assessment of stroke ischemic vs hemorrhagic stroke · 8/2/2015 2 hemorrhagic stroke 20% of all...

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Assessment of

Ischemic vs Hemorrhagic Stroke

Cynthia Bautista, PhD, RN, CNRN, SCRN, CCNS, ACNS-BC, FNCS

Nursing Brains, LLC

[email protected]

Stroke

In the USA 795,000 new or recurrent strokes

Represents 5th leading cause of death in USA

Copyright Nursing Brains, LLC

Ischemic vs Hemorrhagic

Ischemic stroke is 10x more frequent

Hemorrhagic stroke has higher mortality risk

Common risk factors


Ischemic Stroke

80% of all strokes Blockage in blood vessel Fatty deposits lining blood vessel wall

Thrombosis (50%)◦ Thrombi formed by plaque

◦ Greater than 50%stenosis

Embolism (30%)◦ Cardiac emboli

◦ Atrial Fibrillation


Cryptogenic Stroke

30% of ischemic strokes Infarct of undetermined cause Hemispheral infarction Average age 58 No risk factors


Lacunar Stroke

25% of Ischemic strokes Thrombosis of Lenticulostriate arteries

(small penetrating arteries) Predominate in basal ganglia Caused by hypertension and diabetes No treatment Risk factor management


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Hemorrhagic Stroke

20% of all strokes

Rupture of leaking blood vessel

Intracerebral (ICH)

◦ High blood pressure

Subarachnoid (SAH)

◦ Cerebral Aneurysm

◦ Arterial Venous Malformation

Intraventricular (IVH)

◦ ICH and/or SAH

Hemorrhagic transformation of ischemic infarct


Ischemic Stroke

Risk Factors


NonModifiable Risk Factors

Age◦ Risk of stroke doubles every decade after 55

Gender◦ 55,000 more women than men have a stroke each year◦ Men’s stroke incidence rates are greater than women ‘s at

younger ages

Race◦ African American have almost twice the risk of first ever

stroke compared to whites

Prior Stroke◦ 5% chance of stroke/year, 10x higher

Family History Parental ischemic stroke by age of 65 years associated

with a 3-fold increase in ischemic stroke in offspring


Modifiable Risk Factors

High Blood Pressure◦ Powerful determinant of risk for both ischemic

stroke and ICH

◦ 77% of first time stroke patients BP > 140/90

◦ Blacks more aware of hypertension than whites

Diabetes◦ Increases ischemic stroke incidence at all ages

◦ Most prominent before 65 years old in blacks & whites

◦ Doubles stroke risk with history of TIACopyright Nursing Brains, LLC

Modifiable Risk Factors (con’t)

Tobacco use

◦ Ischemic and hemorrhagic stroke

◦ Aggravates atherosclerosis and raises BP

◦ 50% reduction of risk with cessation

◦ Counseling, nicotine products, oral smoking cessation medications

◦ Implement 5 A’s

ASK about tobacco use

ADVISE to quit

ASSESS willingness to attempt to quit

ASSIST in the quit attempt

ARRANGE follow-up



Carotid Disease

Atrial Fibrillation◦ 50% of all embolic strokes

◦ Anticoagulation reduces risk by 68%

Cardiac Disease◦ Routine screening

◦ Aggressive treatment

Sickle Cell Disease


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High blood Cholesterol

Poor diet

Physical Inactivity

◦ Moderate intensity exercise ≥ 30 minutes most days

Obesity

◦ Weight reduction

◦ Maintain BMI < 25 kg/m2

◦ Waist circumference <40” men, < 35” women



Alcohol Use◦ Men no more than 2 drinks/day

◦ Women no more than 1 drink/day

◦ Drink in moderation

1.5 oz hard liquor

4 oz wine

12 oz beer


Hemorrhagic Stroke

Risk Factors


NonModifiable Risk Factors

Age◦ Risk of stroke doubles every decade after 55

Gender◦ 55,000 more women than men have a stroke each year◦ Men’s stroke incidence rates are greater than women ‘s at

younger ages

Race◦ African American have almost twice the risk of first ever

stroke compared to whites

Prior Stroke◦ 5% chance of stroke/year, 10x higher

Family History Parental ischemic stroke by age of 65 years associated

with a 3-fold increase in ischemic stroke in offspring


Modifiable Risk Factors

High Blood Pressure◦ Incidence of stroke increases with severity

◦ Goal ≤ 120/80 with risk factors



Tobacco use ◦ Most important risk factor in preventing SAH

◦ Discontinuation shown a reduction in stroke risk

◦ Exposure to secondhand smoke is risk factor


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Alcohol Use◦ Men no more than 2 drinks/day

◦ Women no more than 1 drink/day

◦ Drink in moderation

1.5 oz hard liquor

4 oz wine

12 oz beer



Drug Abuse◦ Occurs first time or long-term user

◦ Amphetamines, cocaine, heroin

◦ Hypertension

◦ Intracerebral Hemorrhage

◦ Screen

◦ Rehabilitation


Ischemic Stroke Presentation


Left (Dominant Hemisphere)

Left gaze preference Right visual field deficit Right hemiparesis Right hemisensory loss


Right (Nondominant Hemisphere)

Right gaze preference Left visual field deficit Left hemiparesis Left hemisensory loss◦ Neglect (left hemi-inattention)


Brainstem Stroke Syndrome

Decreased consciousness Diplopia, dysconjugate gaze, gaze palsy Hemiparesis or quadriplegia Sensory loss in hemibody or all 4 limbs Dysarthria Dysphagia Vertigo, tinnitus Nausea/vomiting Abnormal respirations


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Cerebellum Stroke Syndrome

Gait ataxia Limb ataxia Neck stiffness Nystagmus


Warning Signs of Stroke

Think F-A-S-T

F = FACE numbness or weakness especially one side of body

A = ARM numbness or weakness one side of body

S = SPEECH slurred or difficulty speaking or understanding

T = TIME to immediately call 9-1-1 and note time symptoms started or last time person was seen normal


Hemorrhagic Stroke

Presentation


Hemorrhage Stroke Syndromes

Decreased level of consciousness Focal neurological deficits Headache Neck pain Light intolerance Nausea, vomiting


Level of Consciousness

Glasgow Coma Scale

Eye Opening

◦ 4 - Spontaneous

◦ 3 - To Speech

◦ 2 - To Pain

◦ 1 - None

Verbal Response

◦ 5 - Oriented

◦ 4 - Confused

◦ 3 - Inappropriate Words

◦ 2 - Inappropriate Sounds

◦ 1 - None

Motor Response

◦ 6 - Obeys Commands

◦ 5 - Localizes

◦ 4 - Withdraws

◦ 3 - Abnormal Flexion

◦ 2 - Abnormal Extension

◦ 1 -None


Ischemic Stroke Imaging


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Early CT Finding

Hypodensity

Infarction – darker area Obscures gray white matter contrast Effacement of sulci or

loss of insular ribbon


Early CT FindingHyperdense Middle Cerebral Artery

Sign (HDMCA)

Observed in 50% MCA occlusions Development of large infarct Poor clinical outcomes


CT Technologies

CT Angiographey◦ Details vessels

◦ Large vessel occlusions

CT Perfusion◦ Tracks arterial blood in brain

◦ Perfusion maps

Multimodal CT (CT, CTA, CTP)◦ Detects absence of hemorrhage

◦ Presence of ischemia

◦ Vascular anatomy/perfusion deficits


MRI

Magnetic energy DWI◦ Abnormal within 7 minutes of onset

Gradient Recalled Echo (GRE)◦ Detects hemorrhage

Fluid attenuated inversion recovery (FLAIR) and T2-weighted ◦ Evolving infarction

Perfusion-weighted Images (PWI)◦ Abnormal flow


DWI and PWI

DWI (Diffusion-Weighted Imaging) ◦ Ischemic region within minutes

◦ Lesion size, site, age

◦ Detects random movements of water protons

PWI (Perfusion-Weighted Imaging) ◦ Hemodynamic status

◦ Provides information regarding cerebral blood flow

◦ Extremely sensitive to cerebral ischemia

Same lesion size and location are matched Larger PWI lesions are mismatched


Carotid Ultrasound

Inexpensive, safe Non-invasive screen Blood velocity Patient that cannot receive contrast or MRA 90% sensitivity and specificity


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Digital Subtraction Angiography

(DSA)

Gold Standard for cerebral vasculature Degree of stenosis Provides interventions◦ Thrombolytics

◦ Thrombectomy

◦ Angioplasty and stenting


Echocardiogram

Transthoracic

Noninvasive utilizing sound waves

Transesophageal

Combines ultrasonography & endoscopy

Image posterior of the heart

Heart structures

Clots, valves, PFO, LV function


Hemorrhagic Stroke Imaging


Early CT Finding

Hyperdensity

Hemorrhage appears white Petechial is scattered hyperdense points Hematoma is solid, homogenously

hyperdense legion


Predicting ICH Expansion

Spot sign on CTA


CT Scan in SAH


http://www.vascularweb.org/_CONTRIBUTION_PAGES/Patient_Information/NorthPoint/Angiogram.html

http://www.vascularweb.org/_CONTRIBUTION_PAGES/Patient_Information/NorthPoint/Angiogram.html

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MRA

Extracranial & intracranial cerebral circulation abnormalities

86% sensitivity 98% specificity Aneurysm detection 95% sensitivity


CT Scan in

Intraventricular Hemorrhage


CT Scan in

Hemorrhagic Transformation of

Ischemic Stroke


Transcranial Doppler (TCD)

Safe, inexpensive Flow of blood through arteries of the brain High frequency sound waves pass through

tissue Detects, monitors stenosis, vasospams,

reperfusion Concern with

◦ Velocity of >120

◦ Lindegaard ration > 3


Stroke Case Studies


Case Presentation #1

T.E. is a 39 year old Caucasian man who works in construction. Ten years ago he had a myocardial infarction, EF 45% with apical akenesis and an intraventricular thrombus (was on warfarin). Has a history of TIAs, hypercholesterolemia and smokes 2-3 packs per day.

He left his house about 8:15PM and was found lying on the sidewalk. People passing by called 9-1-1.


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Case Presentation #1 (con’t)

At 8:45 PM T.E. was weak on the RIGHT side, unable to speak, and had a LEFT gaze deviation.

Copyright Nursing Brains, LLC Copyright Nursing Brains, LLC


Mr. A. is a 41 year old African American, obese, male, with hypertension and a history of CABG 10 years ago. He went to the bathroom at about 3:55PM. His family heard a load noise coming from the bathroom. He was found by his family lying in the shower at 4PM. He was unable to talk and weak on the RIGHT side. They called 9-1-1.


53 year old male (WR) was in a car accident in which he could not see oncoming traffic. He was having piercing headache in his right occiput. He took ASA 325mg with no relief. He was at work when the symptoms started, went home, and then was driving to the bank with his girlfriend when he crashed his car into the side of the road. His family picked him up and brought him to the ED.



Construction worker History of diabetes and hypertension Medications: lisinopril, glipizide, metformin, ASA Quit smoking 4 years ago Drinks 6 pack of beer on the weekends



Upon arrival to ED …

NIHSS = 2 (LEFT hemianopsia)

BP 211/118

Glucose 247



MM is a 60 year old female who was at the gym on an elliptical machine when she experienced the “worst headache of her life”. She went into the restroom with her sister where she began to vomit. Her sister called 9-1-1She has a history of hypertension and her cousin died of a ruptured cerebral aneurysm


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D.B. is a 75 year old Caucasian man in good health. He quit smoking over 30 years ago and has no family history of stroke. He has not seen a physician in over 40 years. He was taking his family to McDonalds for lunch. After leaving the drive thru window he began to drive erratically over curbs and islands. D.B. had a sudden onset of right facial droop, right arm weakness, and difficulty speaking.

His daughter got him to stop the car and she called 9-1-1.


A 57-year-old female (CB) last spoke to her relatives on Sunday. She did not answer her phone on Monday. The landlady entered her apartment on Thursday and found her lying face down on floor of living room covered in vomit and feces. Landlady called 9-1-1


Pre Hospital◦ Vital signs 149/94 – 79 – 20, 99.3, pulse

oxygenation 98%

◦ Not moving right side

Emergency Room◦ 162/83 – 87 – 20

◦ Pupils equal react to light

◦ Opens eyes, difficult to remain awake


History of chronic atrial fibrillation Coumadin started in 2007 Noncompliant Sub therapeutic INR Patient on ASA only


83 year old man (JP) fell at home x2 last night. He was able to getup on his own after the first fall, unable to getup after 2nd

fall. According to wife, JP began acting abnormal (asking strange questions, using inappropriate words). Wife dragged JP from living room to bedroom. They slept together on the floor in the bedroom.


In the morning the wife was unable to wake JP up and called 9-1-1

JP had right sided weakness, right facial droop

History of TIA, CAD, hypertension Pre Hospital

◦ 198/80 – 93 – 20 Pulse oxygenation 95%

assessment of stroke ischemic vs hemorrhagic stroke · 8/2/2015 2 hemorrhagic stroke 20% of all...

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