CVA SAMIR TURK, M.D.
Dec 28, 2015
CLINICAL PRESENTATION
• CORRELATES WITH OCCLUDED ARTERY• KNOWLEDGE OF BLOOD SUPPLY ALLOWS
LOCALIZATION• RADIOLOGICAL TESTING CONFIRMS
LOCALIZATION
MOTOR/SENSORY RULE
• BRAIN MEDIATES OPPOSITE SIDE-MOTOR/SENSORY
• BRAIN STEM – SAME SIDE OF FACE MOTOR/SENSATION
• CEREBELLUM –SAME SIDE FINE MOTOR
BLOOD SUPPLY
• 2 MAJOR TERRITORIES :
1- ANTERIOR CIRCULATION – ICA/MCA/ACA
2-POSTERIOR CIRCULATION –VERTEBRALS/BASILAR/POSTERIORCEREBRAL
MCA OCCLUSION
LEFT DOMINANT - 90%
LANGUAGE – RIGHT FACE AND ARM MOTOR AND SENSORYRIGHT SIDE NEGLECTEYES DEVIATE TO LEFT
RIGHT MCA
• APROXIA• LEFT SIDED FACE/ARM MOTOR AND SENSORY• LEFT SIDED NEGLECT AND VISION LOSS• EYES DEVIATE TO RIGHT
ICA OCCLUSON
• BOTH ACA AND MCA OCCLUSION• MONONUCLEAR BLINDNESS –OPTHALMIC
ARTERY OCCLUSION• PARTIAL HORNER SYNDROME : PTOSIS/MIOSIS
BUT ANHYDROSIS IS ABSENT
POSTERIOR CIRCULATION
• REMEMBER THE 5 D’s• 1-dizziness• 2-diplopia• 3-dysarthria• 4-dysphagia• 5-dystaxia
POSTERIOR CIRCULATION
• CROSSED FINDINGS : CRANIAL NERVES DEFICIT- IPSILATERAL MOTOR/SENSORY DEFICIT- CONTRALATERAL
LATERAL MEDULLARY SYNDROME• 1- SPINOTHALAMIC TRACT- CONTRALATERAL DECREASE IN TEMP
AND PAIN • 2- 5TH 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
STROKE MIMICKS
• HYPOGLYEMIA• MASS LESIONS• SEIZURES• MIGRAINE• ENCEPHALOPATHIES• CONVERSION DISORDERS• PERIPHERAL VESTIBULOPATHIES
TREATMENT
• TRADITIONAL : SUPPORTIVE• THROMBOLYSIS : IV • THROMBOLYSIS : INTRAARTERIAL IN SITU• RETRIEVAL DEVICES
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
INDICATION FOR IV TPA
• AGE >18• DEFINED TIME OF ONSET• WITHIN <3 HOURS• MEASURABLE NIHSS • NO CONTRAINDICATION
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
CONTRAINDICATION OF IV THROMBOLYSIS
• RECEIVED HEPARIN WITHIN 48 HRS AND PTT IS ABNORMAL
• BP > 185/100• INR >1.7• PLTS <100K• GLUCOSE <50 OR >400
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
OTHER CONSIDERATIONS
• IF THERE IS CONTRAINDICATION TO IV LYSIS THEN CONSIDER : 1- INTRAARTERIAL LYSIS – LESS TPA 2- MECHANICAL RETRIEVAL DEVICES PENUMBRA SYSTEM OR MERCI DEVICESHOULD CONSIDER FOR ALL CASES OF NIHSS OF >10 AS THE CHANCE OF OPENING AN MCA OCCLUSION WITH IV LYSIS IS ONLY 15%
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%
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
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
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
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
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
BASILAR ARTERY INTERVENTION
• IN ER FOUND TO BE TOTALLY UNRESPONSIVE• EMERGENCY MRA SHOWED TOTAL
OCCLUSION OF BASILAR ARTERY
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
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