management of ischemic stroke
DESCRIPTION
Deals with common issues like management of hypertension and diabetes during stroke, as well as the role of surgical procedures.TRANSCRIPT
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Acute Ischemic Stroke
Rahul KumarConsultant Interventional Neurologist
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant 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.
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Which Guidelines to follow ?
• AHA• AAN• RCOP• Australian SA• ESA
• IAN
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
The Continuum of Stroke Care
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
How do we approach a patient with suspected stroke ?
• Assesment Phase– History, Clinical Evaluation
• Sudden Onset• Time of Onset• Grading of Severity - Clinical
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
How do we approach a patient with suspected stroke ?
• Assesment Phase– History, Clinical Evaluation– Imaging
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Other Imaging Modalities
• MRI– standard– DWI/PWI
• Xenon CT• Perfusion CT• CT Angiography
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
How do we approach a patient with suspected stroke ?
• Assesment Phase– History, Clinical Evaluation– Imaging– Other Supportive Tests
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Diagnostic Testing
• Laboratory studies– CBC, differential, platelets– electrolyte profile, glucose (finger stick)– INR, aPTT– Troponin
• ECG• CXR
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Stroke Mimics – Exclusion Establishes Stroke
• Hypoglycemia• Seizure• Migraine with aura• Hypertensive encephalopathy• Wernicke’s encephalopathy• CNS tumor• Drug toxicity• CNS abscess• Psychogenic
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Stroke – General Assessment
• Airway – Foreign Bodies, dentures, tongue• Breathing and oxygenation – ABG, Pulse Ox• Circulation- BP, Urine Output, Peripheral
Circulation• Glucose > 60• Temperature - Normothermia
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
How do we approach a patient with suspected stroke ?
• Assesment Phase– History, Clinical Evaluation– Imaging– Other Supportive Tests
• Treatment Phase– Supportive Treatment
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Vascular Access
• Two peripheral IVs• Use .9NS or .45 NS unless hypotensive• Use .9NS if hypotensive• Replace blood products as indicated
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Treatment of Hypertension
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Autoregulation
• The ability of the vasculature in the brain to maintain a constant blood flow across a wide range of blood pressures
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
0 50 100
150
200
250
0
20
40
60
80
100
Ischemic
Normotensive
Hypertensive
MAP mm Hg
CB
F
ml/
100m
g/m
inAutoregulationof Cerebral Blood Flow
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Hypertension Ischemic Stroke
• Treat judiciously if at all• Treatment guidelines - not receiving rt-PA
– AHA: MAP > 130 or Sys BP > 220 – NSA: 220/115
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
For how long to allow Hypertension to Continue ? 1 Hr 3 Hr 6 Hr
average
slow
fast
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Treatment of Hyperglycemia
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Target Values
• Intensive – 80 to 110
• Desirable – 140 to 180
• Not above 200
• How to Achieve• Oral agents• Insulins
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Sliding scale insulin
• Abandoned! Retroactive not proactive• Variation in disease state• Dangers of hypoglycemia
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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?
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
How do we approach a patient with suspected stroke ?
• Assesment Phase– History, Clinical Evaluation– Imaging– Other Supportive Tests
• Treatment Phase– Supportive Treatment– Specific Treatment
Rahul KumarMD, DNB, DM, DNB, FINR
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Aspirin (mg)
• Role of Clopidogrel, Dypiridamole• Place for Combination therapy
38
EUSI ASA RCOP (London)
Acute treatment 100-300 325 300
2nd prevention 50-325 150-325 50-300
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Empirical Aspirin !!!
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
PRE AND POSTInterventional Therapy
Pre Procedure, NIHSS - 18 Post Procedure, NIHSS - 0
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist43
Treatment of neurological complication
• Seizures• Cerebral edema and increased intracranial pressure, Hemorrhagic transformation
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Seizures
• Occur in 5% of acute strokes• Usually generalized tonic-clonic• Possible causes:
severe strokescortical involvement unstable tissue at riskspreading depolarizationshx of seizure disorder
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist47
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Hemicraniectomy not Performed
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Hemicraniectomy performed within 4 hours of onset
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Hemicraniectomy performed within 24 hours of onset
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
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
Rahul KumarMD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Thank You.