Linda Bayless, APRN-C, ACNP, FNP, CNRN

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 OBJECTIVES

1. Identify signs and symptoms of possible stroke.

2. Education regarding stroke statistics.
3. Identify mechanisms of stroke and stroke mimics.
4. Learn modifiable and non-modifiable risks for stroke.
5. Learn basic treatment of all stroke types and TIAs.
6. Understand etiology of subarachnoid hemorrhages and treatment
modalities.

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 F.A.S.T.

FACE ARMS
Ask person to smile. Ask person to raise both arms.
Warning sign: one side moves Warning: one arm does not move or
different than the other there is a drift in one

SPEECH TIME
Ask per to repeat a simple sentence. Find out when the last observed well
Warning: unable to speak or slurred time is.
speech

Over 80% have abnormality in at least one area.

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Cincinnati, 2007
 INTRODUCTION TO STROKE

Term “stroke” originated in

16th century. Thought to be a .
“stroke of God’s Hand”.

Rapidly evolving, sudden onset,

non-epileptic neurologic deficit.
.
Cerebrovascular accident (CVA)- not
used today. Correct term is Ischemic
or Hemorrhagic Stroke.

.
American Heart Association, Heart Disease and Stroke Statistics, 2011

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 STROKE STATISTICS

795,000 per year

> 136,000 deaths
7 million survivors alive today
Annual cost of stroke $53.6 billion
Mean lifetime cost per patient $140,048.

One in 6 patients die within 30 days

American Heart Association. Heart Disease and Stroke Statistics—2011
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 NON-MODIFIABLE RISK FACTORS

AGE
About 10% occur in 18-50 year olds.
HEREDITARY
RACE
(Increased incidence in African Americans and Asians)
Gender
Prior Stroke, TIA, or Heart Attack

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 RISK FACTORS
PRIMARY STOKE PREVENTION
MODIFIABLE:

Hypertension
Cigarette Smoking
Diabetes Mellitus
Carotid Artery Disease
Peripheral Artery Disease
Atrial Fibrillation
Heart failure, CAD
Sickle Cell Disease
High Cholesterol
Poor Diet
Physical Inactivity
Obesity
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 UNDERSTANDING STROKE-LESS DOCUMENTED RISKS

Geographic location: Socioeconomic Factors:

Strokes more common in SE United Some evidence stroke is more
States. prevalent in low-income people
“Stroke Belt” compared to more affluent.

Alcohol Abuse: Drug Abuse:

Recommend no more than 2 drinks Cocaine, methamphetamines and
per day in men and 1 drink for heroine.
women. (Can lead to multiple
medical complications).

Stroke Association, Together to End Stroke. 2012

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ESTIMATED PACE OF NEURONAL LOSS IN LARGE VESSEL STROKE

Neurons Accelerated
Lost Aging

Per Stroke 1.2 billion 36 years

Per Hour 120 million 3.6 years

Per Minute 1.9 million 3.1 wk

Per
32,000 8.7 hrs
Second
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Stroke 2006;37:263
MEET YOUR NEXT STROKE
VICTIM…

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 RECOGNIZING STROKE
SYMPTOMS

Numbness of face, arm, leg

Confusion, difficulty speaking or understanding
Visual changes in one or both eyes
Ataxia, loss of balance or coordination
Severe headache

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PRE-HOSPITAL STROKE CHECKLIST

• LAST KNOWN WELL!

• Stroke Symptoms
• Blood Pressure
• Blood Glucose
• Past Medical History
• Medication List

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 IMMEDIATE DIAGNOSTIC STUDIES

All Patients Selected Patients

NIHSS Hepatic function tests
Blood Glucose Toxicology screen
Blood Pressure Blood ETOH level
CT Scan Head (non-contrast) Serum HCG
CBC CXR
INR EEG

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 STROKE ASSESSMENT TOOLS

Canadian Neurologic Scale

Four Score
Glascow Coma Scale
Neurologic Assessment
Cincinnati Stroke Scale
NIH Stroke Scale

Journal of Neuroscience Nursing, 46:2, 2014.

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 NIHSS

National Institutes of Health Stroke Scale:

Developed in 1983 as a research tool to measure severity
of ischemic stroke. Allows examiner to rank focal
neurological deficits often overlooked by other scales.
Composed of 11 items using a 0 to 4 point score.

First used by nurses in 2009 to structure communication

between providers.
Higher score correlates with severity of neurological
deficits.

Brott et al., 1989

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 Acute Focal Neurological Deficit

Migraine
Seizure Stroke
Multiple Sclerosis
Radiculopathy

Large vessel disease (35%) Acute Ischemic

Stroke (82-85%)
Small vessel disease (25%)

Cardio-embolic (15-20%) Hemorrhagic

Stroke (9-13%)
Cryptogenic (5-7%)

ICH SAH AVM

CVT
IVH (3-5%) (1%)
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STROKE TYPES

15% Intracerebral
Hemorrhage (ICH)

87% Ischemic
Stroke (IS)

3% Subarachnoid
Hemorrhage (SAH)

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VASCULAR ANATOMY/TERRITORY

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ARTERIAL WALL

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LEFT OR RIGHT BRAIN
DOMINANCE

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 COMMON PATTERNS OF
NEUROLOGICAL IMPAIRMENTS

• Left Hemisphere • Right Hemisphere

Aphasia (? Handed-ness) Left hemiparesis / hemisensory
Right hemiparesis / hemisensory
Left sided spatial neglect
Right hemianopia
Right gaze preference
Left gaze preference

Subcortical (Lacunar) Brain Stem

• Motor / sensory in all 4 limbs
• Pure hemiparesis
• Crossed findings (face/arm-leg)
• Pure hemi-sensory
• Nystagmus
• Dysarthria clumsy hand
• Ataxia
• Ataxic hemiparesis
• Dysarthria / Dysphagia
• No abnormalities of cognition,
language, or vision

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 EFFECTS OF STROKE

Right Brain: Brain Stem:

Paralysis on left side of body. Can effect both sides of body.
Visual problems. Concern for “locked in” state.
Memory Loss.

Left Brain: Occipital:

Paralysis on right side of body. Vision problems.
Speech/Language Problems* Cerebellum:
Slow, cautious behavior. Coordination, balance issues.
Memory Loss.

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 ISCHEMIC STROKE

Embolic
Blood clot or plaque forms in the body
and travels through the blood stream
to the brain.
Maximal at onset, MCA most
commonly involved, may be associated
with seizures.
Thrombotic
Fatty deposits develop in the lining
of the blood vessel wall which
narrows the blood vessel.
Stuttering or progressive course.
Sensitive to BP fluctuations.

(Cardiac sources, artery-to-artery embolism, (Progressive or Sudden Closure of Vessel

systemic veins). Lumen: atherosclerosis, fibromuscular
. dysplasia, arteritis, vasospasm, arterial
Handbook Neurocritical Care, 2011. dissection, hypercoagulable states).

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MENINGES

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BASIC ANATOMY

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MENINGEAL LAYERS

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MORE ANATOMY

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 INTRACRANIAL LARGE
ARTERY STENOSIS

High prevalence in African

Americans, Asians, Hispanics

Annual risk of stroke 7%-

25%

Under studied

Lack of proven therapy

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 CAROTID STENOSIS

85,000 strokes per year

20% of all ischemic stroke

26% risk of stroke in 2 years

CEA reduces risk 4%/year?

Carotid Angioplasty ?

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 ATRIAL FIBRILLATION

70,000 strokes per year

15% of ischemic stroke

Annual risk 5%-25%

Warfarin effective

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UGLY

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 LACUNAR DISEASE

Overall good prognosis

Classic clinical syndromes

Rx Antiplatelet agents

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RIGHT MIDDLE CEREBRAL ARTERY INFARCTION

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STROKE TREATMENT… THE PAST!

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OPEN THE ARTERY FAST!

What Options???
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 Tissue Plasminogen Activator for
Acute Ischemic Stroke.
The National Institute of Neurological Disorders;
Stroke rt-PA Stroke Study Group.

Only “ FDA Approved”

Treatment”
AHA/ASA Class 1 Recommendation, Level of
Evidence A

Since 1996, Activase has been used to treat >

220,000 acute ischemic stroke patients in the
United States
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 NINDS T-PA

Five year study by the National Institute of Neurological Disorders (NINDS):

Found that some stroke patients within 3 hours onset –
Received IV t-PA-
Were at least 30% more likely to recover with little or no disability after three
months!

NIH Publication No. 10-4872, 2010

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 CONTRAINDICATIONS: IV T-PA

Beyond 3 hours from symptom onset, up to Head CT :

4.5 hours in specific situations.
Early Changes in > 1/3 MCA Territory
Time of onset cannot be determined
reliably.
Diagnosis not established by physician with
expertise in this area.
NIHSS rapid improvement.
INR >1.7
CT scan not assessed by physicians with
expertise in this area.

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RADIOLOGIC EVIDENCE OF ISCHEMIC STROKE

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 ENDOVASCULAR INTERVENTION

1. First Generation: Intra-arterial t-PA, Merci Stent

retriever (Concentric)
2. 2nd Generation: (Penumbra) Suction
3. 3rd Generation: “Stent on a Stick”, (Trevo), Penumbra
5MAX ACE

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CONCENTRIC CLOT RETRIEVAL
DEVICE

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 MERCI

Typically used up to 6 hours

Posterior strokes can even extend to 24 hours.

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PENUMBRA

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TREVO

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SOLITAIRE

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 CLOT RETRIEVALS
RETRIEVED

62 year-old Male 82 year-old Female 32 year-old Male

ICA Occlusion MCA Occlusion Basilar Occlusion
History: Atrial Fibrillation History: Atrial Fibrillation
Failed IV t-PA

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 HUGE CLOT

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APM0115/A/2312, 2005-12
 “TICI”

The original Thrombolysis in Cerebral Infarction Scale:

Designed to aid in the objective description of
angiographic results., standardized data, and assist in
outcome prediction.

Proposed by Higashi et al., 2003.

American Journal of Neuroradiology, 2013.

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 TICI

Varyiing definitions of TICI grades in literature.

•Grade 0: No flow/canalization, complete occlusion, no reperfusion.

•Grade 1: <20% recanaliztion, limited to no perfusion, minimal flow without
significant flow distal to occlusion.
•Grade 2: Partial recanalization, incomplete reperfusion, Near-normal flow
with flow distal to the occlusion, but not filling distal branches normally.
•Grade 2a: Perfusion<50% of MCA, partial filling of entire vascular
territory.
•Grade 2b: Partial reperfusion, >/= 50-99% of expected territory, complete
filling but is slow.
•Grade 2c: Near complete perdusion withour clearly visible thrombus but
delay in contrast run-off.
•Grade 3: Full perfusion, normal flow, partial recanalization with >50%
reperfusion.

AJNR, 2013, 34:1792-1797.

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 SECONDARY
STROKE PREVENTION

Get with the Guidelines!

American Heart and Stroke Association.

Provides hospitals with a Web based Management tool.

Guides decision making, real time benchmarking capabilities,
and other performance improvements toward the goal of
enhancing patient outcomes and saving lives.

Get with the Guidelines Stroke, 2013

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 HYPERTENSION

HTN is the most common condition seen in

primary care: leading to MI, stroke, renal
failure, and death if not appropriately
controlled.

JAMA. 2013.284427

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 ANTITHROMBOTICS

•IV t-PA within 180 minutes of last known well.

•Antithrombotics by end of hospital day 2.

•Anticoagulation for AFIb/Flutter prior to discharge.

Get with the Guidelines, 2013.

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 CIGARETTE SMOKE
Doubles the risk of ischemic stroke

Clearly associated with a 2 to 4 fold risk for

hemorrhagic stroke.

Can clearly interact with oral contraceptives in

increasing stroke risks for young women.

Ischaemic stroke and combined oral contraceptives: results of an international, multicentre, case-
control study: WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone
Contraception. Lancet. 1996;348:498–505. 65
 DYSLIPIDEMIA

In general, increased levels of total cholesterol are

associated with stroke.

High LDL levels is a risk factor for ischemic stroke

Recommend Atorvastatin 80 mg daily
(LDL < 100)
Patients with known CAD and hypertensive
patients at high risk should be treated with
lifestyle measures and a statin.

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 DIABETES

Tight control of hypertension with

ACEI or ARB treatment reduces
stroke risk in diabetics.
(BP <120/80 mm Hg)
Glucose <100 mg/dL
Glycemic control reduces
microvascular complications but is
not as potent at stroke prevention.

Statin treatment of diabetic

patients substantially decreases
their risk of first stroke.

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 TRANSIENT ISCHEMIC ATTACK

“brief episode of neurological dysfunction caused by focal disturbance

of brain or retinal ischemia, with a clinical symptom typically lasting
less than 24 hours, typically less than 1 hour, without evidence of
ischemia”

TIA is caused by a clot; the only difference between stroke and TIA is that with
TIA the blockage is temporary (transient). Most last less than five minutes,
with average duration one minute.

Circulation 2006;113:409-449

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200,000-500,000 Americans with TIAs / year
15% of Strokes with history of TIAs

5% stroke in 2 days
8.6% in 1 week
12% in 30 days
10% in 90 days
29% in 6 months
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 TIA WORKUP

-Hospitalization
-At least a CT head
-Labs and EKG
-Consider MRI/MRA
-Carotid / Vertebral A. Dopplers
-2D Echocardiogram w/bubble
-Aspirin 325mg /day OR
PLAVIX
-Anticoagulation in A-fib
-Consider CEA
carotid grade 70-99% stenosis
?angioplasty
-Target BP < 120/70
-Cholesterol<200 and LDL < 100
-Alcohol: Limit to 1 drink / day
-Smoking: Cessation
-Diabetes: Tight control (<124mg/dl)
-Exercise: 3 time per week
-Harmful to continue OCP/HRT

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 ICH

ICH results from bleeding of a vessel directly into the brain substance.

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ICH SECONDARY TO HTN

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 TYPES AND LOCATION OF ICH

- Hypertensive ICH
- putamen
- thalamus
- pons
- cerebellum

- Lobar Hemorrhage
- Vascular malformation
-Iatrogenic
-Tumors
-Trauma

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SUBARACHNOID HEMORRHAGE

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 PRESENTATION

Severe headache of sudden onset ("thunderclap headache")

accompanied by loss of consciousness

"worst headache of my life.“

Neck stiffness, photophobia, and low back pain

Nausea and vomiting
seizure at onset (10-25%)

An estimated 10-15% of patients with pre-ruptured symptoms:

headache (48%), dizziness (10%), orbital pain (7%), diplopia (4%), and visual loss (4%).

The premonitory symptoms may represent small leaks ("sentinel bleed") or expansion of
the aneurysm.

Approximately 30-40% of patients are at rest at the time of SAH.

Physical or emotional strain, defecation, coitus, and head trauma contribute to varying
degrees in the remaining 60-70% of cases.
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SUBARACHNOID HEMORRHAGE

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SUBARACHNOID HEMORRHAGE

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SUBDURAL HEMATOMA

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INTRACEREBRAL HEMORRHAGE WITH EDEMA

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 EPIDURAL
HEMATOMA

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 FEVER AND FUNCTIONAL OUTCOME
THE COPENHAGEN STUDY

390 consecutive acute stroke patients

Classified on admission as hypothermic,

euthermic, or hyperthermic (>37.5)

Positive correlation to initial severity, infarct

size, mortality, and functional outcome

For every 1°C rise,

2.2 fold increase in poor outcome
(CI 1.4-3.5)

Lancet. 1996;347:422–425
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DECOMPRESSIVE HEMICRANIECTOMY

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 Temperature and Neurologic Injury
Fever Hypothermia
Accelerates Injury Preserves Tissue

37°

41° 36°

40° Clinical Goal: 35°

39° 34°
33º
38°
37°
Tissue Preservation 32º

1o C rise in temperature on admission

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correlated with a 15
mm increase in infarct diameter
HYPOTHERMIC TREATMENT

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ALSIUS COOLING CATHETER

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EMS HYPOTHERMIC SYSTEM!

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SURGICAL CLIPPING ANEURYSM

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 CLIP LIGATION

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Endovascular Coiling for aSAH

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PENUMBRA COIL

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 ONYX

Onyx is a liquid polymer approved by FDA to treat brain

aneurysms.
Majority patients go home next day.
Cameo Trial (Europe), demonstrated Onyx as safe as coil
embolization in thus safer than surgery.
Goal: Seal the aneurysm shut.

Medical News and Health Information, 2009.

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 THANK YOU!

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