Stroke Case Conference

5 Jan 2015

Prof Dr Tan Kay Sin, FRCP(Edin)

Senior Consultant Neurologist
University of Malaya Medical Centre
Kuala Lumpur, Malaysia
 Case 1
• Mr AB, a 59-year-old man was seen in
the Accident and Emergency
Department 10 hours after he
complained of sudden onset, severe
retrosternal chest pain during lunch.
• He had a known history of diabetes and
hypertension for 8 years and was
reviewed on a routine follow up visit in
the outpatient clinic 12 weeks prior to
this admission.
 Case 1

• He appeared sweaty and uncomfortable.

He was obese with a body mass index
(BMI) of 29. His vital signs were BP
110/90 mm Hg, heart rate 110 beats per
minute, temperature 36.5°C and oxygen
saturation was 95% on air. Respiratory
rate was 26 breaths per minute.
 Case 1
• Cardiovascular examination revealed a
normal apex beat on palpation and a
gallop rhythm on auscultation.
• Chest auscultation revealed bibasal
crepitations present on both inspiration
and expiration. His liver was palpable 2
cm below the costal margin. It was non-
tender with a smooth surface. The rest
of the physical examination was
unremarkable
An ECG was performed on admission
 Case 1

• Minutes after the first ECG was

performed, he complained of shortness
of breath and was not able to lie flat in
the hospital trolley. A chest radiograph
was performed urgently and the result
was shown
CXR
Another ECG was repeated shortly after he
was noted by nursing staff to be hypotensive.
 Case 1(cont’d)
• He was treated with streptokinase,
intravenous digoxin, amiodarone and
frusemide
• Subcutaneous low molecular weight
heparin was started and continued
 Case 1 (continued)
• He improved after treatment and was
relatively stable until Day 3 of admission.
After breakfast. Mr AB was noted by
nursing staff to have slumped forward in
bed with left sided upper and lower limb
weakness. He also became confused and
talked irrelevantly.
• An urgent CT brain was performed.
 Case 1 (cont’d)

• Vital signs: BP 150/100, pulse 90

irregular, apyrexial.
• Clinical examination revealed left sided
visuo-spatial neglect and right sided
gaze preference denotes an acute inability to produce gaze contralateral
gaze preference. to the side of the lesion and is accompanied by a tendency for tonic
deviation of the eyes toward the side of the lesion.

• There was a dense left sided hemiplegia

• Absent reflexes on the left side and a left
up-going plantar reflex.
CT brain
 Thrombolysis

• Established treatment for stroke

• Small therapeutic window
• Intravenous recombinant tissue plasminogen activator; rt-
PA in a dose of 0.9 mg/kg (maximum of 90mg) given over
1 hour for use within 3 hours of stroke
• 5 large trials; mainly the landmark NINDS rt-PA trial(1995)
• ECASS 3 (2009)

13
 rt-PA Eligibility & Contraindications
• Age > 18 years
• Clinical diagnosis of ischemic
stroke causing a measurable
neurological deficit
• Onset of stroke symptoms well
established to be less than 4.5
hours before treatment
14
• Strong contraindications
• Symptoms minor or rapidly
improving
• Other stroke or serious head trauma
within the past 3 months
• Major surgery within the last 14
days
• History of intracranial haemorrhage
• Sustained systolic BP > 185 mm Hg
• Sustained diastolic BP > 105 mm
Hg
• Aggressive treatment to lower blood
pressure
• Symptoms suggestive of
subarachnoid haemorrhage
• GI or urinary tract haemorrhage
within 21 days
• Heparin/thrombolytic use within
48 hours
• Low platelets
 Benefits of rt-PA
• Alteplase (rtPA) is indicated for the management
of acute ischaemic stroke in adults
• NINDS trial demonstrated 30% improvement in
overall functional outcome at 3 months with the
benefits maintained at 1 year.
• Symptomatic brain haemorrhage was higher in
the alteplase treated group (6.4%) compared to
the placebo group (0.6%)
• Overall, numbers needed to treat to avoid one
death or person permanently disabled = 9.(the
15
faster time, the less needed)
16
Recent update MR.CLEAN
trial:Dec 2014
MR CLEAN study Dec 2014
Endovascular Procedure
Video
 Case 1 Conclusion

• After procedure, was transferred to

stroke unit where telemetry and
continuing care.
• The patient recovered some motor
power of the lower limb on day 3 (3/5
MRC scale) after procedure. Other
deficits remained.
• Discharged to rehabilitation ward on day
10 after admission
Stroke Chain of Survival and Recovery
Detection: Early recognition
Dispatch: Early EMS activation and response
Delivery: Transport and management
Door: ER triage
Data: ER evaluation and management
Decision: Specific stroke therapies
Drugs: Thrombolytic for ischemic stroke
 Emergency Diagnostic Tests for
Stroke
Computed tomography (CT)
• Distinguishes reliably between hemorrhagic and ischaemic stroke
• Early signs of ischemia detected as early as 2 h after stroke onset
• Identifies hemorrhages almost immediately
• Detects sub-acute hemorrhage in the majority of cases
• Helps to identify other neurological diseases (e.g., neoplasms)

Magnetic resonance imaging (MRI)

• Becoming more common
• Diffusion- and perfusion-weighted MRI may help to differentiate between
infarcted tissue and tissue at risk
• More expensive than CT and not as widely available

22
 Diffusion weighted MR Imaging
*measures the microscopic movement of water protons; uses a spin echo sequence
with a pair of magnetic field pulses. Reduced movement of water molecules result in
signal loss. In stroke, cytotoxic oedema causes a hyperintense signal corresponding
to a decrease in the apparent diffusion coefficient(ADC).

23
 Investigations - Imaging
For all suspected stroke

1. Chest x-ray (Mandatory)

2. CT brain – The emergency neuroimaging scan of choice for all
patients. Differentiates haemorrhage from infarction. Confirms
site of lesion, cause of lesion, extent of brain affected.
3. 12 Lead ECG

4. Vascular assessment- Allows identification of

extracranial vessel disease

24
 BRAIN IMAGING

1. Do non-contrast CT or MRI ASAP, preferably

within 24 hrs
2. For stroke onset within 3 hrs, do CT or MRI
emergently
3. Differentiate hemorrhagic from ischemic
stroke
4. Differentiate stroke from mimics
5. Repeat imaging if patient worsens
 Other Investigations

Echocardiography - For suspected

cardioembolism, to assess cardiac function

MRI (magnetic resonance imaging) –

Sensitive.
Not readily available in emergency setting, limited by expense.

Useful tool to select patients for thrombolysis where available

Transcranial Doppler Ultrasound -

Identifies intracranial vessel disease with prognostic and
therapeutic implications

26
Indications for urgent inpatient
echocardiogram
• Multiple arterial territory stroke on brain
imaging
• Evidence for systemic venous clots or
emboli
• Stroke within 3 months after myocardial
infarction, or new EKG changes
• Suspicion for cardiomyopathy or
congestive heart failure
Indications for urgent inpatient
echocardiogram
• Suspicion for infective endocarditis
(fever, risk factors such as IVDA) or non-
infective endocarditis (cancer, DIC,
elevated ESR, positive antiphospholipid
antibodies)
• High suspicion for ASA/PFO, e.g.
embolic appearing stroke in a patient
with DVT/PE, high risk for DVT, known
hypercoagulable state, age < 50
 Investigations - Imaging

In Selected Patients

CT angiography (multislice CT scan) - Non invasive tool

to assess intra- and extra-cerebral circulation. Involves
intravenous contrast injection
MR venography - In suspected cerebral venous thrombosis
Digital subtraction angiogram - Gold standard
assessment of cerebral vasculature. Reserved for patients
planned for intervention

29
CT angiogram
MR angiogram
Digital Subtraction contrast
angiography
 Routine TCD
examination

33
 Case Study (Imaging Findings)

Transcranial Doppler(TCD) Left M1 middle

demonstrates right distal cerebral artery
M1 middle cerebral artery Insonation showed
stenosis at 48 mm depth
insonation confirmed on
normal flow
magnetic resonance
angiography(MRA)

34
 Carotid Duplex Ultrasound

35
 Brain Imaging
• In about 1% of patients with TIA, CT shows
a nonvascular lesion accounting for
neurological symptoms (e.g. tumors, SDH)
• CT and MRI may also identify other vascular
lesions such as aneurysms or
arteriovenous malformations that can be
present in patients with TIAs
• 5-10% of suspected ischemic stroke are
found to have hemorrhage on CT scan
 Computed Tomography

• Widely available, relatively inexpensive,

non-invasive, and quick
• Accurately differentiate hemorrhagic
and ischemic stroke
• Inferior to MRI in posterior fossa lesions
due to bony artifacts
CT Scan: Infarct vs ICH
CT Scan: SAH
Early Changes on CT Scan
Early Changes on CT Scan

Hyperdense
MCA sign
 Magnetic Resonance Imaging
• More expensive and less widely available
• Longer acquisition time compared to CT
- difficult in uncooperative patients
• Contraindicated in patients with metallic
implants (e.g. IOL, pacemaker)
• More sensitive in detecting small lesions
• Can detect lesions as early as 6 hours from
stroke onset (as early as 11 min for
Diffusion MRI)
MRI: Infarct vs. ICH
Early Changes on MRI
 ACUTE MANAGEMENT

45
46
 ADMIT TO STROKE UNIT VS WARD
1. Admit all suspected strokes to SU, unless
co-existing conditions require ICU, etc.
2. If no SU available, admit to ward and refer
to mobile stroke team or neurologist
3. Assess and monitor neurological status
4. Start treatment and perform diagnostics
5. Multidisciplinary team care
6. Monitor for complications and treat early
7. Start education program for patient/family
OTHER MANAGEMENT ISSUES
 BLOOD SUGAR
1. Preferably use only normal saline
2. Aim for glucose between 5 – 8 mmol/L
3. 1500 cal DM diet for diabetic patients
4. AVOID hypoglycemia
 FLUID AND NUTRITION
1. If IV fluid required, use isotonic saline
2. Assess patient’s nutritional status
3. Most patients require 30 kcal or energy and
0.8 - 1 g of protein / Kg BW / day (dietitian
input required)
4. Dysphagia screening
- Insert NGT if sign of dysphagia, altered sensorium, failed
water swallowing test, or unable to consume fluid and food
adequately
5. For mod to severe stroke, give GI prophylaxis
6. Monitor I / O
 Dysphagia Screen

Drooling, excessive secretions

Coughing or choking while eating

Regurgitation through nose, mouth, or tracheostomy tube

Pocketing of food in cheek, under tongue, or on hard palate

Poor tongue control

Significant facial weakness

Significant slurred speech

Wet “gurgly” voice after eating or drinking or frequent throat
clearing

Hoarse voice

Delay or absence of laryngeal (Adam’s apple or thyroid
cartilage) elevation
 Water Swallowing Test (WST)
1. Dysphagia screen
Do not perform if drowsy, brainstem stroke
suspected, or bilateral stroke
2. Test with teaspoons of water followed by
asking patient to drink from cup containing 3
oz (90 mL) of water without interruption
3. Abnormal if coughing occurs during or within 1
min after completion or wet-hoarse voice after
swallowing
 WORSENING AFTER STROKE
1. Urgently workup any neuro deterioration
2. Check for oversedation
3. Treat seizures if occurs
4. Supplemental O2 if saturation <93%
5. Correct hypo- or hyperglycemia
6. Treat fever and infection
7. Treat severe hypertension/hypotension
8. If chest pain, dyspnea, diaphoresis, rule out
AMI and PE
 WORSENING AFTER STROKE
9. Perform repeat brain imaging ASAP to rule out
- Worsening cerebral edema
- Progression or recurrence cerebral infarct
- Hemorrhagic conversion of cerebral infarct
- Expansion/extension of intracerebral hematoma
- Development of hydrocephalus
- Rebleeding
10.Manage increased ICP, if present
11.Facilitate pending diagnostic tests and
consider “escalation” of treatment according to
stroke subtype
 INCREASED ICP
1. Suspect ↑ ICP if GCS downtrend or Cushing’s
triad (increased blood pressure, bradycardia
& irregular breathing)
Normal ICP 3 - 15 mm Hg (50 - 200 mm H2O)
• Ensure adequate O2, avoid hypercapnea
• Use only isotonic fluid
4. Elevate head 20º - 30º, keep head midline
5. Avoid coughing and straining
6. Maintain normothermia
7. If ICP available, keep CPP 70 – 100 mm Hg
 INCREASED ICP
8. Use osmotherapy, hyperventilation if needed;
do not use prophylactically
9. Steroids not recommended
10.Relieve pain and agitation
11.Refer to neurosurgeon for possible:
- Evacuation of hematoma
- Hemicraniectomy for malignant MCA infarct
- Suboccipital craniectomy for cerebellar lesions
- Ventriculostomy for IVH, hydrocephalus
 FEVER AND INFECTION
1. Urgently workup any fever
2. Correct dehydration
3. Consider IE in patients with stroke, fever,
cardiac murmur
4. Remove IV catheter is not needed or if
phlebitis; change site at least every 3 days
5. Treat skin breakdown
6. Start empirical antibiotics for suspected
source of infection
 REHAB, PT, OT, ST
1. Refer to PT for loss of motor function
2. Refer to OT for loss of functional skills
3. Refer to ST for swallowing or communication
difficulties
4. Refer to Rehab Med specialist for amelioration
of disability/handicap, prevention of
complications, functional prognostication, and
management in rehab unit
5. Assess need for inpatient or community-based
rehab program
 DVT AND PE
1. DVT prophylaxis to stroke patients at high risk
- LMWH, SQ UF Heparin, Intermittent Pneumatic Compression
2. If DVT suspected, do venous duplex
scan/compression ultrasound
3. If suspected, assess probability of PE
4. Consider initiating treatment pending
diagnostic tests if high probability
- IV heparin
- LMWH
- IVC filter, if cannot anticoagulate
 FEVER AND INFECTION
7. Antipyretic, if necessary
8. Change antibiotic if fever does not lyse in 48 -
72 hrs
9. If calf swelling, check for DVT
10.If no obvious source, check:
- abdominal - gynecological
- musculoskeletal - drug fever
- endocrine - neoplasm
- autoimmune
- unusual infection, e.g. fungal, TB, parasitic, etc
 Stroke Units

• Organised stroke care reduces mortality and

increases the proportion of patients making full
functional recovery
• Reduces death & dependency by 56 per 1000
patients treated
• Stroke unit triallist’ collaboration noted divergence
between stroke and general medical groups within 72
hours of admission
• High temperature, low diastolic blood pressure & high
blood glucose have detrimental effects on clinical
stroke
61
 Long Term Effects of Stroke
Unit

• Long Term Effects of Stroke Unit

Indredavik et al Stroke 1999. 30;1524-7

110 Stroke Units & 110 General Ward; 5

years on
* At home:21(19.1%) vs 9 (8.2%)
* Dead: 83(75.5%) vs 96(87.3%)
* Barthel Index >60 :22(20%) vs 9(8.2%)
62
 Management of Ischemic Stroke
Clinical Practice Guidelines

http://www.neuro.org.my

63