Professional Documents
Culture Documents
OF
STROKE MANAGEMENT
1
Stroke
Hemorrhage
Infarction
2
Immediate Diagnostic Studies
All patients Selected patients
Cranial CT scan Hepatic function tests
ECG Toxicology screen
Blood glucose Blood alcohol
Serum electrolytes determination
Renal function tests Pregnancy tests
CBC + platelet ABG
PT + INR CXR
aPTT Lumbar puncture
EEG
3
Cerebral infarction
4
Cerebral infarction
Acute phase
Admission to stroke unit
ABCs
Maintenance of normal physiologic parameters
Measures to restore circulation
Thrombolysis – within 3 hours of stroke onset
Permissive hypertension
Treatment of Cerebral edema and raised ICP
Antiplatelet and anticoagulant agents
Surgery for symptomatic carotid stenosis
5
Cerebral infarction
Physical Therapy & Rehabilitation
Measures to prevent stroke
Aspirin vs Anticoagulation
Hypotensive agents
Maintain systemic BP, oxygenation,
intracranial blood flow during surgical
procedures, esp elderly
Lifestyle modification:
○ Discontinue smoking
○ Low cholesterol, low fat diets
Cholesterol lowering agents
6
Stroke Units
7
The Stroke Unit - Team
9
Stroke units
reduced deaths due to secondary complications
careful and systematic assessment of dysphagia
reduction in the use of urinary catheters
more aggressive management of infections
Programs of early activation and mobilization
10
General supportive care
Airway and ventilatory support
Blood pressure management
Cardiac monitoring
Control of fever
Blood sugar regulation
Fluid and electrolytes
11
Respiratory monitoring
Adequate oxygenation is important to
preserve the penumbra
Most common causes of hypoxemia in
stroke
Previous pulmonary disease
Airway obstruction
Acute aspiration
Hypoventilation due to large hemispheric
infarct or bleed , brainstem involvement,
seizure, heart failure and pulmonary
embolism
12
Respiratory monitoring
no data favor O2 administration to all stroke
patients
O2 administration is required in case of
hypoxemia ( O2 sat <92%)
Consider intubation in case of
○ Severe pre existing and /or acute pulmonary disease
○ Acute aspiration
○ Impaired level of consciousness with risk of aspiration
○ Loss of caudal brainstem reflexes
13
Blood Pressure Management
Why treat?
Worsens cerebral blood flow
Promotes hemorrhagic transformation
and ICH after t-PA
Why withhold treatment?
Precipitous decline may worsen
ischemia
14
Guidelines in BP Management in
Acute Ischemic Stroke (first 5 days)
Avoid precipitous drop in BP; not > 20% of baseline MAP
Do not use rapid acting sublingual agents e.g. Nifedipine
Use easily titratable IV anti-HPN medications e.g.
Nicardipine, Esmolol
Treat if with any of the ff: SBP > 220 or DBP > 120 or MAP
> 130mm Hg
15
Anti hypertensive Medications
Indicated for:
aortic dissection
acute myocardial infarction
heart failure
acute renal failure
hypertensive encephalopathy
thrombolytic therapy
16
Cardiac monitoring
Cardiac enzymes may be elevated after
stroke
15% to 40% of stroke patients may
experience
arrhythmias (AF)
congestive heart failure
AMI
sudden death
17
Cardiac monitoring
At hospital entry: ECG and clinical chemistry to
check for concomitant MI
Continuous cardiac monitoring in the first 48 hours
of stroke onset
Abnormal baseline ECG
previous known cardiomyopathies
History of arrythmias
Heart failure
Unstable blood pressure
infarct in the insular cortex
18
Body temperature
Body temperature increase in 50% of
patients
Why treat?
Fever increase infarct size
High body temperature increase stroke
progression and bad outcome
Why withhold treatment?
Inc. temperature is part of the acute phase
response
19
Body Temperature
20
Fluid and Electrolyte
All acute stroke patients need hydration
D5 containing and hypotonic solutions (NaCl 0.45%)
are contraindicated : risk of brain edema
Glucose solutions are contraindicated: detrimental
effect of hyperglycemia
PNSS at 80cc/hour
Hypokalemia may appear during insulin infusion
Hyponatremia may be consequent to
○ Inadequate antidiuretic hormone secretion syndrome
○ Cerebral salt wasting syndrome
21
Hyperglycemia in Stroke
Accounts for 25 to 50% of patients
Associated with worse outcome
increases cerebral edema
hemorrhagic transformation of ischemic strokes
increases mortality with BS > 130mg%
EUSI and AHA Recommendations:
- Treat hypoglycemia
- Give Insulin for Blood Glucose > 300 mg
%
22
Effective Acute Stroke Treatment
based on Evidence
Treatment NNT
Aspirin w/in 48 hrs. 81.1
Stroke Unit 19.3
rTPA
overall 18.3
0-3 hours 9.1
3-6 hours 33.6
Bussiere M, Wiebe S, et al
Can. J. Neurol. Sci. 2005;32:440-49
23
IV tPA - Acute Ischemic Stroke Inclusion Criteria*
24
IV tPA - Acute Ischemic Stroke
Exclusion Criteria
Symptoms rapidly improving Hx of any recent hemorrhage,
or very minor AVM, aneurysm, cancer,
Hemorrhage on CT scan bleeding diathesis, or other
glucose < 50 or > 400, Hct < serious or terminal illness
25, or platelets < 100,000 Active or new seizures
On anticoagulant therapy
Any other condition that the
physician feels would pose a
IV medications needed to significant hazard to the
lower BP below 185/110 patient if tPA therapy were
Hx suggestive of initiated.
subarachnoid hemorrhage
Presumed septic embolus Higher Hemorrhage Risk
Recent stroke, MI, trauma, Age > 80 (unknown)
pregnancy, surgery Signs of a very severe stroke
Early ischemia CT changes
25
NINDS tPA Stroke Trial
30 30
Hemorrhage
p < .05
20 20
31
10
9 20
20 10
0 8
0
1
tPA Placebo tPA Placebo
NIHSS Excellent Total Death
Recovery (%) Rate (%)
NEJM, 1995
26
rTPA RULE of “3”
Should be given during the FIRST 3
HOURS
30% will improve (complete recovery or
mild deficit)
Improvement seen in 3 months
27
Stroke: The Challenge
28
Early secondary prevention
Risk of recurrent stroke following stroke or TIA was
thought to be about 10%.
30
Aspirin in Acute Stroke
Recommendation: 160 to 325 mg/day within 24 to 48
hours
Avoid in potential candidates for thrombolytic therapy
Delay for at least 24 hours after the administration of
rtPA
Do not administer prehospital (i.e. pre-CT)
31
Antiplatelet & Anticoagulant therapy
Aspirin reduces the risk of recurrent ischemic stroke by 18 %.
Aspirin is as effective or more effective than anticoagulation in non-
cardioembolic stroke prevention.
32
Antiplatelet & Anticoagulant therapy
CAPRIE trial
Patients treated with clopidogrel had a 5.32% annual risk of
ischemic stroke, myocardial infarction or vascular death
whereas patients treated with aspirin had a 5.83% annual risk
of the same events.
CAPRIE Steering Committee. .
Lancet 1996;348:1329–1339
ESPS2 study
dipyridamole + ASA may be more effective than aspirin alone
criticized for the low dose of aspirin used
33
Antiplatelet & Anticoagulant therapy
34
Antihypertensive treatment
Any agent is better than no agent!!
If BP > 20/10 above goal, initiate Rx with 2
medications!!
The choice of specific drugs and targets should be
individualized on the basis of reviewed data and
consideration of specific patient characteristic (ex, DM,
renal impairment, etc)
35
Diabetes control
More rigorous control of HTN and dyslipidemia should be
considered in patients with DM (BP targets of 130/80 mm
Hg)
ACEIs and ARBs are recommended as first-choice
medications for patients with DM
Glucose control is recommended to near normoglycemic
levels to reduce microvascular complications and
possibly macrovascular complications
Hemoglobin A1c goal <7%
JAMA. 2001;285:2486-97
36
Statin therapy
Statin therapy risk of vascular events (including
myocardial infarction, cardiovascular death, and stroke) by
25 %
Amarenco P, et al. Cerebrovasc Dis 2004;7(Suppl
1):81–88.
37
Revascularization procedure
Endarterectomy for patients with
symptomatic carotid artery stenosis
>70% effective in reducing incidence of
ipsilateral hemispheral stroke
Carotid angioplasty and stenting
38
Intracerebral hemorrhage
Accounts for 10-
30% of all stroke
hospital admissions
30 day Mortality
~35-52%; half in the
first 2 days
Only 20% of ICH
patients functionally
independent at 6
months
Broderick J et al. Stroke 2007; 38: 2001-23
39
ICH score
Component Points
GCS
3-4 2
97 100
5-12 1 100
13-15 0 90
80 72
ICH vol
41
ICH related to Anticoagulation
Occurs with a frequency of 0.3-0.6% per year
in patients on chronic warfarin tx
OAT use increases risk for ICH, worsens the
severity of ICH and significantly increases
the likelihood of death when ICH occurs
Hematoma expansion maybe be more
common and occur over a longer time frame
Risk factors: age, history of hypertension,
intensity of anticoagulation, associated
conditions such as CAA, leukoaraiosis
Hart RG, et al. Stroke 2005; 36: 1588-93
Steiner T, et al. Stroke 2006; 37: 256-62
42
EUSI Recommendations
Normalization of INR (<1.5)
PCC
○ 10-30 (-50) U/kg
○ Measure INR after 15 min
○ If INR is still >1.5, consider redosing w/ reduced dose
FFP
○ 10ml/kg will reduce an INR of 4.2 to 2.4, an INR of 3.0
to 2.1, or an INR of 2.4 to 1.8
○ To reduce an INR of 4.2 to 1.4 would require 40ml/kg
Vitamine K
○ 1-2 x 5-10mg PO or IV
Prevention of DVT
Compression stockings
Low dose heparin/heparinoids
45
Management Goals
Stop or slow initial bleeding during first
hours after onset
Remove blood from parenchyma or
ventricles to eliminate mechanical and
chemical factors causing brain injury
Management of complications of blood
in the brain (increased ICP, decreased
cerebral perfusion)
General supportive management
46
Surgical Treatment of ICH
Craniotomy
Minimally invasive surgery
Endoscopic aspiration of hematoma
Stereotactic placement of flexible catheter
followed by administration of thrombolytic
agents
47
STICH
Early surgery vs initial conservative
therapy
N = 1033
Inclusion criteria
CT evidence of spontaneous supratentorial
ICH w/in 72 hours
Neurosurgeon uncertain of benefits of either
treatment
Min hematoma diameter 2 cm & GCS > 5
48
STICH
49
Mendelow AD, et al. Lancet 2005; 365: 387-397
50
Surgical Treatment of ICH
Cerebellar bleed
No prospective RCT
Patients w/ cerebellar hemorrhage >3cm
who are deteriorating neurologically or who
have brain stem compression and/or
hydrocephalus from ventricular obstruction
should have surgical removal of the
hemorrhage as soon as possible
51
Management Goals
Stop or slow initial bleeding during first
hours after onset
Remove blood from parenchyma or
ventricles to eliminate mechanical and
chemical factors causing brain injury
Management of complications of blood
in the brain (increased ICP, decreased
cerebral perfusion)
General supportive management
52
Treatment of ICP
Head of bed elevation
CSF drainage
Analgesia and sedation
Neuromuscular blockade
Osmotic therapy
Hyperventilation
Barbiturate coma
53
Hyperosmolar therapy
Studies on mannitol, glycerol, and
steroids have been disappointing
Therapy should be directed at patients
with deterioration secondary to mass
effect or hydrocephalus
54
Management Goals
Stop or slow initial bleeding during first
hours after onset
Remove blood from parenchyma or
ventricles to eliminate mechanical and
chemical factors causing brain injury
Management of complications of blood
in the brain (increased ICP, decreased
cerebral perfusion)
General supportive management
55
Brain supportive therapy
Blood pressure management
Ventilatory support
Glucose control
Fever control
Management of seizures
Nutritional supplement
Prophylaxis for DVT
56
Guidelines for BP management
SBP >200 or MAP >150
Aggressive BP lowering w/ IV anti HPN, w/
BP monitoring q5 min
SBP >180 or MAP >130
w/ ICP – monitor ICP and reduce BP w/
intermittent or IV meds to keep CPP >60-80
w/ normal ICP – reduce BP to MAP=110 or
BP 160/90 using intermittent or IV meds;
monitor patient q15 min
57
IV drugs used in ICH
Labetalol Enalaprilat
Esmolol Hydralazine
Urapidil Fenoldam
Nitroprusside Furosemide
Nicardipine
58
Brain supportive therapy
Antiepileptic drugs
Seizures after ICH
○ occurred at onset in 4% of patients
○ 30 day risk of seizure post ICH - 8%
cEEG abnormal in 28% in 1st 72 hrs
○ Associated w/ higher NIHSS scores and midline shift
○ trend towards poor outcome
Lobar hematomas associated with early seizures
No RCT re: prophylactic AED use
61