From the Guidelines
A PICA stroke is a medical emergency that requires immediate attention, as it can cause significant morbidity and mortality due to its location near vital brainstem structures controlling breathing and heart function. This type of stroke typically presents with vertigo, nausea, vomiting, difficulty swallowing, hoarseness, and ipsilateral limb ataxia, as well as loss of pain and temperature sensation on the ipsilateral face and contralateral body, along with Horner's syndrome (ptosis, miosis, and anhidrosis) 1.
Key Considerations
- The initial CT can be normal in as many as 25% of patients, making clinical diagnosis crucial 1.
- Peak swelling occurs several days after the onset of ischemia, and careful attention to speech, gait, coordination, and eye movements is required to make the diagnosis 1.
- Clinical signs that signify deterioration in swollen cerebellar infarction include a decrease in level of consciousness, early loss of corneal reflexes, and the development of miosis 1.
Treatment and Management
- Treatment begins with immediate medical attention and often includes intravenous thrombolysis with alteplase (tPA) if within 4.5 hours of symptom onset at 0.9 mg/kg (maximum 90 mg), with 10% given as bolus and remainder over 60 minutes.
- Antiplatelet therapy typically follows with aspirin 325 mg initially, then 81 mg daily, often combined with clopidogrel 75 mg daily for 21 days.
- Blood pressure management, maintaining systolic below 180 mmHg, is crucial.
- Supportive care includes swallowing evaluation, respiratory monitoring, and early rehabilitation.
- Long-term management focuses on secondary prevention through antiplatelet therapy, statins, blood pressure control, and lifestyle modifications.
Important Considerations for Quality of Life
- PICA strokes can be particularly dangerous due to their location near vital brainstem structures controlling breathing and heart function, potentially causing life-threatening complications like respiratory failure.
- Early recognition and treatment are essential to improve outcomes and reduce morbidity and mortality.
From the Research
Overview of PICA Stroke
- PICA stroke is not explicitly defined in the provided studies, however, we can discuss the general overview of stroke and its related aspects.
- Stroke is a clinically defined syndrome of acute, focal neurological deficit attributed to vascular injury (infarction, haemorrhage) of the central nervous system 2.
- It is the second leading cause of death and disability worldwide, and its causes can be attributed to a wide range of risk factors, disease processes, and mechanisms 2.
Types of Stroke
- Most (85%) strokes are ischaemic, predominantly caused by small vessel arteriolosclerosis, cardioembolism, and large artery athero-thromboembolism 2.
- Approximately 15% of strokes worldwide are the result of intracerebral haemorrhage, which can be deep (basal ganglia, brainstem), cerebellar, or lobar 2.
Prehospital Care and Emergency Response
- Prehospital care of the acute stroke patient is crucial, and emergency medical services (EMS) play a pivotal role in the identification and treatment of acute cerebrovascular brain injury 3.
- Rapid detection and treatment of stroke are essential, and trained personnel in the preclinical setting should recognize the relevant warning symptoms and collect the necessary information to quickly refer the patient to the appropriate additional care structure 4.
- The use of mobile stroke units and teleradiological networking can improve preclinical stroke care and reduce delays in access to intravenous thrombolytic therapy and mechanical thrombectomy 4.
Importance of Timely Admission
- The time to admission of patients with suspected stroke to the emergency department is crucial, and factors such as contacting the emergency medical call centre and immediate transfer to an appropriate hospital establishment without waiting for prior medical intervention can significantly impact timely treatment 5.
- Among patients with suspected stroke, those admitted within 3 hours of symptom onset had better outcomes, highlighting the importance of timely admission 5.