1. CVA SAMIR TURK, M.D.

2. SYMPTOMS OF STROKES AND TIA PARALYSIS NUMBNESS LANGUAGE VISUAL ATAXIA VERTIGO

3. CLINICAL PRESENTATION CORRELATES WITH OCCLUDED ARTERY KNOWLEDGE OF BLOOD SUPPLY ALLOWS LOCALIZATION RADIOLOGICAL TESTING CONFIRMS LOCALIZATION

4. MOTOR/SENSORY RULE BRAIN MEDIATES OPPOSITE SIDE- MOTOR/SENSORY BRAIN STEM – SAME SIDE OF FACE MOTOR/SENSATION CEREBELLUM –SAME SIDE FINE MOTOR

5. BLOOD SUPPLY 2 MAJOR TERRITORIES : 1- ANTERIOR CIRCULATION – ICA/MCA/ACA 2-POSTERIOR CIRCULATION – VERTEBRALS/BASILAR/POSTERIORCEREBRAL

6. MCA OCCLUSION LEFT DOMINANT - 90% LANGUAGE – RIGHT FACE AND ARM MOTOR AND SENSORY RIGHT SIDE NEGLECT EYES DEVIATE TO LEFT

7. LEFT ACA RIGHT LEG-- MOTOR AND SENSORY BEHAVIOR : ANGER/HOSTILITY

8. RIGHT MCA APROXIA LEFT SIDED FACE/ARM MOTOR AND SENSORY LEFT SIDED NEGLECT AND VISION LOSS EYES DEVIATE TO RIGHT

9. RIGHT ACA LEFT LEG MOTOR AND SENSORY BEHAVIOUR : ANXIETY AND DEPRESSION

10. ICA OCCLUSON BOTH ACA AND MCA OCCLUSION MONONUCLEAR BLINDNESS –OPTHALMIC ARTERY OCCLUSION PARTIAL HORNER SYNDROME : PTOSIS/MIOSIS BUT ANHYDROSIS IS ABSENT

11. POSTERIOR CIRCULATION REMEMBER THE 5 D’s 1-dizziness 2-diplopia 3-dysarthria 4-dysphagia 5-dystaxia

12. POSTERIOR CIRCULATION CROSSED FINDINGS : CRANIAL NERVES DEFICIT- IPSILATERAL MOTOR/SENSORY DEFICIT- CONTRALATERAL

13. VERTEBRAL OCCLUSION PRODUCES OCCLUSION IN PICA LEADS TO LATERAL MEDULLARY SYNDROME

14. LATERAL MEDULLARY SYNDROME 1- SPINOTHALAMIC TRACT- CONTRALATERAL DECREASE IN TEMP AND PAIN 2- 5 TH CRANIAL NERVE PALSY –IPSILAT EYE PAIN,NUMB FACE AND DECREASE CORNEAL REFLEX 3- VESTIBULAR NUCLEUS – DIZZINESS/VOMITTING AND NYSTAGMUS 4- INFERIOR CERBELLAR PEDUNCLE –IPSILAT.ATAXIA 5- IPSILATERAL HORNER- LABILE BP AND TACHY 6- HOARSNESS AND DYSPHAGIA 7-ABNORMAL RESPIRATION

15. STROKE MIMICKS HYPOGLYEMIA MASS LESIONS SEIZURES MIGRAINE ENCEPHALOPATHIES CONVERSION DISORDERS PERIPHERAL VESTIBULOPATHIES

16. CHAMLEONS CONFUSION STATES VIT DEF MS MOVEMENT DISORDERS TRANSIENT GLOBAL AMNESIA

17. TREATMENT TRADITIONAL : SUPPORTIVE THROMBOLYSIS : IV THROMBOLYSIS : INTRAARTERIAL IN SITU RETRIEVAL DEVICES

18. TREATMENT IV THROMBOLYSIS. TPA FOR TREATMENT OF CVA APPROVED IN 1996 NINDS TRIAL

19. IV THROMBOLYSIS 31% OF THOSE WHO RECEIVED TPA HAD EXCELLENT OUTCOME 20% OF THOSE WHO DID NOT RECEIVE IV TPA HAD EXCELLENT RECOVERY 11% ABSPLUTE IMPROVEMENT

20. IV THROMBOLYSIS TPA HEMORRHAGE 6.4% DEATH 11% NO TPA HEMORRHAGE <1% DEATH 20%

21. INDICATION FOR IV TPA AGE >18 DEFINED TIME OF ONSET WITHIN <3 HOURS MEASURABLE NIHSS NO CONTRAINDICATION

22. CONTRAINDICATION FOR IV THROMBOLYSIS MINOR SYMPTOMS OR IMPROVING SEIZURE AT ONSET STROKE OR HEAD TRAUMA < 3 MONTHS ANY HX OF ICH GI/GU HEMORRAGE < 3 WEEKS MAJOR SURGERY < 3 WEEKS NONCOMPRESSIBLE ARTERIAL PUNCTURE<7 DAYS

23. CONTRAINDICATION OF IV THROMBOLYSIS RECEIVED HEPARIN WITHIN 48 HRS AND PTT IS ABNORMAL BP > 185/100 INR >1.7 PLTS <100K GLUCOSE 400

24. IV TPA 3-4.5 HOURS SOME BENEFIT IN SELECTED PATIENTS NOT FDA APPROVED ADDITIONAL EXCLUSION CRITERIA : AGE>80 ON ORAL ANTICOAGULATION REGARDLESS OF INR NIH SCORE >25 HX OF STROKE AND DM

25. OTHER CONSIDERATIONS IF THERE IS CONTRAINDICATION TO IV LYSIS THEN CONSIDER : 1- INTRAARTERIAL LYSIS – LESS TPA 2- MECHANICAL RETRIEVAL DEVICES PENUMBRA SYSTEM OR MERCI DEVICE SHOULD CONSIDER FOR ALL CASES OF NIHSS OF >10 AS THE CHANCE OF OPENING AN MCA OCCLUSION WITH IV LYSIS IS ONLY 15%

26. LIMITATIONS OF IV TPA ONLY 4% OF CVA PTS RECEIVE TPA 22% PRESENT WITHIN 3 HRS 51% OF THOSE PRESENTING WITHIN 2 HRS ARE INELIGIBLE POOR RECANALISATION RATES- M1 SEGMENT ONLY 13%

27. INTRAARTERIAL THROMBOLYSIS SAME AS IV THROMBOLYSIS – THE RISK OF BLEEDING IS HIGHEST WITH LAERGER STROKES RISK OF DISSECTION,PERFORATION AND DISTAL EMBOLISATION TECHNICALLY VERY DEMANDING AND CHALLENGING CEREBRAL VESSELS ARE VERY TORTUROUS

28. INTAARTERIAL THROMBOLYSIS ONLY FEW MG OF TPA IS NEEDED MAY NEED AN HOUR OR MORE TO LYSE THE CLOT BEST TO DO WITHOUT INTUBATIONS IF POSSIBLE LARGER VESSELS MAY BE IMPOSSIBLE TO OPEN WITH LYSIS ALONE

29. MEDICAL TREATMENT IS AS IMPORTANT AS LYSIS BP MEDICATIONS SHOULD BE WITHHELD UNLESS SBP >220 OR DBP>120 TREAT HYPOTENSION WITH SALINE AND PRESSORS IF NEEDED TREAT CARDIAC ARRYTHMIAS

30. MEDICAL TX TREAT HIGH BP BEFORE IV LYSIS IF SBP>185 OR DBP>110. USE IV LABETOLOL OR NICARDIPINE AFTER LYSIS MAINTAIN SBP <180 OR DBP<100

31. MEDICAL TX HYPGLYCEMIA MAY MIMIC STROKES HYPERGLYEMIA WITH BS > 140 HAS WORSE OUTCOME

32. Dr. Turk Basilar Intervention May 2011

33. PRESENTATION 50 YEAR OLD MAN LIVES ALONE WOKE UP FROM SLEEP WITH DIZZINESS AND SEVERE NAUSEA AND ATAXIA CALLED AMBULANCE COLLAPSED. INTUBATED AND BROUGHT TO ER COMATOSE

34. BASILAR ARTERY INTERVENTION IN ER FOUND TO BE TOTALLY UNRESPONSIVE EMERGENCY MRA SHOWED TOTAL OCCLUSION OF BASILAR ARTERY

35. ARCH ANGIO

36. BRACHIOCEPHALIC ARTERY

37. RIGHT ICA

38. RT VERTEBRAL

39. INFUSION CATHETER IN BASILAR ARTERY

40. REESTABLISHMENT OF FLOW

67. STENT ADVANCED TO BASILAR ARTERY

71. BASILAR ARETERY STENTED TO KEEP OPENED

75. LEFT CAROTID OCCLUSION 54 YEAR OLD MAN AT GRANDCHILD BIRTHDAY COLLAPSED PRESENTED TO ER WITHIN 30 MINUTES. LEFT HEMIPARESIS WITH APHASIA STUDIES SHOWED ACUTE RIGHT CEREBRAL INFARCT IV THROMBOLYSIS GIVEN 9O MG TPA RECOVERED FULLY

76. L CAROTID OCCLUSION STUDIES SHOWED SEVERE STENOSIS OF LEFT CAROTID AND A SMALL INFARCT ON MRI/MRA STARTED ON PLAVIX AND ASPIRIN AND WAS PLANNED TO COME BACK FOR CEA WITHIN A WEEK OR TWO WHILE GETTING READY FOR DISCHARGE COLLAPSED AGAIN AND WAS COMATOSE DENSE RIGHT HEMIPARESIS AND APHASIA

77. INTERVENTION TAKEN PROMPTLY TO CATH LAB ANGIO DONE

78. OCCLUDED LEFT ICA

79. OCCLUDED LEFT ACA AND PART OF MCA

82. Post PTA

101. Third patient

102. 77 year old with sudden aphasia WAS FOUND TO HAVE NEW ONSET ATRIAL FIBRILLATION

103. OCCLUDED MCA

104. FLOW REESTABLISHED WITH 5 MG OF TPA