AHA/ASA ACUTE ISCHEMIC

STROKE GUIDELINES 2018

DISUSUN OLEH
N I M A S F E L I A N I R O B OT ( 0 0 0 0 0 0 0 7 2 8 7 )

PENGUJI
D R . V I V I E N P U S P I TA S A R I , S P S
EMERGENCY SUPPORTIVE CARE AND
TREATMENT
• Airway, Breathing, and Oxygen
• Blood Pressure
• Temperature
• Blood Glucose
• IV Alteplase
• IV Thrombolytic and Sonothrombolysis
• Mechanical Thrombectomy
• Other Endovascular Treatments
• Antiplatelet Treatment
• Anticoagulants
• Volume Expansion/ Hemodilution,Vasodilators, Hemodynamic Augmentation
• Neuroprotective Agents
• Emergency Carotid Revascularitation
• Other
ISCHEMIC AREA
NEUROPROTECTION

Neuroprotective Neuroprotective agents

Intervention CITICHOLINE / CDP–choline
The 5 “H” Principle
• Hypotension
• Hypoxemia
• Hyperglycemia
• Hypoglycemia
• Hyperthermia (fever)
AIRWAY, BREATHING AND
OXYGENATION
 BLOOD PRESSURE
• Ideal BP in AIS remains unknown – observational studies variable
• BP with IV alteplase
(some data suggest hemorrhage risk higher with higher BPs and BP variability, but exact BP that increase
risk unknown)

Prior administration 24 hours after

• <185/110 • <185/105

• BP with intra-arterial therapy

– ≤185/110
BLOOD PRESSURE
BP TREATMENT OPTION IN AIS PATIENS ELIGIBLE FOR
REPERFUSION
Labetalol Nicardipine Clevidipine

• 10-20mg IV over 1-2min,
may repeat 1x
• If continues to be elevated,
10mg IV x1 followed by
infusion 2-8mg/min
• 5mg IV, titrate 2,5mg/h • 1-2mg/h IV, double dose
every 5-15min (max every 2-5min to titrate
15mg/h) (max 21mg/h)

Monitoring BP after reperfusion

2 hours 16 hours
Every 15 min Every 60 min

6 hours
Every 30 min
TEMPERATURE
New data from retrospective cohort study (9366 pts)
Peak temperature in first 24 hours

<37oC
Source of
hyperthermia Find Out Treat
(>380C) >39oC

Increased risk of
in-hospital death
BLOOD GLUCOSE
Recommendation is unchanged from 2013 guidelines
The first 24 hours after AIS

Common in stroke pts (elevated admission blood glucose in >40%,

most frequently in diabetes pts)
Persistent hyperglycemia associated with worse outcomes
NEUROPROTECTIVE AGENTS
IN HOSPITAL SUPPORTIVE CARE
• Stroke units
• Supplemental Oxygen
• Blood Pressure
• Temperature
• Glucose
• Dysphagia Screening
• Nutrition
• DVT Prophylaxis
• Depression Screening
• Other
• Rehabilitation
 SUPPLEMENTAL OXYGEN
Maintian O2
sat >94% Supplemental O2 is not
recommended in
nonhypoxic patients

New RCT with 8003 pts randomized within 24 hours

Continously for
O2 sat >93% O2 sat ≤93% 72hours OR
Duration
2L/min 3L/min Nocturnally for 3
nights
BLOOD PRESSURE
• Optimal BP strategy for stroke pts remain unclear and depends on the clinical situation

Concomitant Initial BP <220/120 Initial BP >220/120

comorbidities • reinitiating anti-HTN is • lower by 15% in the
• lower BP by 15% safe but NO BENEFIT first 24 hours

Neurologically Hypotension and

stable pts hypovolemia
• restart anti-HTN if should be
>140/90 corrected
BLOOD PRESSURE
BLOOD PRESSURE
TEMPERATURE

• Hypothermia is promising as a neuroprotectant but benefit in AIS pts is not proven

GLUCOSE
Hypoglicemia
Hyperglycemia
(<60mg/dL)

Treat with IV push of

SC or IV Insulin
25ml of 50% Dextrose
CONCLUSION
• Oxygenation
– Maintain SaO2 >94%
– Supplemental O2 is not recommended in non-hypoxic patients
• Blood Pressure
– Ideal BP in AIS remains unknown – observational studies variable
– The previous recommendation not to lower the BP during initial 24 hours of AIS unless the BP is
>220/120 mmHg or there is a concomitant specific medical condition that would benefit from blood
pressure lowering remains reasonable
• Temperature
– Find the source of hyperthermia (>380C) and treat
– Avoid hypothermia
CONCLUSION

• Blood glucose
– Hyperglycemia should be treated. Target 140-180 mg/dL
– Hypoglycemia should be treated
• Neuroprotective agents is not recommended