (supplying
  the posterior portion of the brain and brainstem)

112
Read my lipids cholesterol numbers

• The good cholesterolHDL (greater than 40 mg/dl
  for guys greater than 50 mg/dlwould be ideal)
• The bad cholesterol(LDL less than 100 mg/dl if
  you have diabetes or heart disease or a risk 70
  mg/dl would be ideal
• Triglycerides (less than 150 mg/dl new AHA
  guidelines say less than 100 mg/dl)

113
Say YES to drugs to lower LDL cholesterol

• The statin sisters
• Simvastatin (Zocor)
• Atorvastatin (Lipitor)
• Fluvastatin (Lescol)
• Rosuvastatin (Crestor)
• Pravastatin (Pravachol)
• Pitavastatin (Livalo)

114
Statins

• The statins should also be prescribed for all
  patients who have had an ischemic stroke/TIA to
  goal of LDL-C less than 2.0 mmol/L
• Aggressive reduction results in a 20 to 30
  relative risk reduction in recurrent vascular
  events for patients with a history of stroke
  without coronary artery disease

115
What do the statins do?

• Reduce total cholesterol and LDL levels
• Decrease fatty plaque formation, shrink plaques
  that are already present in major arteries,
  stabilize plaques, and prevent plaque rupture in
  the aorta and carotid arteries
• Increase the bioavailability of nitric oxide
  (vasodilator)
• The statins also lower BP!
• anti-inflammatory effects prevent plaque rupture

116
Sugar diabetes

• Risk of stroke is 2.5-4x greater in diabetics
• Diabetes is a proatherosclerotic disease
• Increased triglycerides and low HDLs
• High triglycerides cause the LDLs to be small and
  dense
• Small and dense LDLs are deposited easily into
  the walls of the arteries
• Diabetics also have hypertension
• Treat the hypertension, treat the elevated
  lipids, and treat the hyperglycemia

117
Excessive alcohol consumption

• Limit of drinks to less than 9 per week for
  women and less than 14 per week for men
• 12 ounces of beer of 5 alcohol
• 5 ounces of wine of 12 alcohol
• 1.5 ounces of 40 alcohol
• This is a YES

118
Physical inactivity

• Physical inactivity increases the risk of heart
  disease or stroke by two-fold
• 30 minutes most days of the week, working your
  way to 60 minutes most days of the week

119
Oral contraceptives and strokes

• There are about 4.4 ischemic strokes for every
  100,000 women of childbearing age. Birth control
  pills increase the risk 1.9 times, to 8.5 strokes
  per 100,000 women, according to a well-performed
  "meta-analysis" cited in the article. This is
  still a small risk there's one additional stroke
  for every 25,000 women who take birth control
  pills

120
Oral contraceptives and strokes

• For women who take birth control pills AND also
  smoke, have hypertension, or have a history of
  migraines, the stroke risk is significantly
  higher.
• balance the risks and benefits for each
  individual patient
• The higher the estrogen content of the pill, the
  greater the risk (old OCs vs. new OCs)
• two possible mechanisms are the increased risks
  of blood clots and hypertension associated with
  oral contraceptives

121
Stroke, causes in young adults

•    Cardiac factors (ASD, MVP, patent foramen
  ovale) Inflammatory factors (SLE, polyarteritis
  nodosa) Infections (endocarditis,
  neurosyphilis) Drugs (cocaine, heroin, meth,
  decongestants)
• Arterial dissectionHematologic factors
  (DIC, TTP, homocysteinemia, lupus
  anticoagulant)migraine WITH aura postpartum
  angiopathy
• Others premature atherosclerosis,
  fibromuscular dysplasia, sickle cell disease
• (Ferri 2010, 8th edition)

122
New studyischemic stroke in young adults

• Ages 16-54 15 atherothrombosis 8 small vessel
  disease 8 cardioembolism usually associated
  with atrial fibrillation 14 other definitive
  causes including cervical or cerebral artery
  dissection
• 19 potential but not definite causespatent
  foramen ovale
• Ages 16-44 less likely to have a definitive cause
• Larrue V et al. Etiologic investigation of
  ischemic stroke in young adults. Neurology 2011
  June 7 761983

123
Carotid stenosis and the risk of ischemic stroke

• Up to half of all ischemic strokes are associated
  with carotid stenosis
• Stenting vs. ASA 325mg and Clopidogrel/Plavix
  75mg x 90 days followed by ASA monotherapy?
  Followed by ASA monotherapy
• Chimowitz MI, et al. N Engl J Med 2011 Sept 15
  365993

124
A few more notes on carotid artery disease

• Patients with carotid territory TIA or minor
  stroke and high-grade ipsalateral carotid artery
  stenosis are at very high risk of early stroke
  recurrence. The absolute benefit from carotid
  endarterectomy is highly time-dependent.
• Carotid artery imaging (ultrasound) should be
  performed within 24 hours of the event

125
Atrial fibrillation (AF)

• Greater than 10 over 80 median age 75 AF
  reduces CO by 10-15
• Fibrillation potentiates clot formation and
  results in 2-5 fold greater risk for embolic
  stroke
• of stroke attributable to atrial fibrillation
  is lt 2 under age 60 20 over age 80

126
Atrial fibrillation--anticoagulation

• Warfaringold-standard, long-term anticoagulation
  with warfarin reduces risk of stroke by 66
  Vitamin K antidote 80/month
• INR 2-3 mitral valve disease or mechanical
  prosthetic valvesINR 2.5 to 3.5
• Dabigatran (Pradax in Canada Pradaxa in
  US)direct thrombin inhibitorno monitoring
  prevents 5 more strokes per 1000 patients per
  year BID/240/month
• Rivaroxaban (Xarelto)first oral factor Xa
  inhibitor QD no better than warfarin cost same
  as dabigatran

127
Stay tuned

• Apixaban (Eliquis)to be approved this year more
  effective than both of the above with less
  bleeding

128
Ischemic/embolic strokes

• If the ischemia continues long enough, brain
  infarction occurs. In the case of large-vessel
  ischemic stroke, an initial core area of infarct
  is often surrounding by a watershed area of
  ischemic tissue known as the penumbra. If
  circulation is restored within the first few
  hours of the ischemia, some or all of the
  penumbra may be salvaged
• TIME IS BRAIN!!!

129
Ischemic/embolic strokes

• As stroke volume increases, risk increases that
  opening a blocked vessel may result in
  catastrophic intracerebral hemorrhage rather than
  reperfusion, because necrotic, infarcted vessels
  cannot contain blood.
• This phenomenon, known as hemorrhagic conversion,
  imparts severe time limitations on the treatment
  of large vessel stroke.

130
Treatment of Ischemic/embolic strokes

• Prehospital careABGs, O2, IV lines, serum
  glucose
• Notify ER of possible stroke patient to mobilize
  the stroke team
• ERcontinuing assessment with NIH STROKE SCALE
  prep for fibrinolytic therapy

131
NIH STROKE SCALE (NIHSS)

• Higher NIHSS score with large vessel strokes
• NIHSS score is a measure of stroke severity rated
  from 1 to 42 based on findings on physical exam
• The higher the number, the greater the impairment
• 1-7 mild impairment
• 8-15 moderate impairment
• Over 15 severe impairment
• NIHSS score greater than or equal to 12 has a 91
  predictive positive value of a central
  large-vessel stroke
• EMERGENCY! Actions taken during first few hours
  have a significant impact on the extent of future
  disability

132
Recommended stroke evaluation time

• Door to MD 10 minutes
• Access to neuro expert 15 minutes
• Door to CT scan completion 25 minutes
• Door to CT scan interpretation 45
• Door to treatment 60 minutes
• Admission to monitored bed 3 hours
• Time is brain

133
General Management--LAB

• Glucosehypoglycemia is the most common
  electrolyte abnormality that produces stroke-like
  symptoms
• a) treat with D50
• b) hyperglycemia at the time of the acute
  stroke increases the infarct size and is
  associated with poor clinical outcomes Treat
  with insulin

134
General Management--LAB

• Electrolytes
• CBCHemoglobin, Hematocrit, platelet count
• PT and aPTTmany patients with acute stroke are
  on anticoagulants, such as heparin or warfarin
  Rx decisions such as thrombolytic use, require
  data on coagulation status an increase in INR
  may preclude patients from thrombolytics

135
General Management--LAB

• Cardiac enzymes/troponinpatients with stroke may
  also experience an acute coronary syndrome
• ABGsavoid if thrombolytics are considered
• Other tests tailored to individual patientsANA,
  homocysteine, coagulation factors such as protein
  S, C, antithrombin III, Factor V Leiden,
  anticardiolipin antibodies

136
Imaging studies

• CTnoncontrast CT scans are very sensitive in
  detecting intracerebral bleeds and subarachnoid
  hemorrhages, as well as subdural hematomas
• Not sensitive for early ischemia (less than 6
  hours) some findings can suggest early changes
• May also p/u tumors, meningeal bleeds, aneurysms
  abscess, AV malformation, hydrocephalus

137
General management

• Blood pressure managementelevated BPs in
  patients with ischemic stroke typically are not
  treated until they reach 220/120 mg
• ECGAcute coronary syndrome, atrial fibrillation
• ECHO in a young patient may pick up a patent
  foramen ovale
• IVavoid D5W use isotonic saline _at_ 50 mL/h
  unless otherwise indicated
• NPO until swallowing is assessed (usually
  brainstem strokes) 55 of new-onset stroke
  patients have dysphagia high risk of aspiration,
  pneumonia, dehydration, poor nutrition

138
General Management

• Supplemental O2 saturated O2 less than 93 or
  hypotensive
• Temperatureavoid hyperthermia, use oral or
  rectal acetaminophen, cooling blankets PRN

139
Ischemic strokes

• Fibrinolytic therapyIV rtPA (alteplase) for
  appropriate patients within 4.5 hours from
  symptom onset in carefully selected patients
• Converts plasminogen to plasmin plasmin breaks
  down fibrin and dissolves clots
• 0.9 mg/kg via combined IV bolus and 60 minute
  infusion
• Strict exclusion criteria due to increased risk
  of bleeding
• When did the symptoms start? REMEMBER, TIME IS
  BRAIN

140
Underused!

• Recanalization rates for IV rtPA alone are 6 -
  31 for the MCA and 13 to 30 for the ICA
• An estimated 28.7 of ischemic stroke patients
  would qualify for use, only 1 3 receive it
• Major reason? A delay in presentation!!
• 2nd reason? Lack of designated stroke centers
• 3rd reason? Lack of 24-hour CT availability

141
Intra-arterial rt-PA (prourokinase)

• Delivered directly to MCA via catheter within 6
  hours of symptom onset
• Much smaller dose than IV rt-PA (2-4 mg) directly
  to site of occlusion, within 6 hours of symptom
  onset
• ONLY GIVE AT STROKE CENTER with a highly skilled
  neurointerventional physician

142
Mechanical thrombectomy MERCI retriever and the
Penumbra device

• Used for large-vessel stroke
• May be used up to 8 hours after symptom onset
• When used alone? 57.3 recanalization
• When used with IA rtPA the recanalization rate is
  69.5
• Penumbra devicebreaks up clot with continuous
  aspiration with 81.6 revascularization

143
General Management

• Start rehabilitation assessment within 24 to 48
  hours
• OT
• PT
• Speech therapy
• Interdisciplinary approach decreases death and
  improves outcomes

144
Nursing care

• Frequent neuro assessment of course!
• Bleeding risk assessment
• Skin
• Bowel
• Bladder
• Lungs
• Musculoskeletal
• Psychological assessment

145
Stroke and depression

• Left cerebral cortex with damage to frontal
  poledepression (especially seen with stroke
  patients high risk within 1st 2 years after
  stroke)
• Subcortical infarcts in thalamus and caudate
  predispose to depression also
• SSRIs for patients with severe, persistent
  tearfulness
• Sertraline (Zoloft) and escitalopram (Cipralex)
  are excellent choices
• Improves compliance with physical therapy
• Recent evidence that SSRIs may improve motor
  recovery

146
REMEMBER!!!

• TIME IS BRAIN!!!

147
Thanks.

• Barb Bancroft, RN, MSN, PNP
• bbancr9271_at_aol.com
• www.barbbancroft.com

148
Selected Bibliography

• 1-888-4STROKE American Stroke Association
• Canadian Best Practice Recommendations for Stroke
  Care 2006
• Gommans J, Barber PA, Fink J. Preventing strokes
  the assessment and management of people with
  transient ischemic attack N Z Med J.
  2009122(1293)3556.
• Halsey MP. TIA Update. Clinician Reviews.
  200919(10)18-22.

149
Selected Bibliography

• Johnston SC, et al. National Stroke Association
  Guidelines for the management of transient
  ischemic attacks. Ann Neurol. 2006 60(3)301-13.
• Josephson SA, Sidney S. Pham TN, et al. Higher
  ABCD2 score predicts patients most likely to have
  true transient ischemic attack. Stroke.
  200839(11)3096-3098.
• Kang JH, Ho JD, Chen YH, Lin HC. Increased risk
  of stroke after a herpes zoster attack. A
  population-based follow-up study. Stroke 2009.
  October 8, 2009.

150
Selected Bibliography

• Klein-Ritter D. An evidence-based review of the
  AMA/AHA guideline for the primary prevention of
  ischemic stroke. Geriatrics. 2009 64(9)16-20.
• Lloyd-Jones D, Adams R, Carnethon M, et al. Heart
  disease and stroke statistics2009 update. A
  Report from the AHA Statistics Committee and
  Stroke Statistics Subcommittee. Circulation.
  2009119(3)321-e181.
• Roger VL, et al. Heart disease and stroke
  statistics2011 update a report from the AHA.
  Circulation. 2011123(4)

151
Bibliography

• Smith WS, et al. Significance of large vessel
  intracranial occlusion causing acute ischemic
  stroke and TIA. Stroke. 200940(12)
• Weinberger J. Antiplatelet agents for stroke
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• Wu CM, McLaughlin K, Lorenzetti DL, et al. Early
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