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Management of

STROKE Kalkidan Gulilat , Sujin Kim (MMC 2nd yr)

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Outline• Objective• Introduction and prevalence of stroke• Types and Risk factors of stroke• Primary and secondary prevention• Management and Rehabilitation• Summary• References

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Objective• know the different types of stroke

• Identify the signs and symptoms of stroke

• Describe the pathophysiology of both types of stroke

• Describe the primary and secondary prevention methods

• Identify the acute management of stroke

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Introduction – Stroke

• apoplexy, cerebrovascular accident (CVA)

• is a sudden interruption of the blood supply to the

brain.

• a medical emergency

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The Global burden of stroke

Source: http://www.world-stroke.org/advocacy/world-stroke-campaign - 2016

STROKE

15 million have a sroke

5th cause of death in 15- 59years old

2ND leading cause of

death >60 years old

six million die

• Every 53 sec some one will have a

stroke

• Every 3.3 min someone will die of stroke

6Source: World Health Statistics 2007

Trends in Global Deaths 2002-30

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Stroke in Ethiopia

http://www.cdc.gov/globalhealth/countries/ethiopia/ 2016 Data

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Time lost is brain lost!!

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Types of stroke

85%15%

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Embolic - cardiogenic sources such as atrial fibrillationThrombotic - associated with atherosclerotic plaque

Ischemic Stroke

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Ischemic stroke symptoms

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• ‘‘mini-strokes’’

• symptoms resolve completely (<24hr) and the person

returns to normal

Transient Ischemic Attack (TIA)

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Risk Factors for IS

Oral contraceptives, HRT

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Pathophysiology of IS

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Hemorrhagic Stroke

• weakened regions of blood

vessels rupture as a result of

increased pressure

• HTN, cocaine,Amphetamine

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Risk Factor of HS

Brain Aneurism

Arteriovenous malformation

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Type of Hemmorhagic stroke

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SSx of HS

• depressed level of

consciousness,

• higher initial blood

pressure,

• or worsening of

symptoms after onset

favor Hs

“Worst headache of my life”

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Remember

• determine cause of stroke before you start treatment

• emergency head CT scan

• No reliable clinical findings separate ischemia from

hemorrhage

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Management of a Stroke

21General Picture of Tx

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Primary and secondary prevention

• A- antiplatelet and anti coagulants

• B- blood pressure lowering medication

• C- cholesterol lowering, cessation of smoking

• D- diet

• E- exercise

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Asprin• Antiplatelet agent, irreversible COX inhibitor

• Prevent adhesion and aggregation of platelets

• dose of 81 mg enteric-coated aspirin is usually

started

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Platelet aggregation inhibitors• Abiciximab

• Clopidogrel, Ticlopidine

• Dipyridamole

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Warfarin• Oral anticoagulant

• Slow onset

• Narrow therapeutic index, teratogenic

• Drug- drug interaction – Inducers - phenytoin, rifampin, barbiturates

– Inhibitors – amiodarone,SSRI, cimetidine

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Lipid lowering drugs• ↓LDL

• Atorvastatin, Cholestyramine,

Ezetimibe

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Antihypertensive dugs• Diuretics- thiazide• ACE inhibitors – Enalapril• CCB, beta blockers

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Acute management

Harrison 19th ed. 2015 pg. 2560

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Treatment fall into 6 categories(1) Medical support (2) Intravenous thrombolysis(3) Endovascular techniques(4) Antithrombotic treatment(5) Neuroprotection(6) Stroke centers and rehabilitation

Acute management for IS

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(1) Medical support

•ABC •IV fluid•Cardiac monitoring & treat arrhythmia•Antipyretics

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• Should be normoglycemia (90-140 mg/dL) : Treat hypoglycemia(D50) & hyperglycemia(insuline)

• Candidates for IV fibrinolytic treatment Plus BP >185 /110 mmHg

First, labetalol, nitroglycerin paste, or IV nicardipine

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(2)Intravenous thrombolysis• Restore blood flow to ischemic regions of the brain

• “< 3H” : prevent neurologic deficits

tPA – the major tx of IS

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Exclusion Criteria for tPA Use

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(3) Endovascular techniquesOcclusions of large arteries(MCA, ICA, BA)

involve a large clot volume

failure to open with IV tPA alone.

thrombolytics via an intra-arterial route

• concentration of drug at the clot site

• systemic bleeding complications

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(4) Antithrombotic treatmentAsprin• Only antiplatelet agent

effective for the acute treatment of IS

• Use within 48 h of stroke onset : recurrence risk and mortality

Rivaroxaban• Selective inhibitor of factor Xa• “bridging anticoagulation”

Abiciximab, Ancrod (clinical trials)

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(5) Neuroprotection•NMDA receptor antagonist

Dextrorphan

•GABA agonistClomethiazole

•Free radical scavenger tirilazad

•Hypothermia, calcium channel blockers

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Treatment of Hemorrhagic stroke

Supportive therapy (no direct therapy)

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•Stablize vital signs

•Intubation and hyperventilation•Stop any medication that could increase bleeding (e.g. warfarin, aspirin).

•Evacuate the hematoma

•Measure and control the pressure within the brain

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Cont…• ICP

osmotic diuretics – mannitol Loop diuretics – furosumide

• Anti hypertensive : Beta blocker

• Vitamin K, Fresh frozen plasma• Acetaminophen : to reduce fever and headache

• Antiemetic agents : Promethazine

• Anti acids : for stress ulcers

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Rehabilitation

• Mobility

• Activity of daily living

• Communication

• Swallowing

Focuses on improving

• Shoulder pain

• Spasticity

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Medical Interventions

• Skeletal muscle relaxants– Botulinum Toxin – regional nerve block– Diazepam, Baclofen, Dantrolene – systemic

• Anti depressant

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Tx of Stroke in Ethiopia• ABC, non contrast and contrast CT then• For IS:

• No rtPA (But it is on the Ethiopian Treatment Guideline)

• Asprin (80mg or 300 mg)• Heparin (first loading dose 10,000 IU and

then maintenance 5,000 IU)• Warfarin

• For HS: • Treat the HTN• No surgery unless the hemorrhage is

massive – blood enter in to the ventricles• For SAH = Nimodipine injection 1 mg/5mlSource:- Standard Treatment Guideline For General Hospitals, 2010- MCM physicians

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Summary• There are two types of stroke: Ischemic and Hemorragic.• The most common cause of

– ischemic stroke (IS) is cerebral infraction caused by thrombi or emboli.

– hemorrhagic stroke (HS) is hypertension.• The treatment goal is to restore cerebral perfusion (IS)

and to decrease the hypertension (HS)• The primary and secondary preventions aimed at

decreasing the risk factors.

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Reference• Harrisons principles of internal medicine, 19th edition, 2015• Applied Therapeutics: The Clinical Use of Drugs, 9th edition• Standard Treatment Guideline For General Hospitals, 2010• Pharmacology: Examination & Board Review, 10th edition• Lippincott illustrative Review of pharmacology; 6th ed., 2015• http://emedicine.medscape.com/• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585721/1/• http://

www.medicaldaily.com/birthcontrolpillsincreaseriskischemicstrokeonlycertainwomenstudy353634

• http://www.world-stroke.org/advocacy/world-stroke-campaign

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THANK YOU!