1. Acute Ischemic Stroke: Introduction to Diagnosis and Treatment
Charles Esenwa, MD
Stroke Fellow, Neurology

2. Risk Factors Age Hypertension Atrial fibrillation Carotid stenosis
Previous stroke
Tobacco
Diabetes
Hypercholesterolemia
Illicit drug use
Hypercoagulable state

3. Blood Flow in Stroke Territory
Cerebral tissues dysfunction relating to to 1)
cerebral blood flow (CBF), 2) time from stroke onset and 3)
distance from the core of the infarct. In the setting of an acute
vascular occlusion, CBF in the vascular territory diminishes rapidly.
The progression from ischemia to infarction is directly related to drop
in CBF and the length of time the tissue is hypoperfused.

4. Types of stroke
Figure 35-2 shows the Trial of Org10172 in Acute Stroke Treatment (TOAST)
classification criteria for ischemic stroke and the estimated relative distribution
of stroke within each category

5. Netter, Neuroanatomy

6. Middle Cerebral Artery
Haines – Neuroanatomy

7. Large Vessel Stroke Syndromes
Emergency Neurology: Acute Stroke Management. 2012

8. Inpatient vs Outpatient Work Up
???

9. Goals in Acute Hospital Care
Time to Treatment
Therapy
revascularization rate
complication rate
practicality and cost
Neuroprotection
extending viability of penumbra
limiting long term effects of ischemia
Patient Selection
stroke type
collaterals and penumbra
prognotic factors
co-morbidities
Goal

11. IV TPA exclusion Contraindications
In patients that are considered for alteplase/rtPA within the 0-3 hour
window, the following exclusions apply:
 Significant head trauma or prior stroke in previous 3 months
 Symptoms suggest subarachnoid hemorrhage
 Arterial puncture at non-compressible site in previous 7 days
 Intracranial malignant neoplasm, arteriovenous malformation, or
aneurysm
 Recent intracranial or intraspinal surgery
 Elevated blood pressure (systolic > 185 mmHg or diastolic > 110
mmHg) that is unable to be controlled
 Active internal bleeding
 Acute bleeding diathesis, including but not limited to platelet count <
100,000/mm³
 Heparin received within 48 hours resulting in abnormally elevated
aPTT, greater than the upper limit of normal
 Current use of anticoagulant with INR > 1.7 or PT > 15 seconds
 Current use of direct thrombin inhibitors or direct factor Xa inhibitors
with elevated sensitive laboratory tests (such as aPTT, INR, platelet
count, and ECT; TT, or appropriate factor Xa activity assays.) With
respect to the oral agents, may consider alteplase/rtPA if there is clear
evidence that the patient meets all three criteria:
1. Normal renal function (creatinine clearance > 50 mL/min),
2. Has not taken dabigatran, rivaroxaban or apixaban for at least
the past 48 hours, and

12. Evidence for IV-TPA
NINDS, NEJM 1995: TPA within 3hours of symptoms onset
no change on NIHSS at 24hrs but
better functional outcome at 3 months (absolute 12%, relative 30%)
ECASS3, NEJM 2008: TPA within 4.5 hours of symptom onset
ARR = 13%, RR = 30%
ARR = 7%, RR = 15%

13. Why Intra-arterial Thrombectomy
Calgary stroke program (Bhatia, et al, 2010)2
Analyzed CT-A database from for patients with proximal occlusions who received tPA (n=127)
Only 27 patients (21.25%) recanalized
1/24 distal ICA (4.4%)
21/65 M1 occlusions (32.3%)
4/13 M2 occlusions (30.8%)
1/25 basilar occlusions (4%)
Recanalization was strongest predictor of good outcome

14. Endovascular therapy Includes: Indicated for large vessel occlusion
Mechanical thrombectomy
Intra-arterial TPA (IA-TPA)
Indicated for large vessel occlusion
Up to 6 hours from symptom onset
Can use those when IV-TPA is contraindicated
No Very clear evidence for benefit over IV-TPA

16. Time to Treament
Saver, Oct 2016

17. Post Emergency Room Management
ALL Stroke Patients
Examine and complete NIHSS
Re-evaluate airway
Dysphagia Screen
Consider duatube
Venodynes
EKG, serial troponins, telemetry, TTE
HgA1C, Lipids, TSH, ESR/CRP, RPR, Utox, UA, U culture
TPA not administered
BP goal <220/120
*Aspirin (PO or rectal)
*Lovenox (heparin if GFR<30) for DVT ppx
TPA administered prior to NICU arrival
BP goal <180/105 x24 hours
Repeat head CT 24 hours post-TPA
*Contraindicated x24hrs after TPA dosing

18. Major Complications of Stroke
Hemorrhagic conversion (2% without vs. 6% with TPA)
Angioedema and anaphylaxis
Cerebral Edema
Myocardial infarction
Respiratory failure
Aspiration
Pneumonia
DVT/PE

20. Acute Stroke Case

21. Early Infarct Signs

22. ASPECTS SCORE
0-10 (10 being best)

23. Case Continued

24. Case Continued
low CBV, prolonged MTT and decreased CBF, surrounded by a widespread area of tissue at risk; defined by relatively stable CBV, prolonged MTT and decreased CBF.

25. Case #2

26. Large Vessel Atherosclerosis

27. Case #3

28. Anti-platelet therapy

29. Case #4

30. Atrial Fibrillation

31. Clinical Cases
Case 1
45 yo M with DM, HTN, HL and two previous strokes without residual deficit presents with acute dizziness, nausea/vomitting, diplopia and unsteadiness
In the ED, NIHSS was 6 for weakness, ataxia and slurred speech

32. Case 1

33. Case 1:
What are you worried about?
How do you manage this case?

34. Case 2
53 yo M presented with sudden onset LOC. On exam he was unresponsive with extensor posturing throughout. Pupils were equal, oculocephalic reflex was absent, corneals were sluggish and he did not gag. NIHSS 30

35. Case 2: What is the syndrome What are the management issues?
What could have been done to try to prevent this?

36. Case 3:
85 yo Woman with HTN and DMII, presented with acute aphasia and R sided weakness starting 20 minutes ago. NIHSS 17. Got IV-TPA within 1 hour of symptom onset.

37. Case 3: What is the syndrome? What is your BP goal?
What do you worry about?

38. Case 3:
On re-examination you note that her BP is 200/110 and NIHSS is now 24 Her nurse also tells you that she is concerned about her breathing. What do you to do next?

39. Case 3

40. Case 4:
A 50 yo M presents with sudden onset L sided weakness and slurred speech. On examine she has a R gaze preference, neglects the L side and is not moving the left at all. NIHSS 20.

41. Case 4
What do you worry about?

42. MR angiogram

43. Case 4: Revisited
What if he were fluctuating? Between NIHSS of 3 and NIHSS of 20 and has this scan?

44. Case 4: Revisited
CT angiogram of the head

45. Case 4: Revisited
MRI – DWI What can you do to further evaluate? How would you manage the blood pressure?

47. Trials

48. Trials