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Recognition and Emergency Management of Posterior Circulation Stroke Todd J. Crocco, MD, FACEP Professor WVU Department of Emergency Medicine November 20, 2015
JB MRN#: 070982372 • [email protected] time of stroke in December 2007 • Presented with H/A, dizziness, diplopia, decreased sensation and weakness right arm and leg.
Initial CT 12/12/2007, 0156 • Clot at the distal right vertebral artery. • Narrowing at the origin of the right pica may be secondary to small clot or stenosis. • Area of mild stenosis left vertebral artery near origin of the basilar artery adjacent to the right vertebrobasilar junction.
MRI 12/12/2007, 1706 • Acute small right lateral medullary infarction with what appears to be occluded distal right vertebral artery. The finding is compatible with abnormalities noted with non-opacification of the distal right vertebral artery on CT stroke protocol of 12 December 2007.
Recurrent stroke several days later… • Readmitted several days after discharge with • dysphagia and now LEFT arm hemiplegia and left leg weakness CTA 12/21/07 was unchanged as compared to prior examination showing distal right vertebral artery thrombus, significant narrowing of the origin of right PICA, and significant stenosis of the proximal basilar artery with a 60 -70%, which is hemodynamically significant and no evidence of new thrombus.
MRI 12/23/2007, 0858 • Infarct involving the lower medulla, which has slightly increased signal than the previous exam, also, now involving the ventral medullary aspect. There is no hemorrhage identified.
Reevaluation in 2010 • CTA 11/12/2010 for recurrent dizziness • Severe intracranial atherosclerotic disease involving the vertebrobasilar system with a worsening of stenosis at junction of left vertebral artery and basilar artery with chronic right distal intracranial vertebral artery occlusion. Stenosis now measures 70% or greater.
MRI 12/7/2010, 1619 • 1. Encephalomalacia within the medulla consistent with tissue loss from remote infarct. There is no evidence to suggest acute or evolving infarct on today's examination. • 2. Loss of flow signal in the right skull base vertebral artery consistent with chronic occlusion depicted on study dated December 21, 2007.
The turning point… • Recurrent episodes of intermittent vertigo and lightheadedness several times a week felt to be due to vertebral-basilar insufficiency. • 12/13/10 Enrolled in SAMMPRIS trial. Randomized to medical therapy arm. • 5’ 11’’, 306 lb, Haic 8. 3, Htn, HLD, OSA on cpap at night.
September 2015 follow up • 53 yo WM here for follow up. He is s/p Gastric bypass • • (Roux-en-Y). Morbid obesity- lost 75 lbs prior to surgery. He has lost 48 lbs more since 12/9/14. HTN- his BP has been doing well. He is off Lisinopril. T 2 DM- his A 1 C is 4. 1, In July. he is off all meds for this. HLD- TC 127 HDL 47 LDL 72 TG 39 off CRESTOR 40 mg a day due to cost since May. He is off fenofibrate 54 mg a day. I started Atorvastatin 40 mg a day last visit.
Posterior Circulation Ischemia Posterior circulation ischemia can range from fluctuating brainstem symptoms, caused by intermittent insufficiency of the posterior circulation (so-called VBI), to the “locked-in syndrome, " which is caused by basilar artery or bilateral vertebral artery occlusion.
Posterior Circulation Ischemia • 20% of all strokes – Up to 20 -60% have an unfavorable outcome – New England Medical Center Registry of Posterior Circulation Strokes • Overall mortality among 407 patients was reported at only 4%, with 79% having minor or no disability • Basilar artery occlusion (BAO) – 8 -14% of all posterior circulation strokes – Mortality of over 90%
Anatomy & Pathophysiology • Etiology thought to be local arterial atherosclerosis (large artery disease) and penetrating artery disease (lacunes) • New evidence that cardiogenic embolization is more common – 20 -50% of posterior circulation strokes
Risk Factors • Uncontrollable risk factors include – Age – Gender – Race – Family history of stroke or TIA – Personal history of diabetes
Risk Factors • Medical stroke risk factors include – Hypertension – Heart disease (atrial fibrillation or LVH) – Previous stroke or TIA – Previous heart surgery – Carotid artery disease – Peripheral vascular disease – Smoking
Risk Factors • Each decade past age 55: 2 x • Past history of stroke or a TIA: 10 x • Atrial fibrillation: 6 x • Smoking: 2 x
Risk Factors • The most common causes for vertebrobasilar occlusion are atherosclerosis in the elderly, and trauma in the younger population
Signs & Symptoms • Wide variety of syndromes – Hemi or quadriparesis – Cranial nerve deficits (III-XII) – Respiratory difficulty – Altered sensorium – Vertigo – Ataxia – Multiple cranial nerve signs indicate involvement of more than one brainstem level
Signs & Symptoms • "5 Ds” – Dizziness – peripheral or central – Diplopia – ophthmalmologic versus neurologic – Dysarthria – Dysphagia – Dystaxia
Signs & Symptoms • “Crossed findings” – Cranial findings on the side of the lesion and motor or sensory findings on the opposite side.
Signs & Symptoms • The most frequent posterior circulation symptoms were dizziness (47%), unilateral limb weakness (41%), dysarthria (31%), headache (28%), and nausea or vomiting (27%) New England Medical Center Posterior Circulation Registry. Arch Neurol. 2012; 69(3): 346 -351.
Shifting Gears…. .
What Does the ED Provide? § Availability 24/7/365 § Speed (when it matters) § Critical care skills § Very broad clinical knowledge
What Does This Imply? § 24/7 availability requires a lot of people and coordination § For speed, need to clarify the stakes § Every specialty has a “special need” § Critical care to patients with perceived critical needs § Broad knowledge base - need specialty backup
Three Important Messages • The ED has limitations – ‘You want a piece of me TOO? !’ • Delays are real – ‘systems’ can fix them – Buy-in and perception is needed • Planning and communication is needed – Develop protocols
ED Evaluation 27
The ED “Stroke Protocol” • Focused history and physical (ABC’s) – General and neurologic assessment • Fingerstick glucose measurement • IV access and STAT labs • Contact stroke team? • Patient monitoring – Frequent monitoring of VS and neuro exam – Oxygen and cardiac monitoring
General Stroke Management • Activate ‘Stroke Team’ • Check glucose & labs • Two large IV lines • Oxygen as needed • Cardiac monitor • Continuous pulse-ox • CT scan…. STAT • Confirm LSNN time • Perform neurologic • exam Get “real” with rt-PA – Prepare to mix – Have pharmacy alerted • Discuss with patient and • family potential treatments Begin general management
General Stroke Management • Cardiac monitor – Observe for ischemic changes or atrial fibrillation • Intravenous fluids – Avoid D 5 W and excessive fluid administration – IV normal saline at 50 cc / hr unless otherwise required • NPO – Aspiration risk, avoid PO until swallowing assessed • Blood pressure – Function of fibrinolytic eligibility
Team Communication • Nursing ED doc Consultants • For the ED team – just like any resuscitation • ED / Consultant communication – Absolutely critical – Complementary roles / complementary skills – Don’t say yo-yo!
NINDS Recommendations • Door-to-MD: 10 minutes • Door-to-Stroke 15 minutes Team notification: • Door-to-CT scan: 25 minutes • Door-to-Drug: 60 minutes (80% compliance) • Door-to-Admission: 3 hours American Heart Association 2005; European Stroke Initiative Executive Committee, Cerebrovasc Dis 2003; 16: 311– 337; NINDS National Symposium on Acute Stroke, 2003. 32
Diagnosis & Evaluation • History and physical • Physical exam – Cranial nerve findings – Eye movements – Cerebellar findings combined with opposite long tract (sensory and motor) signs
Emergency Diagnostic Studies • Brain imaging – CT or MRI? • Electrocardiogram • Complete blood count and platelet count • INR and a. PTT • Blood chemistries • Pulse oximetry, chest x-ray • CSF examination?
Current Treatment Options • Physiologic optimization • No thrombolytics – Aspirin • Death / nonfatal strokes reduced 11% – Heparin • Intravenous rt-PA – Risk stratify although all subgroups benefited from thrombolytics in NINDS • Other treatments – Intra-arterial thrombolysis with rt-PA – Mechanical embolectomy 37
Management • IV thrombolytic therapy • Antiplatelet and antithrombotic therapy is often used, with wide variation in treatment regimens • Intra-arterial thrombolytic therapy has been used successfully for patients with suspected BAO
Management • Traditionally, heparin has been used in the treatment of posterior circulation strokes, based upon uncontrolled trials showing benefit compared to historical controls
Recanalization Strategies • FDA cleared interventions: – IV t. PA (0 -3 hours) Approved 1996 – IV t. PA (3 -4. 5 hours) Practice Advisory 2010 – Devices Cleared for clot removal 2004 Time Window Options 0 -3 hours • IV t. PA • Device 3 -4. 5 hours 3 -6 hours • IV t. PA • IA Lytic / • Device >6 hours • Device 40
Conclusion • Wide variety of symptoms • Crossed findings (cranial nerve findings ipsilateral, with motor and sensory findings contralateral) • 5 Ds (dizziness, diplopia, dysarthria, dysphagia, and dystaxia) • Stroke care is a team sport