Posterior Circulation Stroke Jessica Heckenberger BSN RN 1

Stroke Statistics § Stroke is the 5 th leading cause of death in the U. S. § Stroke kills almost 130, 000 Americans each year—that’s 1 out of every 19 deaths. § On average, one American dies from stroke every 4 minutes. § Stroke costs the United States an estimated $38. 6 billion each year. This total includes the cost of health care services, medications to treat stroke, and missed days of work. St. Luke’s University Health Network 2

F. A. S. T. § F-Face Drooping – Does one side of the face droop or is it numb? Ask the person to smile. Is the person's smile uneven? § A- Arm-Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward? § S-Speech Difficulty – Is speech slurred? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence, like "The sky is blue. " Is the sentence repeated correctly? § T-Time-What was the time the person was last known well? St. Luke’s University Health Network 3

Beyond Fast: B. E. F. A. S. T §B-Balance-Sudden trouble walking, dizziness, loss of balance or coordination §E-Eyes-Sudden trouble seeing in one or both eyes Vision St. Luke’s University Health Network 4

St. Luke’s Primary Stroke Center’s St. Luke’s Allentown Campus St. Luke’s Anderson Campus St. Luke’s Bethlehem Campus St. Luke’s University Health Network 5

Posterior Circulation Stroke § Posterior circulation stroke accounts for 20 -25% of ischemic strokes § Specialist assessment and administration of intravenous tissue plasminogen activator are delayed in posterior circulation stroke compared with anterior circulation stroke § Basilar occlusion is associated with high mortality or severe disability, especially if blood flow is not restored in the vessel; if symptoms such as acute coma, dysarthria, dysphagia, quadriparesis, pupillary and oculomotor abnormalities are detected, urgently seek the input of a stroke specialist St. Luke’s University Health Network 6

The Posterior Circulation § Vertebral arteries § The basilar artery § The posterior cerebral arteries and their branches St. Luke’s University Health Network 7

PCA Supply § Posterior Circulation Brain Structures – – – Brainstem (medulla, pons, and midbrain) Cerebellum Thalamus Hippocampus Areas of temporal and occipital cortex St. Luke’s University Health Network 8

Etiology § Arterial atherosclerosis (large artery disease) and penetrating artery disease (lacunes). § Cardiogenic embolization is more common than previously suspected and is responsible for 2050% of posterior circulation strokes § Vascular obstruction or occlusion is the fundamental disorder leading to hypoperfusion St. Luke’s University Health Network 9

Time is Brain St. Luke’s University Health Network 10

Risk Factors § Uncontrollable Risk Factors – – – Age Gender Race Family history of stroke or TIA Personal history of diabetes St. Luke’s University Health Network 11

Risk Factors § Medical Risk Factors – Hypertension – Heart disease (such as atrial fibrillation or left ventricular hypertrophy) – Previous stroke or TIA – Previous heart surgery – Carotid artery disease – Peripheral vascular disease – Smoking St. Luke’s University Health Network 12

Signs and Symptoms § “ 5 D’s” – – – Dizziness Diplopia Dysarthria Dysphagia Dystaxia St. Luke’s University Health Network 13

Signs and Symptoms § Changes in eye movement– Visual field loss in one or both eyes. – Ptosis – Diplopia St. Luke’s University Health Network 14

Signs and Symptoms § Dizziness/Vertigo – Symptoms ranging from near-syncope, lightheadedness or faintness to a sensation of movement or disequilibrium, unsteadiness, or imbalance – Vertigo with or without nausea and vomiting St. Luke’s University Health Network 15

Signs and Symptoms § Dysphagia or dysarthria § “Crossed” syndromes, consisting of ipsilateral cranial nerve dysfunction and contralateral long motor or sensory tract dysfunction are highly characteristic of posterior circulation stroke § Sensory deficits (numbness, including loss of sensation or par aesthesia in any combination of extremities, sometimes including all four limbs or both sides of the face or mouth) § Isolated reduced level of consciousness is not a typical stroke symptom but can result from bilateral thalamic or brainstem ischemia St. Luke’s University Health Network 16

Posterior Circulation Infarction According to Anatomical Location and Vascular Territory Affected § Lateral medulla (intracranial vertebral artery infarct, also known as Wallenberg syndrome) • • Nystagmus, vertigo, ipsilateral Horner’s syndrome, ipsilateral facial sensory loss, dysarthria, hoarseness, and dysphagia Contralateral hemisensory loss in the trunk and limb—pain and temperature § Medial medulla • • • Ipsilateral tongue weakness and later hemiatrophy of the tongue Contralateral hemiparesis of the arm and leg Hemisensory loss—touch and proprioception § Pons • • Hemiparesis or hemisensory loss, ataxic hemiparesis, dysarthria, horizontal gaze palsy Complete infarction causes “locked-in syndrome” with quadriparesis, loss of speech, but preserved awareness and cognition, and sometimes preserved eye movements St. Luke’s University Health Network 17

Locked-in Syndrome § Locked-in Syndrome (LIS) results from a lesion to the brainstem, most frequently an ischemic pontine lesion. It results in severe impairments due to the complete disruption of the motor pathways controlling eyes, face, trunk and limb movements, including breathing, swallowing and phonation. However consciousness and cortical functions are preserved. § LIS is defined as a syndrome characterized by preserved awareness, relatively intact cognitive functions, and by the ability to communicate while being paralyzed and voiceless. St. Luke’s University Health Network 18

Locked-in Syndrome § Locked-in syndrome affects around 1% of people who have as stroke § Individuals with LIS have the highest level of disability among stroke survivors § It is a condition for which there is no treatment or cure, and it is extremely rare for patients to recover any significant motor functions. § 90% die within four months of its onset – Initial stroke primary cause of death (25% of cases) • Voluntary cough is often impossible, and sometimes there is no reflex cough • Aspiration pneumonias are more common during the acute phase – Secondarily to infections such as pneumonia (40% of cases) St. Luke’s University Health Network 19

Locked-in Syndrome § Acute Phase – Respiratory tract monitoring and cardiovascular support – Thrombolysis or the prescription of blood thinners based on the type of vascular impairment – Peg tube feeding – Tracheostomy – VTE prophylaxis – Skin care management – PT • ROM • Bracing • Proper posturing in bed St. Luke’s University Health Network 20

Locked-In Syndrome § Rehabilitation Phase – Individuals use eye movements to communicate – Communication devices (as computer with synthetic voice) – Some individuals may be suitable for weaning from their tracheostomy as their condition improves during the first months – Exercises to maintain range of motion, as well as breathing, eyes, head, trunk and limb control exercises are performed throughout the rehabilitation process. St. Luke’s University Health Network 21

Diagnosing § History and physical exam – Horner’s syndrome- ptosis, small pupil, and anhydrosis on the same side, bilateral small or fixed pupils, and ataxia may aid early diagnosis. § Non-contrast CT of head § CT angiography- identify basilar artery occlusion § MRI St. Luke’s University Health Network 22

Management § Thrombolysis § Intra-arterial thrombolytic therapy § Heparin Therapy § Neurosurgery St. Luke’s University Health Network 23

t. PA (Activase) § Tissue plasminogen activator. § Activase is indicated for the management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability St. Luke’s University Health Network 24

Rationale for Use § Limit size of infarct by dissolving clot & restoring blood flow to ischemic brain. § Prompt treatment with (t-PA) may promote reperfusion and improve functional outcomes for patient. St. Luke’s University Health Network 25

Time Frame § Given intravenously within 3 hours of acute ischemic stroke (FDA) § The window can be extended to 4. 5 hours if patient meets additional criteria § Goal Door to Needle Time: Administer (t-PA) within 1 hour of arrival to hospital St. Luke’s University Health Network 26

Effects of t. PA § Binds to fibrin in a thrombus and converts plasminogen to plasmin which initiates local fibrinolysis…Tips the scale in the other direction. § Fibrinolysis: the breakdown of a blood clot. Clot/ Fibrin t-PA Activase Coagulation factors Activase Platelet Activation Activase St. Luke’s University Health Network 27

Effects of t. PA Fibrin strand Fibrin Strands Activase (Alteplase) St. Luke’s University Health Network 28

Contraindication 0 -3 hr Window § § § Evidence of intracranial hemorrhage Suspicion of subarachnoid hemorrhage on pretreatment evaluation Recent intracranial or intraspinal surgery, serious head trauma, or previous stroke Major surgery / serious trauma History of intracranial hemorrhage Uncontrolled hypertension at time of treatment (eg, > 185 mm Hg systolic or > 110 mm Hg diastolic) § Allergy to t-PA § § § Seizure at the onset of stroke (unless neuroimaging confirms ischemia) Active internal bleeding Glucose < 50 or > 400 Known bleeding diathesis including but not limited to: Current use of oral anticoagulants (eg, warfarin sodium) or an International Normalized Ratio (INR) > 1. 7 or a prothrombin time (PT) > 15 seconds § Administration of heparin within 48 hours preceding the onset of stroke and have an elevated activated partial thromboplastin time (a. PTT) at presentation § Platelet count < 100, 000/mm 3 St. Luke’s University Health Network 29

Contraindications 0 to 4. 5 Hour Window § CONTRAINDICATIONS - IN ADDITION TO THE 0 TO 3 HOUR WINDOW § Patient age § Patient taking oral anticoagulation despite INR level § History of both stroke and diabetes St. Luke’s University Health Network 30

Risk Factors § Largest risk factors is bleeding St. Luke’s University Health Network 31

Benefits of t. PA St. Luke’s University Health Network 32

Neurosurgical § External ventricular drainage or decompression may be lifesaving in large volume cerebellar infarction with falling level of consciousness attributable to raised intracranial pressure or acute hydrocephalus. § Emergency posterior fossa decompression with partial removal of the infarcted tissue may be lifesaving. St. Luke’s University Health Network 33

Diagnostic Work-up § Diagnostic work-up done to: – Determine etiology of stroke – Identify risk factors – Determine most appropriate secondary stroke prophylaxis • Anticoagulation • Antiplatelet • Statins St. Luke’s University Health Network 34

Cardiac Diagnostics § Electrocardiogram – Look for arrhythmias, conduction problems § Transthoracic echocardiogram (TTE) – screen for cardioembolic conditions § Transesophageal echocardiogram (TEE) – Screen for cardioembolic conditions – Invasive test St. Luke’s University Health Network 35

Other Diagnostic Studies § Carotid Doppler § EEG St. Luke’s University Health Network 36

Inpatient Rehabilitation § Speech Therapy § Physical Therapy § Occupational Therapy § Dietary Consultation – Multidisciplinary Rounds St. Luke’s University Health Network 37

Patient/ Family Education § On going education from all disciplines § Stroke Patient Education Binder – – – – Diagnosis Risk Factor Modification Family Risk Teach S/S of stroke Importance of taking medications Importance of regular medical follow-up § Stroke Club St. Luke’s University Health Network 38

Stroke Prevention § Hypertension – BP < 120/80 (after acute phase of stroke) – Dietary changes, exercise, medications § Smoking – Cessation counseling – Treatment (meds, hypnosis, etc. . ) § Diabetes – Hgb. A 1 C goal < 7. 0% – Meds, diet, exercise St. Luke’s University Health Network 39

Prevention Cont…. § Dyslipidemia – Lipid Profile (goals) • Total Cholesterol < 200 • LDL < 100 (<70) • HDL > 35 • Triglycerides < 200 – Meds, diet, exercise § Obesity – BMI > 25 – Exercise for 30 minutes on most days St. Luke’s University Health Network 40

Stroke Data 90 th SLA/B SLRA SLM SLQ SLW Percentile FY 14 FY 15 YTD FY 14 FY 15 YTD VTE Prophylaxis 98. 65 98. 7 100 100 100 Discharge Antithrombotics 98. 92 100 100 100 Discharge Anticoagulation A. Fib. 94. 12 100 100 100 Thrombolytic Therapy 89. 47 85. 7 90 66. 7 50 50 ----- 100 ---- Antithrombotic by Day 2 98. 53 98. 7 100 94. 7 100 100 100 Discharge Statin 98. 15 99. 6 99. 1 100 100 95. 7 96. 2 Stroke Education 97. 5 99. 5 95. 9 92 100 77. 8 100 88. 9 75 66. 7 Rehab Assessment 98. 8 100 100 100 Door to t. PA 60 min 50 68. 2 80 50 33. 3 0 ----- 0 0 St. Luke’s University Health Network 41

Thank you And please always remember. . . St. Luke’s University Health Network 42

References § http: //brainfoundation. org. au/medical-info/205 -locked-insyndrome-lis § http: //cirrie. buffalo. edu/encyclopedia/en/article/303/ § http: //www. bmj. com/content/348/bmj. g 3175 § Lewandowski, C. , & Santhakumar, S. , Posterior Circulation Stroke, Foundation for Education and Research in Neurological Emergencies. 2012. St. Luke’s University Health Network 43