Acute care of ischemic stroke patient

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  Notes
 
 
Slide 1 : Get Brain Smart!
Slide 2 : Neurology Migraine ALS Parkinson’s Headache Seizures Neuropathy Cardiology Stroke Heart attack Arrhythmias Heart failure Valvular disease
Slide 3 : Everything you ever wanted to know about stroke (but were afraid to ask) Timothy Lukovits, M.D.
Slide 4 : stroke
Slide 5 : Objectives Highlight some important differences and similarities between heart attack and stroke Motivate you to prevent a stroke
Slide 6 : How is a stroke different from a heart attack? A stroke is a sudden neurological deficit caused by a blood vessel problem 2 types Ischemic strokes Hemorrhagic strokes The effects of a stroke are extremely varied
Slide 7 :
Slide 8 : Why is heart attack easier to recognize than stroke ? Painful Public and health care providers commonly recognize symptoms and need for action Often painless the stroke itself often affects awareness of symptoms Poor recognition of symptoms and need for action
Slide 9 : Copyright restrictions may apply. Pancioli, A. M. et al. JAMA 1998;279:1288-1292. Respondents unable to name 1 warning sign or risk factor for stroke
Slide 10 : Which of the following are warning signs of stroke? Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden chest pain Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause
Slide 11 : Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden chest pain Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause
Slide 12 : Diagnosis is relatively easy. EKG and cardiac enzymes readily available. Diagnosis is difficult. Many things can mimic stroke. There is no blood test for stroke. MRI not readily available. Is heart attack easier to diagnose than stroke?
Slide 13 :
Slide 14 : Isolated weakness right index finger JS Kim, Neurology, 2002 MRI with diffusion weighted imaging
Slide 15 : Where is the stroke?
Slide 16 :
Slide 17 : CT scan of arteries of neck and head
Slide 18 : Cause is usually rupture of a plaque within a coronary artery So the diagnostic and treatment strategy is fairly straightforward (find the blockage and open it up!) Atherosclerosis is important, but there are many other causes Determining the cause in an individual is often a deductive process Are the causes of heart attack and stroke different?
Slide 19 : There are many potential causes of stroke
Slide 20 : Stroke is not just a brain disease and often the brain is just an innocent bystander Usually caused by diseases that are affect the entire vascular system (atherosclerosis) Material blocking brain arteries usually comes from outside the brain (atrial fibrillation, carotid artery disease)
Slide 21 : How is a Cardiologist different than a Neurologist Basically a plumber or electrician Diagnostician Detective Daredevil
Slide 22 : Case Healthy 61 year-old man developed confused speech 1 day after falling out of a tree. August 11th, topping a tree, fell and sustained a left collar bone fracture and small puncture of the lung. Next night suddenly developed confused speech.
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Slide 27 : Trauma (fall out of a tree) Vascular problem (leg vein injury) Blood disorder (hypercoagulability) Congenital heart anomaly (patent foramen ovale)
Slide 28 : How are heart attack and stroke SIMILAR? Time is critical The first priority is to save tissue at risk
Slide 29 : Kidwell 2004
Slide 30 : You need to call 911 ASAP for both heart attack and stroke! There is a 3 hour time limit for the medication t-PA, and the sooner it’s given the better! Future strokes may be prevented if we identify the cause of stroke ASAP People brought by ambulance are treated faster Neurological deterioration and other complications may be prevented if a patient is hospitalized earlier
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Slide 32 : June 2006 7AM: A 75 year-old woman collapsed at home, brought to her local emergency room. She cannot move her right side or speak. The doctors there are not comfortable using t-PA so transfer to DHMC is requested. 1:02 PM: Arrival DHMC ED.
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Slide 35 : 4:49 PM artery is opened
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Slide 38 : The system needs to be very coordinated
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Slide 40 : Improving Stroke Care at DHMC PREPARED INDIVIDUALIZED CARE PROTOCOLS TO DECREASE ERRORS A TEAM APPROACH RAPID EVALUATION
Slide 41 : Ways everyone here can prevent a stroke Identify and control risk factors If a warning sign of stroke occurs, get attention
Slide 42 :
Slide 43 :
Slide 44 : 10y risk 88% !
Slide 45 : 10y risk 13% !
Slide 46 : Preventing a heart attack or stroke is MUCH more effective (and safer) than a procedure!
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Slide 49 :
Slide 50 : HJM Barnett 1999
Slide 51 : Copyright restrictions may apply. Barnett, H. J. M. et al. Arch Neurol 2000;57:40-45. The medical and surgical 5-year Kaplan-Meier curves of freedom from ipsilateral stroke and perioperative stroke and death indicate a 5.9% difference favoring endarterectomy at 5 years in the Asymptomatic Carotid Atherosclerosis Study (ACAS)
Slide 52 : Copyright ©2005 American Heart Association Alamowitch, S. et al. Stroke 2005;36:27-31 Kaplan-Meier 5-year risks of ipsilateral ischemic stroke for NASCET patients according to gender and degree of internal carotid artery stenosis in the medical and surgical groups
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Slide 55 : 18/111 (16%) received t-PA Average cost for transportation $4,623
Slide 56 : 2004: 144 pts Rx t-PA 50% had t-PA started at 1 of 47 referring hospitals >50% of these have <60 beds
Slide 57 :
Slide 58 : Meyer 2005
Slide 59 : MGH TeleStroke
Slide 60 : Effectiveness of Stroke Prevention Absolute risk reduction in a year: Strategy ARR (%) Warfarin for atrial fibrillation 8 Carotid endarterctomy for symptomatic dz 4 Smoking cessation 2 Antihypertensive therapy if BP elevated 2 Cholesterol lowering medications 2 Aspirin 1-2
Slide 61 : Schaebitz W-R, 2000
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Slide 63 : anticoag RG Hart 2003
Slide 64 : Stroke Diagnosis 40 years ago
Slide 65 : Stroke Warning Signs Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause
Slide 66 : What is a TIA ? Transient Ischemic Attack=Stroke symptoms that resolve with a short time. Can be a warning sign of impending stroke. The highest risk period of stroke following a TIA is the first 2 weeks. The risk of stroke soon after a TIA can now be estimated.
Slide 67 : ABCD2 Tool risk of stroke following TIA A Age> or = 60 1 B Blood pressure >140/90 1 C Clinical features unilateral weakness 2 speech impairment 1 D2 Duration > 60 min 2 10-59 min 1 Diabetes 1
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Slide 70 : A B C D E F Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148 Diabetes No No Yes Yes Yes Yes Cigarettes No No No Yes Yes Yes Prior Atrial Fib. No No No No Yes Yes Prior CVD No No No No No Yes Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318. *BP in millimeters of mercury (mmHg)
Slide 71 : Which action would you take if you thought someone was having a heart or stroke? take the person a hospital advise the person to call a doctor call 911 call a spouse or family member do something else
Slide 72 : Which action would you take if you thought someone was having a heart or stroke? take the person a hospital advise the person to call a doctor call 911 call a spouse or family member do something else
Slide 73 : Bleeding into the heart doesn’t occur Brain hemorrhage is common
Slide 74 : CT scan: ischemic stroke
Slide 75 : Intracerebral hemorrhage at 1 hour and 6 hours
Slide 76 : Intra-arterial thrombolysis Time window=6 hours
Slide 77 : High resolution MRI to identify the unstable plaque Chu B, Circulation 2005
Slide 78 : You need to open the artery
Slide 79 :
Slide 80 : Like with heart disease, the treatment and prevention of stroke needs to be individualized! A 65 yo man attends a vascular disease prevention fair and an ultrasound shows a blockage of his left carotid artery. He is told to speak to his doctor ASAP and he becomes worried that there is a “time bomb” ticking in his neck.
Slide 81 :
Slide 82 : 11/30/06

 


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