1. UC Neuroscience Institute Sheital Bavishi, DO Assistant Professor University of Cincinnati Department of Physical Medicine and Rehabilitation Director Brain Injury Program University of Cincinnati

2. UC Neuroscience Institute Affects more than 700,000 people in the US annually Third leading cause of death One of the most common causes of long- term disability, certainly one of the most serious and life-changing

3. UC Neuroscience Institute Ischemic, 85% ICH, 10% SAH, 5%

4. UC Neuroscience Institute Stroke: focal neurologic deficit caused by cerebrovascular event lasting at least 24 hours; usually of sudden onset –ischemia: 80% (thrombosis, embolism, hypotension) –hemorrhage: 20% (subarachnoid, intracerebral) TIA (transient ischemic attack): same as above, caused by transient ischemia and resolving completely within 24 hours

5. UC Neuroscience Institute Non-modifiable: Age, Race, Gender, Family history Modifiable/Treatable: –Hypertension --obesity –Diabetes --alcohol/drug consumption –TIA’s/previous strokes --oral contraceptives –Cardiac disease (?PFO) --migraine headaches –Atrial fibrillation --cigarette smoking –Hypercholesterolemia --autoimmune/inflammatory disease –Hypercoagulable states --homocysteine

6. UC Neuroscience Institute Carotid arteries –Internal: brain –External: face “anterior circulation” Vertebral arteries “posterior circulation”

7. UC Neuroscience Institute Catheter angiography CT angiography MR angiography Contrast dye injected in blood stream makes vessels show up

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9. Aneurysm AVM Artery stenosis Tumor Stroke blockage

10. UC Neuroscience Institute Limiting cellular injury Reperfusion Preventing Systemic Complications Preventing Neurologic Complications Rehabilitation

11. UC Neuroscience Institute Maintain cerebral perfusion– auto- regulation/adequate blood pressure (BP) Maintain cerebral oxygenation --(allow increased oxygen extraction as compensatory mechanism for altered perfusion) Maintain normothermia -- (increased temp = increased oxygen metabolism/demand) Maintain euglycemia -- (hyperglycemia exacerbates ischemic damage)

12. UC Neuroscience Institute Acute stroke –Clot dissolve (tPA) –Clot retrieval Aneurysm –Coil –Glue Artery stenosis –Angioplasty & stent AVMs and tumors –Glue (embolization) Onyx glue

13. UC Neuroscience Institute Clot retrieval Device grabs and pulls clot out Suction catheter aspirates clot Clot-buster (tPA) Drug dissolves clot Give within 4.5 hours

14. UC Neuroscience Institute A clot-busting drug called t-PA (tissue plasminogen activator) given within 3 hours after stroke onset New data suggest time window out to 4 ½ hours

15. UC Neuroscience Institute BOTTOM LINE: Appropriate patients without contraindications should be treated at 0-3 hours, as per the NINDS study protocol. TIME IS BRAIN: the sooner treatment is started, the greater the odds ratio of favorable outcome

16. UC Neuroscience Institute blockage t-PA restores blood flow

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18. Inflate balloon and inject for 2 minutes, let Onyx solidify for 3 minutes then re-perfuse

19. UC Neuroscience Institute Bypass reroutes an artery from outside of skull into a brain artery to protect blood supply to brain before clipping the aneurysm bypass

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21.  Medications –Blood thinner –Cholesterol reduction –Blood pressure control  Endarterectomy –Surgery removes plaque  Angioplasty & stenting –Balloon compresses plaque and stent holds artery open

22. UC Neuroscience Institute Angioplasty & stenting –Restores vessel diameter –Reduces clot risk

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26. Dilated arteries and veins with no capillary bed

27. UC Neuroscience Institute Goal is to reduce size of nidus and to occlude arterial feeders difficult to access surgically Surgical dissection and control of fragile deep feeding arteries significantly improved Embolization alone will not cure

28. UC Neuroscience Institute Prevent medical and neurological complications Risk factor modification –Especially treatments for hypertension, diabetes, high cholesterol and smoking cessation Appropriate medical or surgical therapy –must know mechanism of stroke –Echo to look for cardiac source –Imaging to look for carotid source –Otherwise, staged anti-platelet therapy

29. UC Neuroscience Institute Aspiration (feeding tube, intubation) DVT (subQ Heparin) Infection (leading cause of late death) Skin Breakdown

30. UC Neuroscience Institute Increased intracranial pressure –hemorrhagic transformation –cytotoxic edema Edema maximal at 36-72 hours, usually manifests as decline in level of consciousness Herniation is leading cause of death in acute setting (fatal arrhythmia is second)

31. UC Neuroscience Institute Seizures –Approximately 4% of patients –recur in 20-80% cases –treat with anticonvulsants Depression –As high as 75% incidence after stroke –TREAT IT!! –New study suggests that early SSRI might improve outcome even if depression not yet present

32. UC Neuroscience Institute Benefit is well established Mechanism by which this facilitates recovery is unclear Begin Occupational Therapy, Physical Therapy, Speech Therapy immediately Recovery maximal in first weeks, months; can continue --DON’T GIVE UP! --Recovery is the next great frontier for stroke and brain injury

33. UC Neuroscience Institute Spasticity Management Neurogenic bowel and bladder Constraint-Induced therapy Body-weight supported treadmill training Splints and bracing Pain Syndromes Psychosocial Considerations

34. UC Neuroscience Institute Acute hospital therapies Acute Inpatient rehabilitation Short-term skilled rehabilitation Transitional Rehabilitation programs Day Rehabilitation programs Outpatient therapy Home Health therapy

35. UC Neuroscience Institute The Stroke Recovery Center at Drake is a multi-disciplinary evaluation and treatment program for those individuals with physical and cognitive deficits from a previous CVA, designed to maximize independence and function.

36. UC Neuroscience Institute Stroke Recovery Center: –refers now to the full spectrum of services-- from acute rehab on START –Stroke Team Assessment and Recovery Treatment (START) Program –The START program is the outpatient multidisciplinary team evaluation

37. UC Neuroscience Institute The therapeutic plan may be developed around: out patient rehabilitation services, research programs, or a combination of both

38. UC Neuroscience Institute The Stroke Recovery Center was only one of five programs of this type identified in the United States (as of July 2008)

39. UC Neuroscience Institute To provide collaborative care that improves the function and quality of life of people with strokes while scientifically advancing the field of stroke recovery.

40. UC Neuroscience Institute To be the premier destination for the most innovative, aggressive and comprehensive treatment for people with stroke.

41. UC Neuroscience Institute Dr. Brett Kissela Professor Co-Director, Neurology Residency Program Vice-Chair of Education and Clinical Services Department of Neurology University of Cincinnati Dr. Mark Goddard Associate Professor Chairman, Department of Physical Medicine and Rehabilitation University of Cincinnati Rehabilitation Medical Director – Drake Center

42. UC Neuroscience Institute Questions?