STROKE SCHOOL PART 2 Dr. Gurpreet Jaswal and Dr. Albert Jin October - PowerPoint PPT Presentation

STROKE SCHOOL PART 2 Dr. Gurpreet Jaswal and Dr. Albert Jin October 5 2019

OBJECTIVES 1) Review thrombolytic therapy for ischemic stroke: inclusion/exclusion criteria, dose and administration, complications. 2) Review practical aspects of endovascular therapy (EVT) for ischemic stroke 3) Recognize and manage complications of ischemic and hemorrhagic stroke and stroke mimics.

TPA INCLUSION CRITERIA • Ischemic stroke age ≥ 18 years old • Last known well < 4.5 hours

ABSOLUTE CONTRAINDICATIONS Active Hemorrhage or Intracranial Hemorrhage

RELATIVE CONTRAINDICATIONS • Stroke Mimic • Refractory hypertension(185/110) • High Risk of Bleeding: • Ischemic stroke or serious head trauma w/in 3 months • Previous ICH/SAH • Ongoing hemorrhage or major surgery w/in 14d • Arterial non-compressible site w/in 7d • Bloodwork Abnormalities • Glucose < 2.7 mmol/L or > 22.2 mmol/L • INR > 1.7 or high PTT • Platelets < 100,000 per cubic millimeter

TIME IS BRAIN Increased Reduced Increased Reduced achievement of symptomatic discharge to in-hospital independent intracranial home (OR, 1.03; mortality ambulation at hemorrhage (OR, (OR, 0.96; 95% CI, 95% CI, 1.02-1.04; discharge (OR, 0.96; 95% CI, 0.95-0.98; P < .001) P < .001) . 1.04; 95% CI, 0.95-0.98; P < .001) 1.03-1.05; P < .001) • Saver et al. JAMA. 2013;309(23):2480-2488

BENEFIT AND RISKS OF TPA • More patients eventually have a good outcome (~40% vs ~27% function at 3 months in the NINDS trial). • 90 minutes: NNT 3 • 3 hours: NNT 8 • 4.5 hours: NNT 12 • Risk: 5-6% may have major intracranial bleeding, 3% fatal intracranial hemorrhage

0.9 mg/kg Max dose 90 mg. 10% bolus over 1 min 90% dose over an hour

ANGIOEDEMA 1. Benadryl 50mg IV 2. Ranitidine 50mg IV 3. Hydrocortisone 100mg IV 4. Stop tPA if respiratory compromise 5. Icatibant if refractory? 6. Intubate if absolutely necessary

ENDOVASCULAR THERAPY (EVT) FOR ACUTE ISCHEMIC STROKE • Inclusion Criteria • Disabling clinical deficit • Small to moderate ischemic core (ASPECTS ≥ 5) • Occlusion in the anterior circulation of proximal large vessel (distal ICA/MCA) • Occlusion of basilar artery • Time Window • < 24 hours from last known well if using perfusion imaging (i.e. RAPID) to select patients • Some regions will also use multiphase CTA to select patients up to 24 hours • Other regions will use multiphase CTA to select up to 12 hours based on the ESCAPE trial Link: https://youtu.be/cWh1ovlJg24?t=12

THE BIG FIVE EVT TRIALS OF 2015 • Five RCTs comparing IV tPA against an endovascular approach using a “retrievable stent” • MR CLEAN • EXTEND IA • ESCAPE • REVASCAT • SWIFT PRIME

Menon et al Radiology 2015;275: 510-520.

RAPID • CT perfusion scan with RAPID automated image processing has become the standard stroke imaging protocol at KHSC • RAPID was used in DAWN, DEFUSE 3, EXTEND IA, and SWIFT PRIME • The basic principle is that patients with a small ischemic core and a large penumbra should be selected for EVT

STROKE WORK-UP CTA/CT HEAD CBC, lytes, Cr, CARDIAC MRI HEAD coagulation profile ECHO IMAGING BLOODWORK TESTS CAT DOPPLER Hgb A1C HOLTER MONITOR Lipid Profile

STROKE IN THE YOUNG WORKUP ALSO INCLUDES: • Cardiac causes – arrhythmia, structural and valvular heart disease, PFO • Hematologic causes – Thrombophilias (e.g. APLA, Protein C/S def), PCV, SS • Drugs – cocaine, methamphetamine, OCP, • Vascular disease – CTD Ehlers-Danlos, vasculitis, FMD • Infectious – HIV, meningitis • Trauma – dissection/injury • Congenital/rare conditions – Moyamoya, CADASIL, MELAS, Fabry

STROKE RISK FACTOR TARGETS • Blood pressure < 140/90* • Trials with ACEi and thiazide preferred (CHEP) • LDL < 2 or 50% reduction from baseline • Statin • HbA1C ≤ 7% • Optimize DM control • Atrial fibrillation • Anticoagulate • Carotid Stenosis • 50 - 99% symptomatic side – CEA or CAS

IN-HOSPITAL MANAGEMENT • Blood pressure • No more than 24-48 hours of permissive hypertension for ischemic stroke • Hemorrhagic – Target 140-160 systolic in first 24h (ATACH II TRIAL) • Non-TPA ischemic stroke > 220/120, reduce by 15-25% in first 24 hours. • Antiplatelet • Single vs. dual antiplatelet therapy • CHANCE TRIAL: ASA + Plavix x 3 weeks for minor stroke (NIHSS ≤ 3) or TIA in last 24 hours • POINT TRIAL: ASA + Plavix x 90 days • Switching to clopidogrel from ASA may be beneficial if done within the first 72 hours after stroke or TIA (Stroke. 2017;48:2610-2613. DOI: 10.1161/STROKEAHA.117.01789)

IN-HOSPITAL MANAGEMENT • Anticoagulation • TIA (can start immediately), mild/small infarct ( wait ~3d), moderate ( wait ~6d), severe/large (wait ~9d or more) Repeat CT head prior to starting anticoagulation • Carotid Stenosis • Carotid endarterectomy (prefer in everybody) vs. stenting • > 50-99% stenosis on SYMPTOMATIC SIDE • Refer to vascular surgery w/in 48 hrs or w/in 2 weeks if not stable • If asymptomatic, may be still considered for intervention (case-by-case basis) • <50% stenosis – Medical management

CASES

CASE 1 • 65M with Right face, arm and leg weakness & numbness + aphasia + dysarthria + Right HH • PMHx: HTN, dyslipidemia, DM2, Atrial fib, smoker • Meds: Candesartan, Atorvastatin, Metformin, Rivaroxaban • History • Last seen well: 2 hours ago • Onset: sudden • Physical Exam • 195/110 BP, NSR 85, cap glucose 4.6 • NIHSS: 22 • Labwork • Pts 106, INR 1.0 • CT/CTA: ASPECTS 9, LMCA M1 thrombus, good collateral flow

CASE 2 • 75M with resolving L arm numbness • PMHx: HTN, DLP • Meds: Ramipril, Rosuvastatin • History • Last seen well: 30 min ago • Onset: sudden • Physical Exam • 153/68 BP, NSR 72, cap glucose 5.6 • NIHSS: 1 • Labwork normal • CTA: Normal

CASE 3 • 53F with H/A, dysarthria, right arm & leg weak • PMHx: HTN, Atrial Fibrillation • Meds: Amlodipine, Apixaban • History • Last seen well: 30 min ago • Onset: sudden • Course: Worsening LOC • Physical Exam • 220/90 BP, NSR 90, cap glucose 7.8 • NIHSS: 18 • Labwork normal • Plts 260, INR 0.9, aPTT 34s

CASE 4 • 69F with L arm & leg weakness, dec LOC • PMHx: HTN • Meds: HCTZ • History • Last seen well: 2 hours ago • Onset: unclear • Course: Worsening LOC • Physical Exam • 178/76 R arm, 85/50 L arm, 120 HR, 95% 2L NP • AR murmur, Decreased breath sounds • NIHSS: 16 • Labwork: • Lactate 4.6, Hb 84, trop 0.6, Cr 140

CASE 5 • 46M with L sided H/A, dysphagia, dysarthria, R arm/leg numbness, L face numbness, gait ataxia • PMHx: Obesity, GERD, smoker • Meds: Antacids • History • Last seen well: 1 day ago • Onset: sudden • Course: Persistent • Physical Exam • 135/68 arm, 78 HR • As above + Left Horner’s syndrome • Labwork and CT/CTA reported as normal.

LATERAL MEDULLARY SYNDROME

CASE 6 • 32F with R arm & leg numbness • PMHx: Sz after MVA, migraine • Meds: Keppra • History • Last seen well: 40 min ago • Onset: over 5 min. • Course: Resolving • Physical Exam • 110/80, 89 HR • NIHSS: 2 • Labwork normal. Keppra level ok.

THANK YOU!