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ABC Stroke Treatment 062408

ABC Stroke Treatment 062408

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Published by Benjamin Prabhu

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Published by: Benjamin Prabhu on Oct 13, 2010
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  • Stroke
  • Immediate Diagnostic Studies
  • Stroke units
  • General supportive care
  • Blood Pressure Management
  • Anti hypertensive Medications
  • Body temperature
  • Fluid and Electrolyte
  • Hyperglycemia in Stroke
  • rTPA RULE of ´3µ
  • Stroke: The Challenge
  • Aspirin in Acute Stroke
  • Diabetes control
  • Statin therapy
  • Revascularization procedure
  • Intracerebral hemorrhage
  • ICH score
  • Management Goals
  • ICH related to Fibrinolysis
  • Surgical Treatment of ICH
  • Treatment of oICP
  • Hyperosmolar therapy
  • Brain supportive therapy
  • IV drugs used in ICH






Immediate Diagnostic Studies
All patients € Cranial CT scan € ECG € Blood glucose € Serum electrolytes € Renal function tests € CBC + platelet € PT + INR € aPTT Selected patients € Hepatic function tests € Toxicology screen € Blood alcohol determination € Pregnancy tests € ABG € CXR € Lumbar puncture € EEG


Cerebral infarction 4 .

Cerebral infarction € Acute phase y Admission to stroke unit y ABCs y Maintenance of normal physiologic parameters € Measures to restore circulation y y y y y 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 .

esp elderly y Lifestyle modification: Discontinue smoking Low cholesterol.Cerebral infarction Physical Therapy & Rehabilitation € Measures to prevent stroke € y Aspirin vs Anticoagulation y Hypotensive agents y Maintain systemic BP. oxygenation. intracranial blood flow during surgical procedures. low fat diets y Cholesterol lowering agents 6 .

Langhorne. BMJ 1994 7 . . Dennis and P. who are in need of rehabilitation services and skilled professional care (by personnel with special interest on stroke) that such a unit can provide.Stroke Units € This is geographic area within the hospital designated for stroke and stroke-like patients. M.

Team Nurses Medical Doctors Physiotherapists Occupational Therapists Speech Pathologists Nutritionists Social Workers Home Care Case Managers 8 .The Stroke Unit .

Jarman B.93). Stroke Unit Trialists¶ Collaboration 2002. BMJ 2004. A large number of RCTs have compared care on general medical or other wards with that in an organized SU & a meta-analysis has shown a convincing benefit. Bottle A.Stroke Units € Organized stroke care has been shown to reduce mortality by about 30% and improve outcome.89 (95 % CI 0.85²0. Cochrane Database Syst Rev 1:CD000197 € € Patients treated in a hospital with an acute SU had significantly lower odds ratio for death of 0.328:369 9 . Aylin P..

Stroke units € reduced deaths due to secondary complications y careful and systematic assessment of dysphagia y reduction in the use of urinary catheters y more aggressive management of infections y Programs of early activation and mobilization € reduce disability (dependency) after stroke y more coordinated and focused program of rehabilitation involving patients and caregivers y more intensive physiotherapy and occupational therapy input y patient motivation and morale 10 .

General supportive care Airway and ventilatory support € Blood pressure management € Cardiac monitoring € Control of fever € Blood sugar regulation € Fluid and electrolytes € 11 .

brainstem involvement.Respiratory monitoring Adequate oxygenation is important to preserve the penumbra € Most common causes of hypoxemia in stroke € y y y y Previous pulmonary disease Airway obstruction Acute aspiration Hypoventilation due to large hemispheric infarct or bleed . heart failure and pulmonary embolism 12 . seizure.

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 .

Esmolol Treat if with any of the ff: SBP > 220 or DBP > 120 or MAP > 130mm Hg Stroke Society of the Phil. Nicardipine. 2003  15 .g. 1999 AHA Scientific Statement. . 2002 WHO-ISH .Guidelines in BP Management in Acute Ischemic Stroke (first 5 days)    Avoid precipitous drop in BP. Nifedipine Use easily titratable IV anti-HPN medications e.g. not > 20% of baseline MAP Do not use rapid acting sublingual agents e.

Anti hypertensive Medications € Indicated for: y aortic dissection y acute myocardial infarction y heart failure y acute renal failure y hypertensive encephalopathy y 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 € y Abnormal baseline ECG y previous known cardiomyopathies y History of arrythmias y Heart failure y Unstable blood pressure y infarct in the insular cortex 18 .

temperature is part of the acute phase response 19 .Body temperature € Body temperature increase in 50% of patients Why treat? y Fever increase infarct size y High body temperature increase stroke progression and bad outcome € Why withhold treatment? y Inc.

5 C € 85% of fever in stroke are due to infectious disease € Search for possible infection is necessary to start appropriate treatment € 20 .Body Temperature Treatment is advisable if temperature >37.

45%) are contraindicated : risk of brain edema y Glucose solutions are contraindicated: detrimental effect of hyperglycemia y 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 .Fluid and Electrolyte € All acute stroke patients need hydration y D5 containing and hypotonic solutions (NaCl 0.

Hyperglycemia in Stroke € Accounts for 25 to 50% of patients € Associated with worse outcome y increases cerebral edema y hemorrhagic transformation of ischemic strokes y increases mortality with BS > 130mg% € EUSI and AHA Recommendations: .Treat hypoglycemia .Give Insulin for Blood Glucose > 300 mg% 22 .

1 33. Neurol. Sci.3 18. 2005.32:440-49 23 .6 Bussiere M.Effective Acute Stroke Treatment based on Evidence Treatment Aspirin w/in 48 hrs.1 19. Stroke Unit rTPA overall 0-3 hours 3-6 hours NNT 81. Wiebe S. J. et al Can.3 9.

Neurology 1996.27:1711-1718.IV tPA .47:835-839 24 .Acute Ischemic Stroke Inclusion Criteria* Age 18 through 79 years € Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit. Stroke 1996. € Reliably timed onset of symptoms of ischemic stroke within 3 hours of the time to initiation of treatment with intravenous tPA € *Adapted from guidelines published by the American Heart Association and American Academy of Neurology.

pregnancy. aneurysm. trauma. bleeding diathesis. or other serious or terminal illness € Active or new seizures € Any other condition that the physician feels would pose a significant hazard to the patient if tPA therapy were initiated. € Higher Hemorrhage Risk € Age > 80 (unknown) € Signs of a very severe stroke € Early ischemia CT changes 25 . AVM. or platelets < 100. MI. cancer.000 On anticoagulant therapy IV medications needed to lower BP below 185/110 Hx suggestive of subarachnoid hemorrhage Presumed septic embolus Recent stroke. Hct < 25.IV tPA . surgery Hx of any recent hemorrhage.Acute Ischemic Stroke Exclusion Criteria € € € € € € € € Symptoms rapidly improving or very minor Hemorrhage on CT scan glucose < 50 or > 400.

NINDS tPA Stroke Trial 30 30 p < . 1995 26 .05 20 Hemorrhage 20 31 10 20 10 9 8 20 0 0 tPA Placebo tPA 1 Placebo NIHSS Excellent Recovery (%) Total Death Rate (%) NEJM.

rTPA RULE of ´3µ 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 Only 1-3% of all stroke victims receive treatment with tPA in the US € 25% of Acute MI patients receive treatment (lytics or PTCA) in the US € Mean time to presentation € y AMI: 3hrs y Acute Stroke: 4-10hrs 28 .

Recent studies have suggested it is much higher than this with a risk of: first 7 days 1 month1 3 months 8±12% 1±15% 17±18.5% Johnston SC et al. Stroke 2003.328:326±328 29 € . et al.Early secondary prevention € Risk of recurrent stroke following stroke or TIA was thought to be about 10%. Coull AJ. Lovett JK.34:e138-e140. BMJ 2004. JAMA 2000.284:2901-2906. et al.

No recommendation for general use of heparin. or high grade arterial stenosis (Level IV) 3. arterial dissection. LMWH or heparinoids after ischemic stroke (Level I) 2.EUSI and AHA:Heparin in Stroke 1. DVT-prophylaxis 30 . Full dose heparin for selected indications such as AF. other cardiac sources with high risk of re-embolism.

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 .

324:71-86 . Mohr JP. . BMJ 2002.345:1444±1451. et al. Antithrombotic Trialists¶Collaboration. Aspirin is as effective or more effective than anticoagulation in non-cardioembolic stroke prevention. NEJM 2001.Antiplatelet & Anticoagulant therapy € € Aspirin reduces the risk of recurrent ischemic stroke by b 18 %. 32 . € Warfarin is not recommended for non-cardioembolic strokes.

et al.83% annual risk of the same events. Lancet 1996. 33 . J Neurol Sci 1996. CAPRIE Steering Committee.348:1329±1339 € ESPS2 study y dipyridamole + ASA may be more effective than aspirin alone y criticized for the low dose of aspirin used Diener HC.32% annual risk of ischemic stroke. .Antiplatelet & Anticoagulant therapy € CAPRIE trial y Patients treated with clopidogrel had a 5.143:1-13. myocardial infarction or vascular death whereas patients treated with aspirin had a 5.

Antiplatelet & Anticoagulant therapy Warfarin is the treatment of choice in patients with AF € b 60% reduction of stroke in the primary prevention of stroke in AF € Hart RG. All patients with AF should be considered for warfarin therapy unless there are contraindications. et al.342:1255± 1262 34 . Lancet 1993.131:492-501 . Trial) Study Group. € A similar benefit is found in the secondary prevention of stroke in patients with AF. Ann Intern Med 1999. € EAFT (European Atrial Fibrillation .

Antihypertensive treatment Any agent is better than no agent!! € If BP > 20/10 above goal. renal impairment. 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. etc) € 35 .

2001.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.285:2486-97 36 .

Statin therapy € Statin therapy q risk of vascular events (including myocardial infarction. and stroke) by b 25 % Amarenco P. . cardiovascular death. 37 . Cerebrovasc Dis 2004.7(Suppl 1):81±88. et al.

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 1030% 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


ICH score
Component GCS 3-4 5-12 13-15 IC vol >30 <30 IV Yes No Age >80 <80 Infratentorial origin Yes No Points 2 1 0 1 0 1 0 1 0 1 0
30D Mort lity % 100 90 0 70 60 50 40 30 20 10 0 0 97 100


26 13 0 1 2 3 4 5

IC Score

Hemphill JC, et al. Stroke 2001; 32: 891-7

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


Stroke Steiner T. et al.3-0. 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. leukoaraiosis 2005. history of hypertension. Stroke 2006.ICH related to Anticoagulation € € € € Occurs with a frequency of 0. intensity of anticoagulation. 37: 256-62 42 .6% per year in patients on chronic warfarin tx OAT use increases risk for ICH. et al. 36: 1588-93 Hart RG. associated conditions such as CAA.

5.4.5) y PCC 10-30 (-50) U/kg Measure INR after 15 min If INR is still >1. 22: 294-316 43 . an INR of 3.0 to 2.1.4 would require 40ml/kg y Vitamine K 1-2 x 5-10mg PO or IV Cerebrovasc Dis 2006.EUSI Recommendations € Normalization of INR (<1.2 to 1. or an INR of 2.4 to 1.8 To reduce an INR of 4.2 to 2. consider redosing w/ reduced dose y FFP 10ml/kg will reduce an INR of 4.

22: 294-316 44 .0-1.EUSI Recommendations € Normalization of PTT after heparin y Protamine sulphate 1.5ml protamine sulfate inactivates 1000 IU heparin of the total amount applied within the last 4 hrs € Prevention of DVT y Compression stockings y Low dose heparin/heparinoids Cerebrovasc Dis 2006.

ICH related to Fibrinolysis € Symptomatic ICH y 3-9% of patients treated w/ IV tPA y 6% of patients treated w/ IV + IA tPA y 10. 38: 2001-23 45 .9% w/ IA prourokinase y 30D mortality >60% No reliable data re: treatment € Current recommended therapy: € y Platelet infusion (6-8U) and cryoprecipate Broderick J et al. Stroke 2007.

decreased cerebral perfusion) € General supportive management € 46 .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.

Surgical Treatment of ICH Craniotomy € Minimally invasive surgery € y Endoscopic aspiration of hematoma y Stereotactic placement of flexible catheter followed by administration of thrombolytic agents 47 .

et al. Lancet 2005. 365: 387-397 48 .STICH Early surgery vs initial conservative therapy € N = 1033 € Inclusion criteria € y CT evidence of spontaneous supratentorial ICH w/in 72 hours y Neurosurgeon uncertain of benefits of either treatment y Min hematoma diameter 2 cm & GCS > 5 Mendelow AD.

STICH Mendelow AD. 365: 387-397 49 . Lancet 2005. et al.

365: 387-397 50 . et al.Mendelow AD. Lancet 2005.

Surgical Treatment of ICH € Cerebellar bleed y No prospective RCT y 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 Broderick J et al. Stroke 2007. 38: 2001-23 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 oICP Head of bed elevation € CSF drainage € Analgesia and sedation € Neuromuscular blockade € Osmotic therapy € Hyperventilation € Barbiturate coma € 53 .

and steroids have been disappointing € Therapy should be directed at patients with deterioration secondary to mass effect or hydrocephalus € 54 . glycerol.Hyperosmolar therapy Studies on mannitol.

decreased cerebral perfusion) € General supportive management € 55 .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.

Brain supportive therapy Blood pressure management € Ventilatory support € Glucose control € Fever control € Management of seizures € Nutritional supplement € Prophylaxis for DVT € 56 .

38: 2001-23 57 .Guidelines for BP management € SBP >200 or MAP >150 y Aggressive BP lowering w/ IV anti HPN. Stroke 2007. monitor patient q15 min Broderick J et al. w/ BP monitoring q5 min € SBP >180 or MAP >130 y w/ o ICP ± monitor ICP and reduce BP w/ intermittent or IV meds to keep CPP >60-80 y w/ normal ICP ± reduce BP to MAP=110 or BP 160/90 using intermittent or IV meds.

IV drugs used in ICH € € € € € Labetalol Esmolol Urapidil Nitroprusside Nicardipine € € € € Enalaprilat Hydralazine Fenoldam Furosemide 58 .

Epilepsia 2002. 60: 1441-6 59 . 43 (10): 1175-80 Vespa et al.Brain supportive therapy € Antiepileptic drugs y Seizures after ICH occurred at onset in 4% of patients 30 day risk of seizure post ICH . Neurology 2003.8% y cEEG abnormal in 28% in 1st 72 hrs Associated w/ higher NIHSS scores and midline shift trend towards poor outcome y Lobar hematomas associated with early seizures y No RCT re: prophylactic AED use Passero et al.

60 .

MD FPNA Neurologist ± Psychiatrist 61 .Maria Leticia Araullo.

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