1

Stroke

Infarction

Hemorrhage

2

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

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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 .

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

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

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

.328:369 9 . Stroke Unit Trialists¶ Collaboration 2002. Cochrane Database Syst Rev 1:CD000197 € € Patients treated in a hospital with an acute SU had significantly lower odds ratio for death of 0.Stroke Units € Organized stroke care has been shown to reduce mortality by about 30% and improve outcome. 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.85²0. Jarman B. BMJ 2004. Aylin P.89 (95 % CI 0.93). Bottle A.

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. heart failure and pulmonary embolism 12 . seizure.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 .

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 .

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

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 .

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. temperature is part of the acute phase response 19 .

Body Temperature Treatment is advisable if temperature >37.5 C € 85% of fever in stroke are due to infectious disease € Search for possible infection is necessary to start appropriate treatment € 20 .

Fluid and Electrolyte € All acute stroke patients need hydration y D5 containing and hypotonic solutions (NaCl 0.45%) 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 .

Treat hypoglycemia .Give Insulin for Blood Glucose > 300 mg% 22 .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: .

Wiebe S. J. Stroke Unit rTPA overall 0-3 hours 3-6 hours NNT 81.Effective Acute Stroke Treatment based on Evidence Treatment Aspirin w/in 48 hrs.1 33. 2005. Neurol.32:440-49 23 . Sci.3 18.6 Bussiere M. et al Can.1 19.3 9.

€ 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.47:835-839 24 . Stroke 1996.27:1711-1718.Acute Ischemic Stroke Inclusion Criteria* Age 18 through 79 years € Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit. Neurology 1996.IV tPA .

IV tPA . surgery Hx of any recent hemorrhage. bleeding diathesis. or platelets < 100.Acute Ischemic Stroke Exclusion Criteria € € € € € € € € Symptoms rapidly improving or very minor Hemorrhage on CT scan glucose < 50 or > 400. € Higher Hemorrhage Risk € Age > 80 (unknown) € Signs of a very severe stroke € Early ischemia CT changes 25 . MI. Hct < 25.000 On anticoagulant therapy IV medications needed to lower BP below 185/110 Hx suggestive of subarachnoid hemorrhage Presumed septic embolus Recent stroke. pregnancy. 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. aneurysm. cancer. trauma. AVM.

NINDS tPA Stroke Trial 30 30 p < .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. 1995 26 .

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 .

34:e138-e140.328:326±328 29 € .5% Johnston SC et al. et al.Early secondary prevention € Risk of recurrent stroke following stroke or TIA was thought to be about 10%. JAMA 2000. 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±18.284:2901-2906. Stroke 2003. BMJ 2004. Coull AJ. et al. Lovett JK.

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

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. pre-CT) € 31 .e.

BMJ 2002. .324:71-86 . Mohr JP.345:1444±1451. NEJM 2001. 32 . Aspirin is as effective or more effective than anticoagulation in non-cardioembolic stroke prevention.Antiplatelet & Anticoagulant therapy € € Aspirin reduces the risk of recurrent ischemic stroke by b 18 %. et al. Antithrombotic Trialists¶Collaboration. € Warfarin is not recommended for non-cardioembolic strokes.

myocardial infarction or vascular death whereas patients treated with aspirin had a 5. .143:1-13. CAPRIE Steering Committee. et al.32% annual risk of ischemic stroke. 33 .Antiplatelet & Anticoagulant therapy € CAPRIE trial y Patients treated with clopidogrel had a 5. Lancet 1996. J Neurol Sci 1996.348:1329±1339 € ESPS2 study y dipyridamole + ASA may be more effective than aspirin alone y criticized for the low dose of aspirin used Diener HC.83% annual risk of the same events.

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. et al.131:492-501 . € EAFT (European Atrial Fibrillation . Ann Intern Med 1999.342:1255± 1262 34 . € A similar benefit is found in the secondary prevention of stroke in patients with AF. Trial) Study Group. All patients with AF should be considered for warfarin therapy unless there are contraindications. Lancet 1993.

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

2001.285:2486-97 36 .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.

.7(Suppl 1):81±88. Cerebrovasc Dis 2004. 37 . cardiovascular death.Statin therapy € Statin therapy q risk of vascular events (including myocardial infarction. et al. and stroke) by b 25 % Amarenco P.

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

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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

72

26 13 0 1 2 3 4 5

IC Score

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

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3-0.ICH related to Anticoagulation € € € € Occurs with a frequency of 0. Stroke 2006.6% per year in patients on chronic warfarin tx OAT use increases risk for ICH. 37: 256-62 42 . 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. Stroke Steiner T. associated conditions such as CAA. history of hypertension. et al. leukoaraiosis 2005. intensity of anticoagulation. et al. 36: 1588-93 Hart RG.

EUSI Recommendations € Normalization of INR (<1. consider redosing w/ reduced dose y FFP 10ml/kg will reduce an INR of 4. 22: 294-316 43 .5.2 to 1. an INR of 3.2 to 2. or an INR of 2.0 to 2.1.4 would require 40ml/kg y Vitamine K 1-2 x 5-10mg PO or IV Cerebrovasc Dis 2006.4 to 1.4.5) y PCC 10-30 (-50) U/kg Measure INR after 15 min If INR is still >1.8 To reduce an INR of 4.

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. 22: 294-316 44 .EUSI Recommendations € Normalization of PTT after heparin y Protamine sulphate 1.0-1.

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. Stroke 2007.9% 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. 38: 2001-23 45 .

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 .

365: 387-397 48 . Lancet 2005. et al.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. Lancet 2005. et al. 365: 387-397 49 .

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

38: 2001-23 51 . Stroke 2007.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.

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 .

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 .

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.Guidelines for BP management € SBP >200 or MAP >150 y Aggressive BP lowering w/ IV anti HPN. 38: 2001-23 57 . Stroke 2007. monitor patient q15 min Broderick J et al.

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

Neurology 2003. 43 (10): 1175-80 Vespa et al. 60: 1441-6 59 .Brain supportive therapy € Antiepileptic drugs y Seizures after ICH occurred at onset in 4% of patients 30 day risk of seizure post ICH .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. Epilepsia 2002.

60 .

MD FPNA Neurologist ± Psychiatrist 61 .Maria Leticia Araullo.

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