management of ischemic stroke

Rahul KumarMD, DNB, DM, DNB, FINR

Consultant Interventional Neurologist

Acute Ischemic Stroke

Rahul KumarConsultant Interventional Neurologist

Why do we need guidelines ?

• 2.4 per 1000 people per year

• 10,00,000 strokes per year in India• 3000 strokes a day• 2% of all admissions

• Crude prevalence rate is 220/100,000.

Estimated Pace of Neural Circuitry Loss in a typical, large, Supratentorial Ischemic Stroke

Neurons Lost Synapses Lost Myelinated Fibers Lost

Accelrated Ageing

Per Stroke 1.2 Billion 8.3 trillion 7140 Km 36 years

Per Hour 120 million 830 billion 714 Km 3.6 years

Per Minute 1.9 million 14 billion 12 Km 3.1 weeks

Per Second 32,000 230 million 200 meters 8.7 hours

Jeffery L Slaver, Stroke, 2006; 37, 263-66

Which Guidelines to follow ?

• AHA• AAN• RCOP• Australian SA• ESA

• IAN

Which Guidelines to follow ?

• AHA• AAN• RCOP• Australian SA• ESA

• IAN

• Guidelines are Guidelines• Individualize• Deviations

• Not applicable across the board

• Help us in optimizing outcomes

• Preventing therapeutic misadventures

The Continuum of Stroke Care

How do we approach a patient with suspected stroke ?

• Assesment Phase– History, Clinical Evaluation– Imaging– Other Supportive Tests

• Treatment Phase– Supportive Treatment– Specific Treatment

• Treatment of Complications

• Assesment Phase– History, Clinical Evaluation

• Sudden Onset• Time of Onset• Grading of Severity - Clinical

Stroke Scales

• Severity– NIH stroke scale 0-42, 0 = normal

valid, reproducible, assists in patient selection, facilitates communication

• Functional Scales– m-Rankin 0-5, 0 = normal – Barthel index 100, 100 =

normal– Glasgow outcome 0-5, 5= normal

• in NINDS t-PA stroke trial, 0 = normal

Stroke Scales

• NIH stroke scale 0-420-5 mild/minor in most patients5-15 moderate15-20 moderately severe> 20 very severeunderestimates volume of infarct in non-dominant

(R) hemispheric strokes

• Assesment Phase– History, Clinical Evaluation– Imaging

Non-contrast CT of the Head

• Initial imaging study of choice• Readily available• Very sensitive for blood in the acute phase

– blood - 50-85 Hounsfield Units– bone- 120 (70-200) Hounsfield Units

• Not sensitive for acute ischemic stroke– nearly 100% sensitive by 7 days

• Posterior fossa structures - bone artifact

Other Imaging Modalities

• MRI– standard– DWI/PWI

• Xenon CT• Perfusion CT• CT Angiography

Diagnostic Testing

• Laboratory studies– CBC, differential, platelets– electrolyte profile, glucose (finger stick)– INR, aPTT– Troponin

• ECG• CXR

Stroke Mimics – Exclusion Establishes Stroke

• Hypoglycemia• Seizure• Migraine with aura• Hypertensive encephalopathy• Wernicke’s encephalopathy• CNS tumor• Drug toxicity• CNS abscess• Psychogenic

Stroke – General Assessment

• Airway – Foreign Bodies, dentures, tongue• Breathing and oxygenation – ABG, Pulse Ox• Circulation- BP, Urine Output, Peripheral

Circulation• Glucose > 60• Temperature - Normothermia

• Treatment Phase– Supportive Treatment

Vascular Access

• Two peripheral IVs• Use .9NS or .45 NS unless hypotensive• Use .9NS if hypotensive• Replace blood products as indicated

Treatment of Hypertension

Autoregulation

• The ability of the vasculature in the brain to maintain a constant blood flow across a wide range of blood pressures

0 50 100

Ischemic

Normotensive

Hypertensive

MAP mm Hg

inAutoregulationof Cerebral Blood Flow

Hypertension Ischemic Stroke

• Treat judiciously if at all• Treatment guidelines - not receiving rt-PA

– AHA: MAP > 130 or Sys BP > 220 – NSA: 220/115

Hypertension - Ischemic Stroke

• Drugs - short acting, titrate • Labetalol

IV: 10-20 mg increments, double dose Q 20 min, max cumulative dose 300mg

• EnalaprilOral: 2.5 - 5.0 mg/day, max 40mg/dayIV : 0.625-1.25 mg IV Q 6hrs, max 5.0 Q 6 hrs

For how long to allow Hypertension to Continue ? 1 Hr 3 Hr 6 Hr

average

Hypertension: rt-PA Candidate

• Exclude for persistent BP > 185/110• Check BP q 15 min• May not aggressively lower BP to meet entry

criteria• Use Labetolol or Nitropaste

Hypertension -Ischemic Stroke• Nitroglycerine

Paste: 1-2 inches to skinIV Drip: 5mcg/min, increase in increments of 5-

10mcg every 3-5 min • Nitroprusside

IV Drip: 0.3 - 10 mcg/min/kgContinuos BP monitoring

• AVOID NIFEDIPINE

Hypotension

• More detrimental than hypertension• Seek cause and treat aggressively• CVP monitoring may be necessary• Use .9 NS first to ensure adequate preload• Then add vasopressors if needed

Treatment of Hyperglycemia

Glucose

• Worse outcome after stroke:– diabetics– acute hyperglycemia at time of infarct

• Mechanism uncertain– increase in lactate in area of ischemia– gene induction, – increased number of spreading depolarizations

• Insulin is a neuroprotective

Target Values

• Intensive – 80 to 110

• Desirable – 140 to 180

• Not above 200

• How to Achieve• Oral agents• Insulins

Sliding scale insulin

• Abandoned! Retroactive not proactive• Variation in disease state• Dangers of hypoglycemia

Initiating insulin: New to Insulin For most patients with type 2 diabetes (or being initiated to insulin therapy), total daily insulin dose

can be estimated at 0.3 to 0.6 units/kg/day The dosing range represents varying degrees of insulin resistance:

dose kg

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

50 5 10 15 20 25 30 35 40 45 50

60 6 12 18 24 30 36 42 48 54 60

70 7 14 21 25 35 42 43 56 63 70

80 8 16 24 32 40 48 56 64 72 80

90 9 18 27 36 45 54 63 72 81 90

100 10 20 30 40 50 60 70 80 90 100

Insulin drip

Advantages Tightest control Good absorption Rapid adjustments Easy standardized

Disadvantages Frequent monitoring (ICU/IMCU needed?) Nursing time! Catheter complications Problems when switching to SQ regimen Rapid Glucose shifts?

Temperature

• Fever worsens outcome:– for every 1°C rise in temp, risk of poor outcome

doubles (Reith, Lancet 1996)

• Greatest effect in the first 24 hours• Brain temp is generally higher than core• Treat aggressively with acetaminophen, ibuprofen,

or both• Search for underlying cause• Hypothermia currently under investigation

Consultant Interventional Neurologist37

Recanalization, anti Ischemic Treatment

• Recanalization IV rt-PAIA r-proUK

(FDA?)• Neuroprotective

treatment• Aspirin in first 48

hours• Anticoagulant

• Hemodilution• Therapeutic

hypothermia• Stroke unit • Craniectomy

Aspirin (mg)

• Role of Clopidogrel, Dypiridamole• Place for Combination therapy

EUSI ASA RCOP (London)

Acute treatment 100-300 325 300

2nd prevention 50-325 150-325 50-300

Empirical Aspirin !!!

PRE AND POSTInterventional Therapy

Pre Procedure, NIHSS - 18 Post Procedure, NIHSS - 0

• Treatment of Complications

Treatment of neurological complication

• Seizures• Cerebral edema and increased intracranial pressure, Hemorrhagic transformation

Seizures

• Occur in 5% of acute strokes• Usually generalized tonic-clonic• Possible causes:

severe strokescortical involvement unstable tissue at riskspreading depolarizationshx of seizure disorder

Seizures

• Protect patient from injury during ictus• Maintain airway• Benzodiazepines:

– lorazepam (1-2 mg IV)– diazepam (5-10 mg IV)

• Phenytoin: – 15 mg/kg loading dose, at 25-50 mg/min infusion with

cardiac monitor• No need for prophylaxis

Cerebral edema and increased intracranial pressure

• Applicable only in large artery strokes and in some cerebellar strokes

• Elevated head of the bed 20- 30 degrees

• Avoid “Jugular vein” compression• Avoid hypotonic solution• Avoid hypoxia, consider intubation• Hyperventilation

keep pCO2 30-35 mmHg

Cerebral edema and increased intracranial pressure

• Consider osmotherapy20% Mannitol 0.25-0.5 g / Kg IV in 20 mins 4-6 times /

dayor 10% Glycerol 250 ml IV in 30-60mins 4 time / dayor 50% Glycerol 50 ml oral 4 time / dayand / or Furosemide 1 mg / kg IV

• Avoid steroid

• Consider decompressive surgery

Hemicraniectomy not Performed

Hemicraniectomy performed within 4 hours of onset

Hemicraniectomy performed within 24 hours of onset

Conclusions

• Acute stroke is an emergency condition, is the same level as MI, serious trauma

• Emergency management is need• rt-PA & Interventional therapies,

are the major advances• Appropriate general care are

also need• To improve the quality of care :

Multidisciplinary/ network approach

Take Home Message…

• Manitain ABC, low threshold for intubation• Hypertension better than Hypotension• Normoglycemia• No Role of Empirical Antiplatelets• Use of Statins recommended• Try to administer reperfusion if within window• More widespread use of surgical and

interventional procedures• Treatment of Complications

Thank You.

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