Acute Stroke Coordinator Time is Brain Janet Liefso Acute Stroke Coordinator

Acknowledgement to: Richard Wilson Linda Kelloway Andrea Fisher Work revised by: Janet Liefso, 2010

Objectives For Session Increase Stroke Recognition - signs and symptoms Review Basic Neuroanatomy the implications of stroke location Review complications Need to understand basic neuroanatomy to understand and predict signs and symptoms.

Jim 67 year old semi- retired accountant married to Laura. From Niagara region - visiting friends in Teeswater Suddenly at 2100 hours wife witnessed right arm weakness and leg weakness, unable to get up on own, speech slurred Wife called 911- paramedics responded and redirected Jim to Goderich Hospital on stroke protocol- arrived at 2130. Diagnosed as an ischemic stroke- given tPA at new telestroke site at 2220

What Happened?

Stroke is a Brain Attack Abrupt development of a focal neurological deficit as a consequence of a local disturbance in the cerebral circulation The brain can’t store glucose and is dependent on circulation to provide oxygen and glucose for energy production. When circulation is interrupted, brain cells die within minutes. Acute stroke may cause death…it actually leaves 20% of its victims dead within 30 days of their stroke. And for those who survive their stroke, many are left with significant disability necessitating institutionalization. It places a considerable cost burden on the society. But most importantly, it plays an important burden on patient and family. With the emergence of new therapies, like tPA, and new diagnostics and treatments, there is now a window of opportunity to intervene. A stroke is a brain attack. It should be treated with the same urgency as a heart attack.

Know the Warning Signs of Stroke Sudden Weakness Sudden Trouble Speaking Sudden Vision Problems Sudden Headache Sudden Dizziness (especially with any of the above signs)

Stroke Stroke is undoubtedly one of the most devastating events experienced by humans “Many stroke victims would rather die than live without their dignity and quality of life” Bahle, J. (1998). No choice Stroke means to be struck down

Stroke is an Emergency Act Fast Key Message Stroke is an Emergency Act Fast * 6 Million Neurons a Minute are lost Time is Brain Dr. Lownie

Basic Neuro-anatomy

Left Brain and Right Brain

THE BRAIN IS DIVIDED INTO 3 MAJOR AREAS Cerebrum Brain stem Cerebellum 1 3 lb organ – 2% of our body weight but 15- 20 % of our cardiac OP Cerebrum- this is the largest protion and contains 2 hemispheres. Left side controls the right and the right controls the left The two hemispheres are joined by the corpus collosum- Brain Stem Cerebellum 3 2

THE CEREBRUM IS COMPOSED OF FOUR LOBES Each lobe has many functions Frontal lobe is involved in planning, organizing, problem solving and personality. Frontal injuries often identified by behaviour- lack inhibitions- prefrontal cortex- higher cognitive function and personality Speech centre in left frontal lobe in 95% of Right handed and 70% of Left handed- Broca’s aphasia- speech is slow, know what they want to say, utter sounds, simple words- expressive aphasia Parietal lobe controls the sensory sensations such as temperature, pain and light touch, awareness of the body on the other side Temporal lobe organs of hearing- lesion here can cause deafness Wernicks speech are ( receptive speech area in the temporal lobe) Speech is fluent and rapid but not comprehensible- receptive aphasia. Occipital lobe is responsible for visual preception Cerebellum is responsible for movement and balance- Brainstem Pons – BP and respiratory function- hemodynamic function Each lobe has many functions

Key functions are to receive information and control muscle of the head- cranial nerves Composed of 3 specific areas

THE BRAIN STEM HAS 3 MAJOR DIVISIONS Midbrain Pons Medulla 1 2 Midbrain- connections to cerebellum Pons- respiratory, BP, vomiting Medulla- respiratory , BP , swallowing, and connections to cerebellum- movement control 3

THE CEREBELLUM Cerebellum is a compact area. Maintains posture and coordinated movement Do they look drunk??? Cerebellar strokes can cause swelling which puts pressure on brain stem- Dr. Brisbins experience of the cerebellar infarct that they sent to London and Neurosurgery removed the cerebellar lobe The swelling puts pressure on the brain stem- and pushes up into the cerebellum- like a reverse coning www.injuryprevention.ca

Follow the circulation to the brain in the following slides…. If you understand the blood flow and anatomy you are better able to care for your patient.

The Carotid Arteries R Internal carotid L Internal carotid Anterior & middle cerebral arteries Anterior & middle cerebral arteries R Internal carotid L Internal carotid Common carotid a Common carotid a Blood supply from the aorta supplies the carotids and the vertebral arteries. Carotids supply the anterior 2/3 and the vertebrals supply the posterior 1/3 First lets follow the carotid- Carotids supply 2 divisions- internal and external – internal supplies anterior 60% of cerebrum ( some of the temporal and occipital areas not supplied from the interior carotids External carotids supply the face and scalp L subclavian a R subclavian a ANTERIOR VIEW Aorta

Vertebral-basilar Arteries Posterior cerebral a’s L. Vertebral a R Vertebral a Vertebral arteries supply the posterior 2/5 of the cerebrum and the cerebellum and brainstem. Basilar is at the level of the pons Bring the neck from the clinic L subclavian a R subclavian a POSTERIOR VIEW Aorta

Anterior and middle cerebral a’s Post communicating a Post cerebral a Basilar a Internal Carotid Vertebral a The vertebral artery changes its name. It is called the basilar artery at the level of the pons and the and then dvides off into 2 posterior cerebral arteries at the level of the cerebrum. Common carotid Subclavian a Aorta

CIRCLE OF WILLIS Anterior C. artery Internal carotids Posterior C. Communicating artery Anterior C. artery Internal carotids Post. Communicating artery Posterior C. artery Basilar C. artery Circle of Willis is an important structure in circulation This circle provides multiple paths of oxygenated blood to the brain. . At the base of the brain the carotid and vertral arteries form a circle of communication . If any become occluded the attempt is to ensure circulation. Aproximately the size of a loonie. Most aneurysms occurr at the circle of Willis The anterior and posterior communicating arteries connect the right and left side of blood vessels.

Anterior cerebral arteries Middle cerebral arteries Circle of Willis Inferior view Ant. communicating a Anterior cerebral arteries Middle cerebral arteries Internal carotid arteries Post Communicating a’s Posterior cerebral arteries Basilar artery Vertebral arteries 22

CIRCULATION WITHIN THE LOBES OF THE BRAIN IS OFTEN SUPPLIED BY MORE THAN ONE CEREBRAL ARTERY E.g.. ACA and MCA to the frontal lobe

Generally, the Anterior Cerebral Artery (ACA) runs between the left and right hemispheres of the brain within the great longitudinal fissure. Stems from internal carotid Supplies blood to the frontal and anterior parietal areas ACA supplies the primary motor area HAL leg and foot 2nd most common area of stroke Longitudinal fissure

Generally, the Middle Cerebral Artery (MCA) runs on the lateral side of the 2 hemispheres and portions of the ventral (bottom) side of the lobes. The MCA is the largest of the blood vessels and supplies blood to over 2/3 of the cerebrum. It stems from the internal carotid. Most common stroke area. Gina’s tip ACA and MCA supplies eyes, most of hypothalamus, frontal. Parietal, and most of the temporal lobes.

Generally, the Posterior Cerebral Artery (PCA) is located on the bottom of the brain. Stems from the vertebral artery to basilar to posterior cerebrals. Supplies the blood to the brain stem, hypothalamus, thalamus, posterior parietal lobe, parts of temporal and occipital lobe and spinal cord.

POSTERIOR CEREBRAL ARTERY Note the ventral location of this artery

DEFICITS IN A PATIENT WITH A STROKE CAN BE EXPLANED BY: AREAS OF THE BRAIN CIRCULATION OF THE BRAIN AND/OR A COMBINATION OF BOTH Very important to have this information on you patient Lack of 02 for 2 min can result in ischemia. Lack of o2 for 5 min can result in irreversible damage. 6 million cells per minute- from Dr. Lownie.

THIS PATIENT MAY EXPERIENCE: A STROKE IN FRONTAL LOBE BLOOD SUPPLIED BY ACA AND MCA THIS PATIENT MAY EXPERIENCE: Contralateral paralysis or paresis of face, arm, leg Difficulty expressing language “ stuttering, using wrong word, articulation, repeating word(s)” (BROCA’S APHASIA) Urinary incontinence Personality changes and emotional lability ,

FRONTAL LOBE CONTINUED Controls ability to express language IMPORTANT STRUCTURES Broca is speech Controls ability to express language

FRONTAL LOBE CONTINUED Control of muscle movement IMPORTANT STRUCTURES Primary motor strip What is the motor strip called? Homunculus- HAL hand – arm - leg Control of muscle movement

primary motor cortex ( strip ) “ Homunculus” THE HOMUNCULUS SHOWS THE LOCATION OF BODY FUNCTION WITHIN THE MOTOR STRIP Hals lower body bends over the top of the cerebrum- therefore an occlusion of the ACA can result in loss of strenght and sensation in the lower part of the body and an occlusion in the MCA predominately affects the upper body strength. DEFINITION : A figurative representation of the body map encoded in the primary motor cortex ( strip )

THIS PATIENT MAY EXPERIENCE A STROKE IN PARIETAL LOBE BLOOD SUPPLIED BY ACA, MCA, PCA THIS PATIENT MAY EXPERIENCE Sensory deficit – loss of sensation i.e. pain, pressure, touch Talk about neglect- pt.not only cannot use the affected side but unaware that it is there. We will talk later about how to best care for a patient Parietal lobe- remember we said that it was responsible for sensation and awareness- Neglect – patient does not recognize a body part Denial of deficits (often with neglect)

PARIETAL LOBE CONTINUED The primary sensory cortex (strip) of the parietal lobe is arranged in the same topographic scheme as the motor strip in the frontal lobe.

A STROKE IN TEMPORAL LOBE BLOOD SUPPLIED BY MCA AND PCA THIS PATIENT MAY EXPERIENCE Severe communication problem : loss of comprehension of spoken language ( Receptive Aphasia also called Wernicke’s Aphasia) Memory loss or disturbances in memory Aggressiveness

Note location of Wernicke’s Area

BLOOD SUPPLIED BY MCA AND PCA THIS PATIENT MAY EXPERIENCE A STROKE IN OCCIPITAL LOBE BLOOD SUPPLIED BY MCA AND PCA THIS PATIENT MAY EXPERIENCE VISUAL DISTURBANCES Types of blindness- total or hemianopsia’s Loss of recognition of objects when shown them Hallucinations

BLOOD SUPPLIED BY VERTEBROBASILAR ARTERIES PATIENT MAY EXPERIENCE IF A STROKE IN CEREBELLUM BLOOD SUPPLIED BY VERTEBROBASILAR ARTERIES PATIENT MAY EXPERIENCE A gait that looks similar to an inebriated person Tell Dr. Brisbins story of the infarcted Cerebellum- increased swelling pushes up into the brain. Surgical removal of the cerebellum Cerebellum- smooth coordinated body movements Poor balance Complaints of dizziness, light headedness, “floating”

BLOOD SUPPLIED BY VERTEBROBASILAR AND PCA A STROKE IN THE BRAIN STEM The signs and symptoms depend on the location of the stroke in the 3 areas of the brain stem Mid brain Pons Medulla

KEEP IN MIND THAT THE AREAS INTERACT AND SHARE FUNCTION TO SOME DEGREE

A STROKE IN THE MEDULLA dysphagia cardiac, respiratory, blood pressure difficulties limb weakness Can cause bilateral weakness but very rare.

A STROKE IN THE PONS often this stroke is so severe that Respiratory function can be effected and often this stroke is so severe that the patient may die.

Types of Stroke Ischemic (80 %) Caused by blockage of an artery Usually the result of a blood clot Thrombotic or embolic Hemorrhagic (20%) - Caused by an arterial rupture Subarachnoid hemorrhage (SAH) Intracerebral Hemorrhage (ICH) 80% of strokes are ischemic- obstruction of flow. Of the 80%---- 50% of those are caused by blood clots forming within the cerebral arteries caused by atherosclerosis- show picture of atherosclerosis- Thrombus 30% of these are caused by an embolus originating somewhere else in the circulation ie. Heart or carotid artery and this travels to the area of the brain affected 20% are hemorrhagic- rupture of an artery These may be intracerebral hemorrhage in which a diseased artery within the brain ruptures or it may be a SAH in which a blood vessel on the surface of the brain ruptures and bleed into the meninges. Main causes of hemorrhagic bleeds are AVM or ruptured aneuryms. Elevated blood pressure is often a predisposing factor Hemorhagic strokes can be treated with surgical evacuation, control of edema and control of ICP, control of BP

Stroke Types CIHI/NACRS, 2005-06 Less bleeds probably due to better control of hypertension 10 % of TIA patients will go on to stroke within 3 months and 5.5 % within 48 hours. CIHI/NACRS, 2005-06

Definition of TIA TIA = transient ischemic attack – resolution must be complete Sudden onset of focal neurological dysfunction, presumably of vascular origin, lasting less than 24 hours. 1/3 last less than 15 min 70% < 1 hour 10 % more than 12 hours No permanent damage

Mechanism of Stroke Feature Hemorrhage Ischemic Preceding TIA No 30% Onset With Activity Sedentary Hypertension Usually Present Often Present Clinical Course Rapidly Progressive Stepwise or static Signs of ICP Present Absent - later CT Scan Presence of blood Normal or subtle changes Motor weakness is the most common manifestation of stroke- 80-90 % Dizziness is rarely the only neurological symptom Headache, vomiting and decreased LOC often more indicative of hemorrhagic rather than ischemic stroke

Ischemic (80%) Hemorrhagic (20%) Let’s now shift to stroke mechanism. Strokes may be classified into two general types: ischemic and hemorrhagic. The ischemic strokes account for 88% of all strokes whereas hemorrhagic strokes for 12%

What is tPA? Clot buster Works by dissolving the clot that is blocking the vessel in the ischemic stroke patients Not all patients are eligible Must be initiated within 4.5 hrs. from onset of symptoms Given by IV bolus and infusion- takes about 1 hour Management of Ischemic stroke See attached handout for tPA inclusion and exclusion criteria The active drug is an enzyme that binds to fibrin in a thrombus and breaks it down. Cochrane review – good evidence for tPA- increased likelhood of a neurological recovery. 42% reduction in odds of being dead or dependent ( see save the brain powerpoint-Dr. Sahlis)

Penumbra Penumbra is the salvageable brain Remember 6 million cells per minute.

Occlusion and Re-canalization

Conclusion Time is Brain Deficits of a stroke can be explained by area of the brain affected, circulation of the brain or a combination of both. Rapid Assessment and treatment is critical Time is Brain

Coffee Break!