Managing CVA in ED Learning Objectives Is it a stroke? Diagnosis ...

Managing CVA in ED
Dave Moen, MD
Medical Director Emergency Services
Fairview Lakes Health Services
I have no financial
relationships to
disclose………
…I remain quite boring, really
Learning Objectives
• Understand evolving emergency
evaluation of CVA
• Understand imaging choices
• Discuss initial therapy options
• Understand TIA risk and work-up
• Discuss CVA reperfusion strategies
• Discuss Posterior Circulation CVA
Diagnosis of Acute CVA
Is it a stroke
Initial Clinical Diagnosis CVA
• Approx. 10 – 15% have another
condition
CVA look alikes
• Seizures
• Subdural hematoma
• Metabolic causes – hypoglycemia
• Delerium (toxic or organic)
• Mass or tumor
1

CVA look alikes tend to:
Initial work-up
• less prominent focal findings
• Associated mental status changes
(global brain dysfunction)
• History and exam
• Lab work
• Imaging
evolution in treatment options demand
attention to pace of workup/treatments
Important Acute CVA
complications
• Hypoxia/airway
• Hypo/hypertension
• Hypo/hyper glycemia
• Fever associated with poorer outcomes
• Seizures
Complication Caveats
• Airway interventions if needed
• Oxygen for hypoxia (no help if not hypoxic)
• Treat symptomatic hypoglycemia
• Treat BP >220/120; no lytics till 150)
CVA Etiology
Timing/clinical course critical
15%
15%
hemorrhagic
• When did the stroke start
220%
atherothrombotic
cardio-embolic
25%
unknown/rare
• Is it dense/unchanging clinically
• Is it “stuttering” or fluctuating in symptoms
• Level of severity (NIHSS stroke scale)
lacunar
25%
2

What about timing
• If therapy available under 3 hrs most now
recommend intervention
• If therapy available under 4.5 hrs., some
recommend
• If therapy available under 6 hrs., a few still
recommend
NIHSS stroke scale
• Tool for communication/decision-making
• Higher scores correlate with higher
mortality
• www.strokecenter.org
CVA Patient
Imaging Options
Acute Symptoms
< 5 hrs.
Or “stuttering”
Assess/address
complications
Determine
NIHSS Score
Subacute
>5hrs
• CT scan
• CT with contrast (CTA or CTP)
Imaging
•MRI
Acute CVA ED Goal – Evaluation to CT read = 45 mins.
CT scan (no contrast)
• Remains as standard of care due to availability
and sensitivity excluding blood
• More sensitive than MRI for detecting blood
• ECASS trial demonstrated that early signs of
major cerebral infarction (e.g. sulcal effacement,
mass effect, edema, and loss of the insular
ribbon) are associated with an increased risk for
intracerebral hemorrhage in patients who
receive thrombolytic therapy.
Subtle CT findings may increase
risk of bleeds with lytics
• Sulcal effacement
• Edema
• Mass effect
• Loss of insular ribbon
If you are certain that onset

CT Scan (with contrast) - CTA
• 98% sensitivity for large vessel occlusion
• Shows thickening/calcification vessel wall
• Better sensitivity for ischemia
• Adds approx. 10-15 mins. to study
• Including neck to aortic arch defines
important vascular anatomy
Diffusion-weighted MRI
• 94% sensitivity/96% specificity in early
ischemic stroke
• More accurate from lacunar/brainstem
infarcts
• Changes progress in a fashion that allows
timing of stroke onset (wake up stroke)
Limitations MRI
• Take a long time
• Tough to monitor patients
• Not widely available for emergencies
• Not as sensitive for detecting blood
Review Imaging Options
• CT – Still the gold standard; better for
blood
• Consider CTA if acute, large CVA and
considering aggressive intervention and
readily available
• MRI – brainstem strokes and “wake up”
strokes; better posterior circulation
CVA Patient
Sub-acute CVA management
Acute Symptoms
< 5 hrs.
Or “stuttering”
Assess/address
complications
Determine
NIHSS Score
Subacute
>5hrs
• Etiology
• Acute treatment
• Hospitalize or not
Imaging
Subacute CVA
4

Clinical Caveats
• ASA within 24 hrs. CVA improves
outcomes slightly (1 in 100 treated)
• Heparin not useful except in known cardioembolic
causes (A.Fib, AMI, PFO)
• Cyto-protective agents under study; some
promise
Hospitalize or not
• Safety at home
• Cardiac monitoring
• Pace of work-up
• Medical Home
• Open discussion of risks/available
interventions
CVA Patient
TIA
Acute Symptoms
< 5 hrs.
Or “stuttering”
Imaging
Subacute
>5hrs
• Evolving definition
• Many now consider TIA as focal neuro
deficit lasting < 60 mins. (with no
subsequent imaging findings)
No Bleed
No Bleed
Improving!
Bleed
TIA facts
TIA with higher stroke risk
• 10% TIA patients have CVA within 90
days
• 5% have CVA within 48 hrs.
“TIA should be promptly evaluated
because delaying diagnosis risks
preventable stroke.” AHA Council on
Stroke Update
• Age > 60
• Sign or symptom of weakness
• Speech disturbance
• diabetes
• Symptoms lasting > 10 mins.
5

Relative 90 day risk of CVA
• One risk 3%
• Two risks 7% >1700
patients
• Three risks 11%
• Four risks 15%
• Five risks 34%
Relative 90 day Risk of Adverse
Event
• >25% have an adverse event
12.7% recurrent TIA
10% CVA
2.6% cardiac event
2.6% deaths
Johnson, C. et al; Short term prognosis after emergency department diagnosisof TIA; JAMA 2000 Vol 284
No. 22
Johnson, C. et al; Short term prognosis after emergency department diagnosisof TIA; JAMA 2000 Vol 284 No.
22
TIA work-up
• Carotid evaluation (MRI/MRA, CTA, U/S)
• ECHO bubble study (r/o PDA)
• Lab work
• EKG, telemetry to r/o paroxysmal A.fib.
Reducing CVA risk with TIA
patients
• ASA and other anti-platelet meds
• HTN management
• Diabetes management
• Endarterectomy or stenting for carotid
disease
• Anticoagulation with atrial Fib.
• Statins
Clinical approach to TIA
CVA Patient
• Appropriate discussion/disclosure of risk
• Timely work-up to rule out treatable
causes
• ASA or other antiplatelet meds
• Clinical home to address risk factor
management
Acute Symptoms
< 5 hrs.
Or “stuttering”
No Bleed
Imaging
Subacute
>5hrs
No Bleed
Persistent Neuro
Deficit
Bleed
6

Aggressive Interventional
Options
• Systemic rTPA
• Neuro cath with targeted lytics
• Neuro cath with lytics/embolectomy
Systemic rTPA
• Still controversial after all these years!
• Generally accepted caveats:
-no mortality impact (save some, lose some)
-improves neuro outcome in 12 patients/100
treat.
-MUST do it right to receive benefit!
(overdosing is most common error)
-NIHSS >22; severe strokes = no benefit
-Cost/benefit is positive
Systemic rTPA
Neuro-interventional
approaches
• Earlier in course is better
• Expeditious process and decisionmaking
will change outcomes (minutes
matter)
• Community institutions can do this well
• Appropriate disclosure of risk/benefit
-12 improved outcomes/100 treated
-1 in 15 have severe bleed
• Targeted approach – fewer
complications
• Can cause delays in treatment
• Limited resources
• Limited efficacy data
Single Center Experience With IA Intervention in
177 Consecutive Patients With Angiographically
Confirmed Large Vessel Ischemic Stroke from
2003–2007
Michael T. Madison M.D., James K. Goddard, III. M.D.,
Jeffrey P. Lassig M.D., Mark E. Myers M.D.
Background
• IA thrombolytics and mechanical intervention have been
shown to recanalize acute ischemic strokes at high rates
(PROACT II = 66%; Multi MERCI = 68%)
• Less data has been presented on use of these
interventions in community based settings
• Goal: to see if results from our group of 4 Neuro-
Interventionalists covering acute stroke at 5 hospitals in
the Minneapolis/St. Paul area were consistent with
outcomes presented in other trials
St. Paul Radiology, St. Paul, MN
7

Protocol
• Neurologic examination suggesting a major stroke
syndrome (NIHSS >8) of recent onset
– 6 hours or less for thrombolysis
– 8 hours or less for mechanical thrombectomy
• Non-contrast head CT (patients with defined
infarcts, hemorrhage or tumors are excluded)
– CTA Circle of Willis, CT perfusion, MRI
• Discuss and formulate treatment plan with Stroke
Neurologist
• Cerebral angiography to confirm large vessel
occlusion
Protocol
• Direct intra-arterial thrombolysis with tPA
dose < 40 mg) and Integrilin ®
(eptifibatide) (single weight-based bolus)
to treat vascular occlusions correlating
with clinical stroke syndrome
• Concentric Merci ® retriever device
• Penumbra ® mechanical thrombectomy
devices (FDA trial)
Stroke Interventions by Year
Demographics
60
50
40
30
20
10
0
54
43 43
17
20
2003 2004 2005 2006 2007
• Mean baseline NIHSS: 14.4 (Range 8–29)
• Mean time from symptom onset to intervention:
4 hrs 11 minutes (Range 1–7.5 hrs)
• Etiology of Strokes:
– Atrial Fibrillation 43%
– Unknown 20%
– Carotid Atherosclerosis 11%
– PFO 9%
– Intracranial Stenosis 5%
– Other (mural thrombus, 9%
atrial myxoma, hypercoagulable)
IC
Stenosis
5% Other
9%
PFO
9%
Carotid
Athero
11%
Unknown
20%
Afib
43%
Demographics: Occlusion
Locations
Procedural Data & Outcomes
• ICA 18%
• MCA 71%
• Vertebrobasilar 7%
• PCA 2%
• ACA 2%
PCA
2%
VB
7%
MCA
71%
ACA
2%
ICA
18%
• IA thrombolytics used in 87% (154/177)
– Mean dose of IA tPA: 24.6 mg (Range: 9-42 mg)
• Mean dose of IA eptifibatide (Integrilin ® ): 4.6 mg (Range:
0-9.5 mg)
• Merci ® Retriever used in 40% (71/177)
– Immediate post-retriever recanalization was 52%
• Final angiographic recanalization for the overall cohort
was 81%
– TIMI III Flow 59%
– TIMI II Flow 22%
8

Clinical Outcomes
Clinical Outcomes (Cont.)
• Average NIHSS (24-48 hrs) post-treatment was 7.4
(Range 0-30)
• Positive clinical outcomes (NIHSS

ED evaluation
• Initial same as other CVA
• Anatomy best defined with MRI/MRA or
CTA
• Treatment (same)
In patients dizziness or vertigo or
HA with accompanying neuro
symptoms – posterior circulation
vascular disease must be ruled
out
Summary
• Evolving treatment options make pace of CVA
workup and treatment important
• CT still gold standard but CTA and MRA add
important vessel anatomy definition
• TIA’s are high risk events; understanding and
communication are critical
• Reperfusion strategies improve outcomes in
selected patients
• Posterior CVA’s are difficult to diagnose and
must be thought of and looked for
References
1. Stroke. 2003;34:1056-1083
doi: 10.1161/01.STR.0000064841.47697.22
2. http://www.aafp.org/afp/990515ap/2828.html
3. Stroke. 1999;30:1440-1443
4. http://www.americanheart.org/presenter.jhtmlidentifier=4724
5. ACEP EMCREG Monograph: Advancing the Standard of Care
Cardiovascular, Neurovascular, and Infectious Emergencies; Oct 2007
10