1. Recognition and Emergency Management of Posterior Circulation Stroke Todd J. Crocco, MD, FACEP Professor WVU Department of Emergency Medicine November 20, 2015

2. JB MRN#: 070982372 45@ time of stroke in December 2007 45@ time of stroke in December 2007 Presented with H/A, dizziness, diplopia, decreased sensation and weakness right arm and leg. Presented with H/A, dizziness, diplopia, decreased sensation and weakness right arm and leg.

3. Initial CT 12/12/2007, 0156 Clot at the distal right vertebral artery. Clot at the distal right vertebral artery. Narrowing at the origin of the right pica may be secondary to small clot or stenosis. Narrowing at the origin of the right pica may be secondary to small clot or stenosis. Area of mild stenosis left vertebral artery near origin of the basilar artery adjacent to the right vertebrobasilar junction. Area of mild stenosis left vertebral artery near origin of the basilar artery adjacent to the right vertebrobasilar junction.

4. MRI 12/12/2007, 1706 Acute small right lateral medullary infarction with what appears to be occluded distal right vertebral artery. The finding is compatible with abnormalities noted with non-opacification of the distal right vertebral artery on CT stroke protocol of 12 December 2007. Acute small right lateral medullary infarction with what appears to be occluded distal right vertebral artery. The finding is compatible with abnormalities noted with non-opacification of the distal right vertebral artery on CT stroke protocol of 12 December 2007.

5. Recurrent stroke several days later… Readmitted several days after discharge with dysphagia and now LEFT arm hemiplegia and left leg weakness Readmitted several days after discharge with dysphagia and now LEFT arm hemiplegia and left leg weakness CTA 12/21/07 was unchanged as compared to prior examination showing distal right vertebral artery thrombus, significant narrowing of the origin of right PICA, and significant stenosis of the proximal basilar artery with a 60-70%, which is hemodynamically significant and no evidence of new thrombus. CTA 12/21/07 was unchanged as compared to prior examination showing distal right vertebral artery thrombus, significant narrowing of the origin of right PICA, and significant stenosis of the proximal basilar artery with a 60-70%, which is hemodynamically significant and no evidence of new thrombus.

6. MRI 12/23/2007, 0858 Infarct involving the lower medulla, which has slightly increased signal than the previous exam, also, now involving the ventral medullary aspect. There is no hemorrhage identified. Infarct involving the lower medulla, which has slightly increased signal than the previous exam, also, now involving the ventral medullary aspect. There is no hemorrhage identified.

7. Reevaluation in 2010 CTA 11/12/2010 for recurrent dizziness CTA 11/12/2010 for recurrent dizziness Severe intracranial atherosclerotic disease involving the vertebrobasilar system with a worsening of stenosis at junction of left vertebral artery and basilar artery with chronic right distal intracranial vertebral artery occlusion. Stenosis now measures 70% or greater. Severe intracranial atherosclerotic disease involving the vertebrobasilar system with a worsening of stenosis at junction of left vertebral artery and basilar artery with chronic right distal intracranial vertebral artery occlusion. Stenosis now measures 70% or greater.

8. MRI 12/7/2010, 1619 1. Encephalomalacia within the medulla consistent with tissue loss from remote infarct. There is no evidence to suggest acute or evolving infarct on today's examination. 1. Encephalomalacia within the medulla consistent with tissue loss from remote infarct. There is no evidence to suggest acute or evolving infarct on today's examination. 2. Loss of flow signal in the right skull base vertebral artery consistent with chronic occlusion depicted on study dated December 21, 2007. 2. Loss of flow signal in the right skull base vertebral artery consistent with chronic occlusion depicted on study dated December 21, 2007.

9. The turning point… Recurrent episodes of intermittent vertigo and lightheadedness several times a week felt to be due to vertebral-basilar insufficiency. Recurrent episodes of intermittent vertigo and lightheadedness several times a week felt to be due to vertebral-basilar insufficiency. 12/13/10 Enrolled in SAMMPRIS trial. Randomized to medical therapy arm. 12/13/10 Enrolled in SAMMPRIS trial. Randomized to medical therapy arm. 5’11’’, 306lb, Haic 8.3, Htn, HLD, OSA on cpap at night. 5’11’’, 306lb, Haic 8.3, Htn, HLD, OSA on cpap at night.

10. September 2015 follow up 53 yo WM here for follow up. He is s/p Gastric bypass (Roux-en-Y). 53 yo WM here for follow up. He is s/p Gastric bypass (Roux-en-Y). Morbid obesity- lost 75 lbs prior to surgery. He has lost 48 lbs more since 12/9/14. Morbid obesity- lost 75 lbs prior to surgery. He has lost 48 lbs more since 12/9/14. HTN- his BP has been doing well. He is off Lisinopril. HTN- his BP has been doing well. He is off Lisinopril. T2DM- his A1C is 4.1, In July. he is off all meds for this. T2DM- his A1C is 4.1, In July. he is off all meds for this. HLD- TC 127 HDL 47 LDL 72 TG 39 off CRESTOR 40 mg a day due to cost since May. He is off fenofibrate 54 mg a day. I started Atorvastatin 40 mg a day last visit. HLD- TC 127 HDL 47 LDL 72 TG 39 off CRESTOR 40 mg a day due to cost since May. He is off fenofibrate 54 mg a day. I started Atorvastatin 40 mg a day last visit.

11. Posterior Circulation Ischemia Posterior circulation ischemia can range from fluctuating brainstem symptoms, caused by intermittent insufficiency of the posterior circulation (so-called VBI), to the “locked-in syndrome," which is caused by basilar artery or bilateral vertebral artery occlusion.

12. Posterior Circulation Ischemia 20% of all strokes – –Up to 20-60% have an unfavorable outcome – –New England Medical Center Registry of Posterior Circulation Strokes Overall mortality among 407 patients was reported at only 4%, with 79% having minor or no disability Basilar artery occlusion (BAO) – –8-14% of all posterior circulation strokes – –Mortality of over 90%

13. Anatomy & Pathophysiology Etiology thought to be local arterial atherosclerosis (large artery disease) and penetrating artery disease (lacunes) New evidence that cardiogenic embolization is more common – –20-50% of posterior circulation strokes

14. Risk Factors Uncontrollable risk factors include – –Age – –Gender – –Race – –Family history of stroke or TIA – –Personal history of diabetes

15. Risk Factors Medical stroke risk factors include – –Hypertension – –Heart disease (atrial fibrillation or LVH) – –Previous stroke or TIA – –Previous heart surgery – –Carotid artery disease – –Peripheral vascular disease – –Smoking

16. Risk Factors Each decade past age 55: 2x Past history of stroke or a TIA: 10x Atrial fibrillation: 6x Smoking: 2x

17. Risk Factors The most common causes for vertebrobasilar occlusion are atherosclerosis in the elderly, and trauma in the younger population

18. Signs & Symptoms Wide variety of syndromes – –Hemi or quadriparesis – –Cranial nerve deficits (III-XII) – –Respiratory difficulty – –Altered sensorium – –Vertigo – –Ataxia – –Multiple cranial nerve signs indicate involvement of more than one brainstem level

19. Signs & Symptoms "5Ds” – –Dizziness – peripheral or central – –Diplopia – ophthmalmologic versus neurologic – –Dysarthria – –Dysphagia – –Dystaxia

20. Signs & Symptoms “Crossed findings” – –Cranial findings on the side of the lesion and motor or sensory findings on the opposite side.

21. Signs & Symptoms The most frequent posterior circulation symptoms were dizziness (47%), unilateral limb weakness (41%), dysarthria (31%), headache (28%), and nausea or vomiting (27%) The most frequent posterior circulation symptoms were dizziness (47%), unilateral limb weakness (41%), dysarthria (31%), headache (28%), and nausea or vomiting (27%) New England Medical Center Posterior Circulation Registry. Arch Neurol. 2012;69(3):346-351.

22. Shifting Gears…..

23. What Does the ED Provide?  Availability 24/7/365  Speed (when it matters)  Critical care skills  Very broad clinical knowledge

24. What Does This Imply?  24/7 availability requires a lot of people and coordination  For speed, need to clarify the stakes  Every specialty has a “special need”  Critical care to patients with perceived critical needs  Broad knowledge base  need specialty backup

25. Three Important Messages The ED has limitations The ED has limitations –‘You want a piece of me TOO?!’ Delays are real – ‘systems’ can fix them Delays are real – ‘systems’ can fix them –Buy-in and perception is needed Planning and communication is needed Planning and communication is needed –Develop protocols

27. ED Evaluation 27

28. The ED “Stroke Protocol” Focused history and physical (ABC’s) Focused history and physical (ABC’s) –General and neurologic assessment Fingerstick glucose measurement Fingerstick glucose measurement IV access and STAT labs IV access and STAT labs Contact stroke team? Contact stroke team? Patient monitoring Patient monitoring –Frequent monitoring of VS and neuro exam –Oxygen and cardiac monitoring

29. General Stroke Management Activate ‘Stroke Team’ Activate ‘Stroke Team’ Check glucose & labs Check glucose & labs Two large IV lines Two large IV lines Oxygen as needed Oxygen as needed Cardiac monitor Cardiac monitor Continuous pulse-ox Continuous pulse-ox CT scan….STAT CT scan….STAT Confirm LSNN time Confirm LSNN time Perform neurologic exam Perform neurologic exam Get “real” with rt-PA Get “real” with rt-PA –Prepare to mix –Have pharmacy alerted Discuss with patient and family potential treatments Discuss with patient and family potential treatments Begin general management Begin general management

30. General Stroke Management Cardiac monitor Cardiac monitor –Observe for ischemic changes or atrial fibrillation Intravenous fluids Intravenous fluids –Avoid D5W and excessive fluid administration –IV normal saline at 50 cc / hr unless otherwise required NPO NPO –Aspiration risk, avoid PO until swallowing assessed Blood pressure Blood pressure –Function of fibrinolytic eligibility

31. Team Communication Nursing  ED doc  Consultants Nursing  ED doc  Consultants For the ED team – just like any resuscitation For the ED team – just like any resuscitation ED / Consultant communication ED / Consultant communication –Absolutely critical –Complementary roles / complementary skills –Don’t say yo-yo!

32. NINDS Recommendations Door-to-MD: 10 minutes Door-to-MD: 10 minutes Door-to-Stroke 15 minutes Door-to-Stroke 15 minutes Team notification: Team notification: Door-to-CT scan: 25 minutes Door-to-CT scan: 25 minutes Door-to-Drug: 60 minutes (80% compliance) Door-to-Drug: 60 minutes (80% compliance) Door-to-Admission: 3 hours Door-to-Admission: 3 hours American Heart Association 2005; European Stroke Initiative Executive Committee, Cerebrovasc Dis 2003;16:311–337; NINDS National Symposium on Acute Stroke, 2003. 32

33. Diagnosis & Evaluation History and physical History and physical Physical exam – –Cranial nerve findings – –Eye movements – –Cerebellar findings combined with opposite long tract (sensory and motor) signs

34. Emergency Diagnostic Studies Brain imaging – CT or MRI? Brain imaging – CT or MRI? Electrocardiogram Electrocardiogram Complete blood count and platelet count Complete blood count and platelet count INR and aPTT INR and aPTT Blood chemistries Blood chemistries Pulse oximetry, chest x-ray Pulse oximetry, chest x-ray CSF examination? CSF examination?

37. Current Treatment Options Physiologic optimization Physiologic optimization No thrombolytics No thrombolytics – Aspirin Death / nonfatal strokes reduced 11% Death / nonfatal strokes reduced 11% – Heparin Intravenous rt-PA Intravenous rt-PA – Risk stratify although all subgroups benefited from thrombolytics in NINDS Other treatments Other treatments – Intra-arterial thrombolysis with rt-PA – Mechanical embolectomy 37

38. Management IV thrombolytic therapy IV thrombolytic therapy Antiplatelet and antithrombotic therapy is often used, with wide variation in treatment regimens Intra-arterial thrombolytic therapy has been used successfully for patients with suspected BAO

39. Management Traditionally, heparin has been used in the treatment of posterior circulation strokes, based upon uncontrolled trials showing benefit compared to historical controls

40. Recanalization Strategies FDA cleared interventions: FDA cleared interventions: – IV tPA (0-3 hours)Approved 1996 – IV tPA (3-4.5 hours)Practice Advisory 2010 – Devices Cleared for clot removal 2004 Time Window0-3 hours3-4.5 hours3-6 hours>6 hours Options IV tPA Device IV tPA IA Lytic / Device IA Lytic Device 40

41. Conclusion Wide variety of symptoms Crossed findings (cranial nerve findings ipsilateral, with motor and sensory findings contralateral) 5 Ds (dizziness, diplopia, dysarthria, dysphagia, and dystaxia) Stroke care is a team sport

42. Questions?