Acute StrokeCase Rounds Acute Stroke Case Rounds

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Acute StrokeCase Rounds Acute Stroke Case Rounds Powered By Docstoc
					Acute Stroke Case Rounds
 Dr Tim Watson Moderator / Calgary Stroke Program

            Date:Friday January 15/2009 12:00-1:00PM (MST)

            Host Site: Foothills Medical Centre, Calgary Alberta

            Purpose:To provide an interactive case based educational
               forum that fosters growth of a shared understanding of
                                 g                p
               acute stroke management between personnel working ing
               Primary and Tertiary Stroke Centers.

            Target Audience:These rounds are intended for all levels of
               health         f i l i l di                     k
               h l h care professionals involved in Acute Stroke Care,
               including: Clinicians, Radiologists, Nursing, and EMS
Copies of the presentation will be posted on the Alberta Provincial
  Stroke Strategy (APSS) website:

    To access click on:
    – ‘Health Care Provider Education’
       Learning Modules’
    – ‘Learning Modules
    – ‘APSS Education Learning Modules (BLMS)’
    – ‘Log in’
    – A username and password can be obtained by contacting
      Diane MacPherson, APSS Administrative Assistant,
                   CME Attendance
• Please email/call Andrea Cole-Haskayne with attendance for your
   (403) 944-8647 office

• Please email us your feedback/suggestions for future Acute Stroke
  Case Rounds:
Upcoming Acute Stroke Case Rounds:
(All will be on a Friday from 12:00 to 13:00 MT)

                January 15, 2010
                          5 2010
                February 5,2010
                  March 5,2010
                  April 9,2010
                  May 7,2010
                   Jun 4,2010
                      Case #1
•   78 yr old LSN 1700 hrs
•   Daughter daily call 2300 – no response
•   Arrived at door to find pt mute, weak on R side
•   EMS called
•   Arrived FMC 0045 hrs
•   Initial exam 0055 hrs:
    – Mute mild R weakness
    – BP 180/90
    – NIHSS = 9
Case #1 Initial CT
Case #1 CT Angiogram
Partial MCA Occlusion?
 Case #1 CT Angiogram
Normal L Atrial Appendage

     Normal Carotids
                    Case #1
•        caudate lentiform,
    EIC caudate, lentiform good cortical ribbon
•   MCA thrombus; partial occlusion?
•    i      f
    Time of onset??
•   8 hrs since LSN
                  Case # 1
• Rx IV tPA 0145 hrs
• Angio team called in for anticipated IA Rx
• A i 0230 h hrs
M1 Occlusion Cleared;
       i l     b li
 Few Distal Emboli
Case #1 Follow up CT
                  Case #1
• Rapidly resolving R sided weakness
• Moderate speech deficit with marked
  improvement over next 4 days in hospital
• Discharged to outpatient rehab/speech therapy

             Scan vs Clock
                    Waker Upper
        Case # 2 – “Waker Upper”
•   70 yr old R handed male with HTN and CAD
•   LSN 2300 hrs previous night
•        d ll      d        b d b if 084 h
    Found collapsed next to bed by wife 0845 hrs
•   Arrived to hospital 0935 hrs
•   Exam
    – Mute / aphasic
    – R hemiplegia + R sensory loss
    – NIHSS = 18
Case # 2 Initial CT
    Case # 2 CTA:
-Distal MCA Occlusion
   -LICA Occlusion
    G d Collaterals
  -Good C ll     l
                 Case # 2

      Good Scan / Big Deficit
• No tPA
• Taken to Angio for mechanical thrombectomy
Case #2 Angio
Case #2 Angio
Solitaire Stent
LICA Plasty / LICA injection
                    Case # 2
• Microcatheter past tight / occluded LICA
• Solitaire stent deployed into thrombus with
  immediate restoration of partial flow
  Stent retracted with partial retrieval / fracture
• S             d ih       i l     i l f
  of thrombus
• TIMI 3 flow with few small distal emboli
Case # 2 follow up CT 24 hrs
                    Case #2
•   ASA only for 24 hrs
•   Rapid improvement to NIHSS 4 next am
•    l i dd d d              l        h   b
    Plavix added day 2 post plasty / thrombectomy
•   NIHSS = 2 in 48 hrs
•   Waiting for CEA or stent
Waker Uppers / Scan vs Clock?
       P    b

Jones et al, J Neurosurg 54:773-82, 1981
 Tissue Viability vs. Time
 Major Determinants of outcome:
      Severity of Ischemia
      Duration of Viability

Effective Treatment Window

 The issue is the Tissue
      Dysfunction ≠ Destruction
•   Limitations rigid time windows
•   Need to individualize management
•       +/              t   f tissue viability
    CT +/- MR surrogates of ti         i bilit
•   Clinical assessment of tissue at risk
•   Clinical – Radiological Mismatch

         g e c            Scan
       Big Deficit + Good Sc
                      Case # 3
•   84 yr old high functioning R handed male
•   1730 hrs unable to get up off couch
•     if           id d     k       d   f i
    Wife notes L sided weakness and confusion
•   To FMC where exam at 1750 hrs:
    – Mild L sensory deficit
    – Dysarthria
    – NIHSS = 2
R M2 Dot Sign + EIC Insula
Case # 3 R Dominant M2 Occlusion
                   Case # 3
• Minor deficit that remains stable over the next
  two hours
          conservatively fluids
• Treated conservatively, fluids, head down
• No tPA
• Over next 24 hrs deteriorates to NIHSS of 6
  with mild L sided weakness and mild neglect
               MR next day;
           - Persistent Occlusion R M2
- Reduced Vascularity and MTTE R Fronto-Parietal
Case # 3 DWI
                 Case # 3
• Gradual improvement over the next 4 days
• NIHSS = 3
    Rx of Minor Deficits with Large Vessel

•   % that progress to disabling deficits?
•   Rx thrombolysis / mechanical?
•   Rx induced Hypertension / volume expansion?
•   Conservative management?
    C         i                ?
•   Appropriate group for penumbral imaging +
    multicenter RCT
                 Case # 4
• 85 yr old R handed high functioning male
• 3 wks PTA episode of transient L visual loss
  for 5 mins
• Described as “dark cloud”
• 2nd episode 4d PTA no hemispheric symptoms
• U/S occluded RICA, > 70% LICA
• Referred for assessment
         High Grade LICA
          O l d d RICA
Poor Collaterals to L Ant Circulation
Thomas Willis 1621-1675
Circle of Willis

                   Pcomhypoplastic or
                   absent 25-30%

                   A1 absent 10%

                   Acom absent 5%

                   Complete Circle
                   present in 30-40%
Isolated R Carotid circulation + CEA
Stenting Symptomatic LICA Stenosis
           Case # 4 Key Points
• Imaging of Circle of Willis should be part of
  pre-op evaluation in candidates for CEA
• Isolated carotid circulation is at high risk of
  ischemic damage during CEA even with
  average clamp times
• Isolated carotid requires either shunt during
          S           i i i i k fi h i
  CEA or Stent to minimize risk of ischemic