Case 3Case 3

63 year old male called EMS at 10 pm with a chief 63 year old male called EMS at 10 pm with a chief complaint of feeling dizzy for 2 hours. No headache, complaint of feeling dizzy for 2 hours. No headache, mild nausea, no vision change, no speech change.mild nausea, no vision change, no speech change.

• Symptoms began after dinner; 2 cocktails and 2 Symptoms began after dinner; 2 cocktails and 2 glasses of wineglasses of wine

• Dizziness described as room spinningDizziness described as room spinning• Patient laid down and symptoms did not change, ie, Patient laid down and symptoms did not change, ie,

no difference lying down or standingno difference lying down or standing

Case 3Case 3

• PMHx: PMHx: • Alcohol Abuse, quit for 3 years (?!)Alcohol Abuse, quit for 3 years (?!)• HypertensionHypertension

• MedicationsMedications• Enalapril, 10 mgEnalapril, 10 mg• Aspirin, 81 mgAspirin, 81 mg

• Social HxSocial Hx• Smoking - 1 pack per daySmoking - 1 pack per day

• ROS: Mild “dizzy spells” for the past 2 ROS: Mild “dizzy spells” for the past 2 weeks, each lasting 5-10 minutesweeks, each lasting 5-10 minutes

EMS calledEMS called

• Upon arrival at 10:30 - symptoms resolvedUpon arrival at 10:30 - symptoms resolved• BP 190 / 110, P 80, RR 14BP 190 / 110, P 80, RR 14• Alert, O x 3Alert, O x 3• No facial droopNo facial droop• No UE driftNo UE drift• Speech fluentSpeech fluent• PERL / EOM intactPERL / EOM intact• Gait – patient felt unsteady and preferred to sit downGait – patient felt unsteady and preferred to sit down

Question 1Question 1

Can vertigo be the sole presently complaint Can vertigo be the sole presently complaint posterior circulation ischemia?posterior circulation ischemia?

a)a) YesYes

b)b) NoNo

Posterior Circulation IschemiaPosterior Circulation Ischemia

• Prodrome very commonProdrome very common• 60 % of patients with basilar artery 60 % of patients with basilar artery

thrombosisthrombosis• Stuttering or progressive onset of Stuttering or progressive onset of

symptomssymptoms• 2 weeks prior to ED presentation2 weeks prior to ED presentation

Emergency Department PresentationEmergency Department Presentation

• Clinical Findings: Depends on the Clinical Findings: Depends on the syndromesyndrome• Range: asymptomatic to comatoseRange: asymptomatic to comatose

• The 5 DsThe 5 Ds: Dizziness, Diplopia, : Dizziness, Diplopia, Dysarthria, Dysphagia, DystaxiaDysarthria, Dysphagia, Dystaxia

• Hallmarks: Hallmarks: Crossed findingsCrossed findings• Cranial nerve deficits - IpsilateralCranial nerve deficits - Ipsilateral• Motor / Sensory deficits - Motor / Sensory deficits -

ContralateralContralateral

Posterior Circulation Stroke: AnatomyPosterior Circulation Stroke: Anatomy

Emergency Department PresentationEmergency Department Presentation

• Prodromal Symptoms (in order of frequency)Prodromal Symptoms (in order of frequency)• Vertigo and NauseaVertigo and Nausea (30%)(30%)• Headache, NeckacheHeadache, Neckache (20%)(20%)• HemiparesisHemiparesis (10%)(10%)• Dysarthria, DiplopiaDysarthria, Diplopia (10%)(10%)• HemianopiaHemianopia ( 6%)( 6%)

Question 2Question 2

Which of the following would you recommend to Which of the following would you recommend to EMS:EMS:

a)a) Do not transportDo not transport

b)b) Transport to the closest hospitalTransport to the closest hospital

c)c) Transport to a designated stroke centerTransport to a designated stroke center

Stroke Centers: The ThesisStroke Centers: The Thesis

• Thrombolytic and other interventions are Thrombolytic and other interventions are effective treatments in improving effective treatments in improving outcomes from acute strokeoutcomes from acute stroke

• Failure to adhere to protocols increase Failure to adhere to protocols increase morbidity and mortalitymorbidity and mortality

Case 3Case 3

• Patient is transported to the closest hospitalPatient is transported to the closest hospital• BP- 190 / 110, P-80, RR-14, 98%, BS 110BP- 190 / 110, P-80, RR-14, 98%, BS 110• Alert, Ox3; NAD Alert, Ox3; NAD • Neck: no bruitNeck: no bruit• Heart and lungs: “normal”Heart and lungs: “normal”• CN: “intact”CN: “intact”• Sensation: “intact”Sensation: “intact”• Gait: “normal”Gait: “normal”• ECG: normal sinus rhythmECG: normal sinus rhythm

Question 3Question 3

Which of the following would you recommend?Which of the following would you recommend?

a)a) Discharge with PMD follow upDischarge with PMD follow up

b)b) Discharge on increased aspirinDischarge on increased aspirin

c)c) Discharge on clopidogrelDischarge on clopidogrel

d)d) Discharge on dipyridamoleDischarge on dipyridamole

e)e) Admit to the hospitalAdmit to the hospital

Case 3Case 3

• Discharge diagnosis: “Dizziness – resolved”Discharge diagnosis: “Dizziness – resolved”• Limit alcohol useLimit alcohol use• Return to ED if symptoms reoccurReturn to ED if symptoms reoccur• Call your doctor in the amCall your doctor in the am

TIA and StrokeTIA and Stroke• Johnston, et al. JAMA 2000; 284:2901Johnston, et al. JAMA 2000; 284:2901

• Follow-up of 1707 ED patients diagnosed with Follow-up of 1707 ED patients diagnosed with TIATIA

• Stroke rate at 90 days was 10.5%Stroke rate at 90 days was 10.5%• Half of these occurred in the first 48 hours Half of these occurred in the first 48 hours

after ED presentationafter ED presentation• Gladstone, et al. CMAJ 2004; 170:1099-1104Gladstone, et al. CMAJ 2004; 170:1099-1104

• 371 consecutive patients with TIA 371 consecutive patients with TIA • 8% ischemic stroke in 30 days; ½ within 48 hours8% ischemic stroke in 30 days; ½ within 48 hours

• 12% in motor deficit group12% in motor deficit group

ED DispositionED DispositionED DispositionED Disposition

• Consider ED discharge if:Consider ED discharge if:• Further testing will not change Further testing will not change

treatmenttreatment• Prior work-upPrior work-up• Not a candidate for CEA or Not a candidate for CEA or

anticoagulationanticoagulation• ECGECG• Cardiac echoCardiac echo• Carotid ultrasoundCarotid ultrasound

Management: Antiplatelet TherapyManagement: Antiplatelet Therapy

• AspirinAspirin• Compared with placebo in patients with minor Compared with placebo in patients with minor

stroke/TIAstroke/TIA• Relative risk of composite endpoint reduced Relative risk of composite endpoint reduced

by 13% to 17%by 13% to 17%• Dose of aspirin probably not importantDose of aspirin probably not important• Lower dose gives lower incidence of GI side Lower dose gives lower incidence of GI side

effects.effects.

ManagementManagement

• Cochrane Systematic Review: September 2004Cochrane Systematic Review: September 2004• Clopidogrel and TiclopidineClopidogrel and Ticlopidine

• Effective in reducing composite endpoint of Effective in reducing composite endpoint of morbidity and mortality from vascular diseasemorbidity and mortality from vascular disease

• Less GI complications than ASALess GI complications than ASA• More skin rash and neurtopenia with More skin rash and neurtopenia with

ticlopidineticlopidine

Management: DipyridamoleManagement: Dipyridamole

• Meta-analysis. Stroke 2005; 36:162-168Meta-analysis. Stroke 2005; 36:162-168• Small absolute risk reduction for stroke Small absolute risk reduction for stroke

compared with ASA alonecompared with ASA alone• Recommended if symptomatic on ASARecommended if symptomatic on ASA

TIA ManagementTIA Management

• Discharged patients should receive ASA 50 - 325 mg/dayDischarged patients should receive ASA 50 - 325 mg/day• Based on cost and small absolute benefit of other Based on cost and small absolute benefit of other

agentsagents• Patients with TIA on ASA should have change in agentPatients with TIA on ASA should have change in agent

• Dipyridamole plus ASADipyridamole plus ASA• ClopidogrelClopidogrel• Increase dose of ASA to 1300 mg/dayIncrease dose of ASA to 1300 mg/day

Case 3Case 3

• While waiting in the waiting room for a taxi, the While waiting in the waiting room for a taxi, the patient acutely developed vertigo, left sided patient acutely developed vertigo, left sided facial droop, right sided weakness, slurred facial droop, right sided weakness, slurred speechspeech

• Alert but decreased gag Alert but decreased gag • BP 210 / 115, P 110, RR 14, POx 92% RABP 210 / 115, P 110, RR 14, POx 92% RA• BS 110BS 110• A decision is made to aero-medical transport to a A decision is made to aero-medical transport to a

stroke centerstroke center

Question 4Question 4

Repeat BPs over the next 15 minute remain 220 / Repeat BPs over the next 15 minute remain 220 / 120. What do you recommend?120. What do you recommend?

a)a) No BP interventionNo BP intervention

b)b) Clonidine .2 mg poClonidine .2 mg po

c)c) Labetolol 10 mg IVLabetolol 10 mg IV

d)d) Nitroprusside .5 ug / kg / minNitroprusside .5 ug / kg / min

Question 5Question 5

BP is treated with labetolol and decreases to 180 / BP is treated with labetolol and decreases to 180 / 100. Would you intubate this patient before 100. Would you intubate this patient before transport?transport?

a)a) NoNob)b) Yes: Ativan / Ketamine / SucYes: Ativan / Ketamine / Succ)c) Yes: Fentanyl / Etomidate / RocYes: Fentanyl / Etomidate / Rocd)d) Yes: Etomidate / SucYes: Etomidate / Suc

Case 3Case 3

• The patient arrives at the stroke center 45 minutes The patient arrives at the stroke center 45 minutes from the onset of symptomsfrom the onset of symptoms

• BP 160 / 90BP 160 / 90• Patient is intubated, left facial droop present, not Patient is intubated, left facial droop present, not

moving right sidemoving right side• CT is done and read within 90 minutes of CT is done and read within 90 minutes of

symptom onset – no infarct, edema, hemorrhagesymptom onset – no infarct, edema, hemorrhage

Question 6Question 6

Which of the following do you recommend?Which of the following do you recommend?

a)a) NothingNothing

b)b) Induced hypothermia to 32 degreesInduced hypothermia to 32 degrees

c)c) Intravenous tPAIntravenous tPA

d)d) Intra-arterial tPAIntra-arterial tPA

e)e) Other Other

Case Study: OutcomeCase Study: Outcome

• Patient received intravenous thrombolysis Patient received intravenous thrombolysis • Significant early improvement but without Significant early improvement but without

complete resolution of symptomscomplete resolution of symptoms• On day 4, the NIHSS score was 10On day 4, the NIHSS score was 10• MRA : Left superior cerebellar artery and both MRA : Left superior cerebellar artery and both

anterior-inferior cerebellar arteries were non-anterior-inferior cerebellar arteries were non-visualizedvisualized

• Cardiac evaluation was negativeCardiac evaluation was negative• He was transferred to rehab on coumadinHe was transferred to rehab on coumadin