1. Cerebrovascular Disease and Stroke Clinical Case Correlation Teresa M. Kilgore,D.O. FACOI 2/3/2012

2. Objectives Define stroke and contrast with TIA Define stroke and contrast with TIA Identify the stroke subtypes Identify the stroke subtypes List common risk factors for stroke List common risk factors for stroke List appropriate laboratory and imaging studies to evaluate the acute stroke patient List appropriate laboratory and imaging studies to evaluate the acute stroke patient Recite acute ischemic stroke therapy Recite acute ischemic stroke therapy Localize the pathology in six common stroke syndromes Localize the pathology in six common stroke syndromes

3. Case #1 A 58 year old man comes to you three weeks after he developed sudden-onset right arm and leg weakness with numbness. Symptoms came on suddenly and have gradually, but incompletely, improved. A 58 year old man comes to you three weeks after he developed sudden-onset right arm and leg weakness with numbness. Symptoms came on suddenly and have gradually, but incompletely, improved. What happened?What happened? What is your approach?What is your approach?

4. Definition of Stroke Vascular event that results in focal brain injury Vascular event that results in focal brain injury By definition, symptoms last at least 24 hours By definition, symptoms last at least 24 hours Damage is often visualized by MRI imaging within minutes, and by CT imaging within 6 hours Damage is often visualized by MRI imaging within minutes, and by CT imaging within 6 hours

5. Definition of TIA Vascular event that results in focal brain injury symptoms, but may not result in injury Vascular event that results in focal brain injury symptoms, but may not result in injury By definition, symptoms last less than 24 hours, but most TIAs resolve within 1 hour By definition, symptoms last less than 24 hours, but most TIAs resolve within 1 hour TIAs are pathologically the same as strokes but symptoms last for less time and usually do not result in visualized brain injury on imaging TIAs are pathologically the same as strokes but symptoms last for less time and usually do not result in visualized brain injury on imaging TIAs result from the same risk factors as stroke and warrant the same evaluation TIAs result from the same risk factors as stroke and warrant the same evaluation

6. Case 2 A 75 year old woman comes in to the doctor’s office. Three days ago, she noted slurred speech and right arm weakness that improved within 30 minutes. She has not noticed recurrence or worsening of her symptoms since onset. Today, her exam shows mild word-finding difficulties and mild right arm weakness. What is the most likely diagnosis? A 75 year old woman comes in to the doctor’s office. Three days ago, she noted slurred speech and right arm weakness that improved within 30 minutes. She has not noticed recurrence or worsening of her symptoms since onset. Today, her exam shows mild word-finding difficulties and mild right arm weakness. What is the most likely diagnosis? A. TIA B. Ischemic stroke C.Intracerebral hemorrhage D.Ruptured intracranial aneurysm E.Hypertensive encephalopathy

7. CT findings

8. Case 3 A 65yo female smoker presents with a 6 month history of intermittent episodes of left body tingling. She has no prior history of stroke but does have poor dietary habits and high cholesterol. A 65yo female smoker presents with a 6 month history of intermittent episodes of left body tingling. She has no prior history of stroke but does have poor dietary habits and high cholesterol. What is your differential diagnosis?What is your differential diagnosis? What diagnostic studies are indicated?What diagnostic studies are indicated? If you assume TIAs, how would you treat? What are her main risk factors?If you assume TIAs, how would you treat? What are her main risk factors?

9. Stroke Risk Factors ModifiableNon-Modifiable ModifiableNon-Modifiable DiabetesAge >75DiabetesAge >75 HypertensionMale genderHypertensionMale gender Tobacco useStroke/vascular dz in youngTobacco useStroke/vascular dz in young Dyslipidemia family membersDyslipidemia family members Heart diseasePersonal historyHeart diseasePersonal history Carotid diseaseAfrican-AmericanCarotid diseaseAfrican-American Alcohol consumptionAlcohol consumption Atrial fibrillationAtrial fibrillation Sickle cell diseaseSickle cell disease Homocysteine >12Homocysteine >12 Oral contraceptive use by smokersOral contraceptive use by smokers Drug use (amphetamines, cocaine, ephedra)Drug use (amphetamines, cocaine, ephedra)

10. Case 4 A 55 year old man presents with sudden onset vertigo, tendency to fall to the left upon standing, left facial numbness, dysarthria, and right arm and leg numbness. A 55 year old man presents with sudden onset vertigo, tendency to fall to the left upon standing, left facial numbness, dysarthria, and right arm and leg numbness. What features suggest stroke?What features suggest stroke? What tests do you want to perform to work this patient up for stroke risk factors and treatment options?What tests do you want to perform to work this patient up for stroke risk factors and treatment options?

11. Stroke History Evaluate history given by patient and family Evaluate history given by patient and family Headache at onset suggests SAH, ICH, or large ischemic strokeHeadache at onset suggests SAH, ICH, or large ischemic stroke Vomiting suggests SAH, ICH, or brainstem or cerebellar strokeVomiting suggests SAH, ICH, or brainstem or cerebellar stroke Seizures at onset often occur with lobar hemorrhages and brain embolism but not small or deep strokesSeizures at onset often occur with lobar hemorrhages and brain embolism but not small or deep strokes Loss of consciousness at onset suggests large SAH, emboli to the basilar artery, or EDHLoss of consciousness at onset suggests large SAH, emboli to the basilar artery, or EDH Headache and vomiting at onset, followed by progressive neurological symptoms suggest large ICHHeadache and vomiting at onset, followed by progressive neurological symptoms suggest large ICH Determine presence and nature of prior strokes or TIAs Determine presence and nature of prior strokes or TIAs Time and activity at onset of symptoms Time and activity at onset of symptoms Timing and progression of symptoms Timing and progression of symptoms Any accompanying symptoms Any accompanying symptoms

12. Stroke Examination Heart – enlargement, murmurs, rhythm Heart – enlargement, murmurs, rhythm Carotid, vertebral, and supraclavicular bruits Carotid, vertebral, and supraclavicular bruits Vital signs Vital signs Symmetry of blood pressures and pulses in the arms Symmetry of blood pressures and pulses in the arms Evidence of peripheral vascular disease Evidence of peripheral vascular disease Evidence of persisting neurological deficits Evidence of persisting neurological deficits

13. Evaluation: First 3 hours r-tPA candidate? r-tPA candidate? Symptoms clearly started within 3 hoursSymptoms clearly started within 3 hours Deficits fixed or worsening, not improvingDeficits fixed or worsening, not improving SBP <185 (or increased risk of ICH with r-tPA)SBP <185 (or increased risk of ICH with r-tPA) Normal PT/PTT/INRNormal PT/PTT/INR Not on anticoagulants (warfarin, LMWH)Not on anticoagulants (warfarin, LMWH) CT normal, no bleeding, no large infarctCT normal, no bleeding, no large infarct No head injury or surgery within 3 monthsNo head injury or surgery within 3 months No history of head bleed, everNo history of head bleed, ever No seizure at the onset of symptomsNo seizure at the onset of symptoms

14. Evaluation: First 24 hours Cardiac monitoring – arrhythmia Cardiac monitoring – arrhythmia Labwork – cholesterol panel, diabetes screen, ANA, ESR, homocysteine, hypercoagulable panel, toxicology screen if needed/appropriate Labwork – cholesterol panel, diabetes screen, ANA, ESR, homocysteine, hypercoagulable panel, toxicology screen if needed/appropriate Carotid ultrasound or MRA or CTA or angiography Carotid ultrasound or MRA or CTA or angiography Echocardiogram (transesophogeal and/or transthoracic, which is more accurate) Echocardiogram (transesophogeal and/or transthoracic, which is more accurate) Regular neuro checks (q2-4 hours) Regular neuro checks (q2-4 hours) Dysphagia screen Dysphagia screen Monitor for signs and/or symptoms of aspiration Monitor for signs and/or symptoms of aspiration MRI with diffusion weighted images detects ischemic stroke quickly and fairly accurately MRI with diffusion weighted images detects ischemic stroke quickly and fairly accurately

15. Case 5 A 16yo female non-smoker presents with a 2 year history of infrequent focal motor seizures, controlled on AED’s. Early this morning after a seizure, she developed a sudden, severe headache, and mild hemiparesis on the same side of her seizure activity. A 16yo female non-smoker presents with a 2 year history of infrequent focal motor seizures, controlled on AED’s. Early this morning after a seizure, she developed a sudden, severe headache, and mild hemiparesis on the same side of her seizure activity. What is the differential diagnosis?What is the differential diagnosis? What diagnostic studies are indicated?What diagnostic studies are indicated?

16. Stroke Diagnosis: Mimics Hypoglycemia Hypoglycemia Tumor Tumor Seizure Seizure Multiple sclerosis Multiple sclerosis Migraine Migraine Trauma Trauma Intracranial hemorrhage Intracranial hemorrhage Encephalitis Encephalitis

17. Case 6 A 24yo male is brought to the ER by ambulance because he was difficult to arouse at home. His mother says he was drinking heavily last night with some friends at a local pub. You see that he has mild flattening of the left nasolabial fold and a left extensor plantar response, but seems to move his limbs equally in response to painful stimuli. A 24yo male is brought to the ER by ambulance because he was difficult to arouse at home. His mother says he was drinking heavily last night with some friends at a local pub. You see that he has mild flattening of the left nasolabial fold and a left extensor plantar response, but seems to move his limbs equally in response to painful stimuli. What is your differential diagnosis?What is your differential diagnosis? What diagnostic studies would be helpful?What diagnostic studies would be helpful?

18. Intracerebral Hemorrhage Clinical featuresClinical features Loss of consciousness with focal findings Loss of consciousness with focal findings Headache – generally severe Headache – generally severe Breathing, pupillary, and/or extraocular movement abnormalities Breathing, pupillary, and/or extraocular movement abnormalities EvaluationEvaluation CT scan; if negative, LP to look for blood CT scan; if negative, LP to look for blood Angiography may locate the aneurysm Angiography may locate the aneurysm TreatmentTreatment Supportive care Supportive care Seizure prevention Seizure prevention Medications to prevent arterial spasm Medications to prevent arterial spasm Prevent seizures Prevent seizures Neurosurgical aneurysm clipping Neurosurgical aneurysm clipping

19. Case 7 A 58 year old diabetic man comes in with acute- onset right hemiplegia and aphasia. He is treated in the ER with r-tPA. Because his blood pressure was elevated on admission (200/120), he was placed on IV labetolol to lower his pressures. Upon arrival to the floor, his pressure has normalized to 120/85. He has now developed new-onset left hemiparesis and depressed consciousness. What might have happened? What tests would you order to evaluate? What other interventions would you start?

20. Definition of Penumbra Penumbra = “stunned” neural tissue surrounding the region of stroke (neural tissue that is rapidly killed in the setting of vascular compromise) Penumbra = “stunned” neural tissue surrounding the region of stroke (neural tissue that is rapidly killed in the setting of vascular compromise) BEWARE low blood pressure!!!! BEWARE low blood pressure!!!!

21. Hypovolemia/Hypotension Reduced cardiac output or hypovolemia result in blood pressure that is too low to maintain perfusionReduced cardiac output or hypovolemia result in blood pressure that is too low to maintain perfusion If systemic hypotension occurs in the setting of a focal artery stenosis, the brain tissue distal to that stenosis is particularly prone to ischemiaIf systemic hypotension occurs in the setting of a focal artery stenosis, the brain tissue distal to that stenosis is particularly prone to ischemia Systemic hypotension even without a focal vessel stenosis may result in infarct in “watershed” regions of the brain – these are areas where overlap between ACA/MCA or PCA/MCA arteries occurs (anterior frontal and temporo-parietal lobes)Systemic hypotension even without a focal vessel stenosis may result in infarct in “watershed” regions of the brain – these are areas where overlap between ACA/MCA or PCA/MCA arteries occurs (anterior frontal and temporo-parietal lobes) Risk factorsRisk factors Orthostatic hypotensionOrthostatic hypotension PerioperativePerioperative Myocardial ischemiaMyocardial ischemia Cardiac dysrhythmiasCardiac dysrhythmias Severe large vessel stenosisSevere large vessel stenosis

22. Stroke Syndrome -1 Internal Carotid Occlusion (acute) Internal Carotid Occlusion (acute) Contralateral hemiplegiaContralateral hemiplegia Contralateral sensory deficitContralateral sensory deficit Homonymous hemianopsiaHomonymous hemianopsia Conjugate eye deviation toward the lesionConjugate eye deviation toward the lesion Contralateral lower facial weaknessContralateral lower facial weakness Either mutism, aphasia, or dysarthriaEither mutism, aphasia, or dysarthria Head position deviation toward the lesionHead position deviation toward the lesion Horner’s syndrome ipsilateral to lesionHorner’s syndrome ipsilateral to lesion Cerebral edema may be life-threateningCerebral edema may be life-threatening

23. Stroke Syndromes – 2 MCA syndrome MCA syndrome Contralateral hemiplegia or hemiparesis (arm>leg)Contralateral hemiplegia or hemiparesis (arm>leg) Contralateral hemisensory syndromeContralateral hemisensory syndrome Homonymous hemianopsiaHomonymous hemianopsia Contralateral lower facial weaknessContralateral lower facial weakness Speech or language abnormalitySpeech or language abnormality

24. Stroke Syndromes – 3 ACA syndrome ACA syndrome Contralateral hemiparesis (leg>arm)Contralateral hemiparesis (leg>arm) Akinetic mutismAkinetic mutism Behavioral or memory disturbanceBehavioral or memory disturbance Dysarthria or transcortical motor aphasiaDysarthria or transcortical motor aphasia Conjugate eye deviation towards lesionConjugate eye deviation towards lesion Head position deviation towards lesionHead position deviation towards lesion

25. Stroke Syndromes – 4 PCA syndrome PCA syndrome Contralateral homonymous hemianopsiaContralateral homonymous hemianopsia May have no other symptoms other than the visual field cutMay have no other symptoms other than the visual field cut

26. Stroke Syndromes – 5 Lacunar stroke syndromes Lacunar stroke syndromes Pure motor hemiplegiaPure motor hemiplegia Contralateral face and arm>leg weakness Contralateral face and arm>leg weakness Possible mild dysarthria Possible mild dysarthria No vision, language, or sensory disturbance No vision, language, or sensory disturbance Lesion usually in the contralateral posterior limb of the internal capsule Lesion usually in the contralateral posterior limb of the internal capsule Contralateral in essence of where you see the symptomsContralateral in essence of where you see the symptoms Pure sensory strokePure sensory stroke Contralateral face, arm, trunk, and leg numbness, paresthesias, and reduction of pain temperature Contralateral face, arm, trunk, and leg numbness, paresthesias, and reduction of pain temperature Lesion usually in the contralateral VPL thalamic nucleus. Lesion usually in the contralateral VPL thalamic nucleus. Contralateral in essence of where you see the symptomsContralateral in essence of where you see the symptoms

27. Stroke Syndromes – 6 Vertebrobasilar artery and brain stem syndromes Vertebrobasilar artery and brain stem syndromes “locked-in” syndrome“locked-in” syndrome Lesions in the bilateral ventral pons, with sparing of the reticular activating system Lesions in the bilateral ventral pons, with sparing of the reticular activating system Characterized by aphonia, quadriplegia, and preserved eye movements (except for horizontal movements which are occasionally affected) Characterized by aphonia, quadriplegia, and preserved eye movements (except for horizontal movements which are occasionally affected) Wakefulness is maintained Wakefulness is maintained

28. Question #1 A right-handed patient presents with mild right leg and moderate right arm weakness. In addition, she mixes up words and cannot figure out how to say certain things. What vascular territory is involved A. Anterior Cerebral Artery B. Posterior Cerebral Artery C. Middle Cerebral Artery D. Vertebral Artery E. Internal Carotid Artery

29. Question #2 A 78-year old gentleman is seen in the ER for confusion. Exam shows a very uncomfortable gentleman grabbing the right side of his head. Exam shows BP 180/90, P 120 and regular, and a dilated right pupil, but before you proceed he passes out and requires intubation. What diagnosis must you consider? A. Hypertensive intracerebral hemorrhage. B. Acute ischemic stroke C. Ruptured intracerebral aneurysm D. Acute head injury E. All of the above

30. Anatomy of SAH

31. SAH Appearance on CT

32. Aneurysm on Angiogram

33. Aneurysm Clipping

34. Question #3 A 47 year old comes in with acute stroke symptoms, and you are considering giving tPA. He arrived 1.5 hours after symptom onset, has no historical contraindicates to tPA. Labs come back normal. BP is 210/130. Can you give tPA? A. Yes (how much time do you have?) B. No (why not?)

35. NIH Stroke Scale