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Stroke, TIA, and ICH

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Stroke, TIA, and ICH Stroke, TIA, and ICH INTRACRANIAL HEMORRHAGE – ICH Etiology: • Commonest causes are: (a) hypertensive basal ganglion and cerebellar hemorrhages and (b) lobar hemorrhages (usually in the elderly) due to amyloid angiopathy • Secondary causes include: vascular malformations, hemorrhages into brain tumors or ischemic strokes, cerebral venous sinus or cerebral vein thrombosis, and sympathomimetic drugs Investigations: • Blood sugar • CT head +- CT angiography • Spot sign: on CTA, the extravasation of contrast into the hemorrhage indicates ongoing bleeding and high risk for deterioration • Routine blood work to include INR and drug screen Mortality Scores: • ↑ Risk of mortality with: GCS <13, ICH volume > 30 cc, IVH (intraventricular hemorrhage), infratentorial bleeding, age > 80 Treatment: • Airway management especially if GCS < 9 or patient deteriorating – do not allow BP to drop precipitously during intubation – particularly risky if significant ↓ LOC (due to probability of increased ICP and chance that cerebral perfusion pressure will drop) • Pre-treatment with fentanyl to minimize jump in BP • After intubation: sedate with fentanyl and sedatives to minimize jump in BP • Do not let SBP drop < 100 at any point • Reversal of anti-coagulants (do not give platelets to reverse asa/clopidogrel (unhelpful and likely harmful) • Give platelets if absolute count is <50,000 (many neurosurgeons prefer if < 100,000) • Ideal BP is SBP of 140 or minimally less • Minimize risk for ↑ ICP and manage ↑ ICP • No compression to neck • Head of bed elevated to 30 degrees • If ICP↑: mannitol at 1 gm/kg over 30 minutes (must insert foley and replace lost fluids to prevent dehydration, hypotension, and renal failure) and may repeat ever 4- 6 hours • if serum osmolality is monitored – serum osmolality should be followed q 4 hours – mannitol plays little role if osmolality is > 320 • Other options: hypertonic saline – 150 ml boluses 3% or 30 ml or 23.4% saline (23.4% needs central line) – monitor serum Na q 4 hours – serum Na should not be > 160 • Blood sugar: maintain at 5 – 10 mmol/l • Temperature: treat if > 37.5 C Seizures: • Prophylaxis not indicated for ICH • If seizure: IV benozodiazepines, then IV dilantin (20 mg/kg) or keppra - levitiracetam- (50 mg/kg) Surgery: • Prophylactic surgery (hematoma evacuation) in the absence of clear indications shown to be unhelpful (STITCH trial I and II) • Clear indication for surgery is cerebellar hematoma if > 3 cm in diameter or if clinical/imaging signs of hydrocephalus or brainstem compression • Indications for ICP monitoring +/- external ventricular drainage: Coma Hydrocephalus Significant intraventricular blood TIA • The distinction between a TIA and a minor stroke has become somewhat less important because the approaches are similar and both are urgent • TIA: traditional definition is a neurological event which is focal, due to focal ischemia of a single vessel, and has symptoms that fully resolve in 24 hours – modern imaging shows that ~1/3 of these patients demonstrates a stroke (infarcted brain tissue) at 24 hrs • New definition: transient neurological dysfunction due to focal ischemia of brain, or retina, or cord AND without evidence of infarction (on imaging) • If imaging is not available: symptoms > 24 hours will define a stroke Etiology: The etiology of TIA is the same as stroke • About ¼ : large vessel • About ¼ : lacunar (small vessel disease) • About ¼ : cardioembolic • About ¼: thrombogenic states (including dehydration), dissections, cryptogenic The ABCD2 Rule: • Age (A) = 1 point for age > 60 • Blood pressure (B) 1 point if BP > 140/90 • Clinical (C) 1 or 2 points – 1 point for for speech disturbance without weakness, 2 points for weakness; • Duration (D) zero points if < 10 min, 1 point if 10-60 minutes, 2 points if > 60 min • Diabetes (D) – this is the second D, 1 point if history of diabetes • Low risk 0-3 • Moderate risk: 4-5 • High risk: 6-7 • Historically, the risk of a TIA leading to a stroke was about 2-17% in the first 3 months and half of this risk was in the first 2 days (up to 5-7%) The ABCD2 rule has been used to predict the specific risk and, traditionally, all patients with a high score (4-7) were felt to need a more urgent assessment Prospective studies have shown that the score is neither sensitive nor specific and is inaccurate, at any cut-point, as a predictor of imminent stroke - so, what to do? The Best Approach Is An Aggressive One The most important risk factor is the “C” – speech deficit or weakness is very significant Best approach is to get imaging of the brain and vessels fast – the move is in the direction of getting immediate CT and CTA of vessels from aortic arch to the vertex (i.e., both extracranial and intracranial vessels) Identifying A. Fib (with ongoing monitoring if necessary up to 30 days in cryptogenic cases) and then treatment with anti-coagulants if found Get to a TIA / Stroke clinic in < 2 days Begin ASA in the department Begin anti-coagulants in the department if cardio-embolic TIA and no acute stroke present Investigations: 1. CT head always indicated - If not available, will have to be delayed - CT is primarily to rule out mimics (tumors, bleeds, other masses) – evidence of previous large vessel stroke or lacunar infarcts (which may have been subclinical) increase the risk of the TIA - CTA of vessels from arch to circle is Willis is an excellent, if not preferred, investigation to Doppler of neck vessels 2. Heart tests: - EKG: always indicated to look for a. fib, flutter - 2D-ECHO HEART: may be indicated if suspect clot or PFO 3. Doppler of neck arteries – primarily to look for stenosis of the ICA – sensitivity for cervical artery dissection is good (if high suspicion for dissection – might be better to get an immediate CT/CTA 4. Basic blood work Anti-platelet Therapy: • ASA: dose is asa 81 mg per day (most will give a loading dose of 160-325mg) - Lower dose effectiveness = higher dose. Therefore, giving more than 81 mg of no value and only increases the side effects - Bleeding risk /year of ASA 81 mg: 0.4%/yr (this is 2.5 times the risk of non-users) • Clopidogrel: dose is 75 mg per day (probably wise to give a loading does of 300 mg) - PPI’s: if one is going to use a PPI – best to use pantoprazole (tecta, pantoloc) – the other PPI’s affect the CYP system (cytochrome P450 system) and may impair the activation of clopidogrel • Aggrenox: another option: aggrenox is a combination drug (asa 25 mg + dipyridamole 200 mg) BID - Some studies suggested it may be more effective than ASA (ESPSII – European Stroke Prevention Study II) –IF it is, the benefit is minimal • Long term use of ASA + Clopidogrel: NO - The MATCH trial clearly showed that long term ASA and clopidogrel together is bad – no benefit and increased risk of ICH • Which is better? Clopidogrel or Aggrenox - Neither - THE PRoFESS trial showed they were equally effective • Is There a Role for Short Term ASA + Clopidogrel after a TIA or Minor Stroke - In high risk TIA: may consider a 21 day combination of asa 81 and clopidogrel 75 – not long term - Three trials have looked at this so far: FASTER, EXPRESS, and CHANCE - Currently, the POINT trial is being conducted in an attempt to determine if ASA 81 + clopidogrel 75 together for a brief period (21 days) is the best option – no definitive answer yet TIA and Internal Carotid Artery (ICA) stenosis and Surgery – Does Time Matter – YES: • For TIA caused by stenosis of the ICA > 70%: - surgery (endarterectomy) is indicated • Time is essential – the highest risk time is the first two days and then the first two weeks: therefore, surgery should be done with 2-14 days after the TIA – the sooner the better • Will reduce risk of a major stroke for 26% over 2 years to 9 % - 17% absolute risk reduction • The absolute risk reduction is 30% if done within 2 weeks • If ICA (internal carotid artery) stenosis 50% - 70%: - surgery still beneficial (22% to 15%) but surgery must be done early ( < 2 weeks) or the benefit is quickly lost • For Intracranial artery stenosis: the best treatment is ASA – surgery (stenting) has shown to be harmful and anti-coagulants to not benefit intracranial artery stenosis causing TIA’s or strokes Recent Updates in Stroke: r-tPA (recombinant tissue plasminogen activator) The American Heart Association/American Stroke Association Guidelines (2018 update) • The AHA/ASA recommends the use of r-pTA for acute stroke up to 4.5 hours in those patients without contraindications • Cannot be used if patient has had LMWN in the previous 24 hrs • Absolute contraindications: BP > 180/110, ischemic stroke within past 3 months, severe head trauma within 3 months, intracranial or intraspinal surgery within 3 months, platelet count < 100,000, INR > 1.7, infective endocarditis • Major changes have occurred in that some of the previous contra-indications are no longer considered contra-indications • Three of the previous contraindications have been removed – for patients > 80 years age: MAY now receive r-tPA even if: (i) they are in the 3 hr – 4 ½ window, or (ii) are on warfarin and have INR <1.7, or (iii) have had a previous stroke and have diabetes. • For the 3 hr – 4 ½ window and very severe stroke (NIHSS > 25): - r-tPA may have no value or be harmful • Mild early improvement is now not a contra-indication to r-tPA – therefore, even with spontaneous improvement, should still give r-tPA if meaningful impairment is still present • Seizure at the onset is not a contra-indication Canadian Association of Emergency Physicians Position Statement on Acute
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