stroke.pdf
TRANSCRIPT
Management and Prevention
of
Ischemic Stroke
Kittawit Rungjang
• Ischemic stroke is defined as an infarction of
central nervous system tissue.
• Approximately 80 percent of strokes.
Stroke.2009;40:2276-2293; originally published online May 7, 2009 UpToDate 19.1
Etiology
• Atherothrombosis
• Embolism
• Low flow
• Other etiologies
Evaluation and Diagnosis
History
single most important piece of historical
information is the time of symptom onset
The time of onset is defined as when the
patient was last awake and symptom free or known to be “normal”
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Evaluation and Diagnosis
History
signs and symptoms on initial presentation can
give an indication as to which vascular territory is affected
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Vascular territory
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Evaluation and Diagnosis
Physical Examination
HEENT: signs of trauma or seizure activity
CVS: JVP, bruits, pulse all extremities
,valvular conditions, irregular rhythm
skin and extremities: jaundice, purpura, petechia
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Stroke Mimics
Conversion disorder
Hypertensive encephalopathy
Hypoglycemia
Complicated migraine
Seizures
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Evaluation and Diagnosis
Neurological Examination and Stroke Scale Scores
degree of neurological deficit
facilitate communication between healthcare
identify the possible location of vessel
occlusion
provide early prognosis
Identify patient eligibility for various
interventions
complications Stroke. 2007;38:1655-1711; originally published online April 12, 2007
National Institutes of Health Stroke Scale
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
NIHSS-T
J Med Assoc Thai 2010;Establishment of the Thai version of National Institute of Health Stroke Scale (NIHSS) and a Validation Study
National Institutes of Health Stroke Scale
The level of stroke severity as measured by the NIH stroke scale scoring system:
0= no stroke
1-4= minor stroke
5-15= moderate stroke
15-20= moderate/severe stroke
21-42= severe stroke
*scores greater than 4 points to be treated with tPA
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Diagnostic Tests
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Non contrast brain CT or brain MRI
Blood glucose
Serum electrolytes/renal function tests
ECG
Complete blood count, including platelet count*
Prothrombin time/international normalized ratio
(INR)*
Activated partial thromboplastin time*
Oxygen saturation
Evaluation and Diagnosis
Brain and Vascular Imaging
Both CT and MRI are options for imaging the brain
CT is relatively insensitive in detecting acute and small cortical or subcortical infarctions, especially in the posterior fossa
Limitations of MRI include cost, limited availability,
and patient contraindications such as claustrophobia, cardiac pacemakers, or metal implants
door-to-interpretation time of 45 minutes
(candidates for rtPA)
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Non–Contrast-Enhanced CT Scan
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Management
Admission
Approximately 25% of patients may have
neurological worsening during the first 24 to 48 hours
after stroke. It is difficult to predict which patients
will deteriorate
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Admission
goals of treatment after admission
1. observe for changes in the patient’s condition that might prompt initiation of medical or surgical interventions
2. provide observation and treatment to reduce of bleeding complications after the use of rtPA
3. facilitate medical or surgical measures aimed at improving outcome after stroke
4. begin measures to prevent acute complications
5. plan for long-term therapies to prevent recurrent stroke
6. start efforts to restore neurological function through rehabilitation and good supportive care
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Nutrition and Hydration
Some patients cannot receive food or fluids
because of impairments in swallowing or mental status
An assessment of the ability to swallow is important
before the patient is allowed to eat or drink
A water swallow test performed at the bedside is a
useful screening tool
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Activity
Most patients are first treated with bed rest,
but mobilization usually begins as soon as the patient’s
condition is considered stable
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
EKG
Electrocardiography is routinely performed. To detect
paroxysmal atrial fibrillation, ambulatory monitoring
is useful.
N Engl J Med 366;20 nejm.org may 17, 2012
General Supportive Care
Ventilatory Support:monitored with pulse
oximetry with a target oxygen saturation level ≥ 92%
Temperature: ≤38o
Cardiac Monitoring: cardiac monitoring for at least
the first 24 hours
Hyperglycemia: desired level of blood glucose
has been in the range of 80 to 140 mg/dL
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
General Supportive Care
Arterial Hypertension
<185/110 :if eligible for rtPA
<180/105 :24 hours after rtPA
<220/120 :if NOT eligible for rtPA
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
General Supportive Care
Patient is eligible for treatment with intravenous
rtPA
Labetalol 10 to 20 mg IV over 1 to 2 minutes, may
repeat x1
Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at
5- to 15-minute, maximum dose 15 mg/h; when
desired blood pressure attained, reduce to 3 mg/h
If blood pressure does not decline and remains > 185/110 mm Hg, do not administer rtPA
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
General Supportive Care Blood pressure during and after treatment with rtPA
or other
Labetalol 10 mg IV over 1 to 2 minutes, may repeat
every 10 to 20 minutes, maximum dose of 300 mg
Nicardipine infusion, 5 mg/h, titrate up to desired
effect by increasing 2.5 mg/h every 5 minutes to
maximum of 15 mg/h
goal would be to lower blood pressure by ~15% during the first
24 hours after onset of stroke
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Intravenous Thrombolysis
Recombinant Tissue Plasminogen Activator
Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is
recommended for selected patients who may be treated
within 4.5 hours of onset of ischemic stroke
should be aware of the potential side effect of angioedema that
may cause partial airway obstruction
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Intravenous Thrombolysis
AHA/ASA Stroke 2007; 38:1655.
N Engl J Med 2008; 359:1317. AHA/ASA Stroke 2009 May 28
Inclusion criteria
Clinical diagnosis of ischemic stroke causing measurable
neurologic deficit with the onset of symptoms <4.5 hours
before beginning treatment; if the exact time of stroke onset is
not known, it is defined as the last time the patient was known to be normal
Intravenous Thrombolysis
AHA/ASA Stroke 2007; 38:1655.
N Engl J Med 2008; 359:1317. AHA/ASA Stroke 2009 May 28
Exclusion criteria
Historical
Stroke or head trauma in the previous 3 months
Any history of intracranial hemorrhage
Major surgery in the previous 14 days
Gastrointestinal or urinary tract bleeding in the previous 21 days
Myocardial infarction in the previous 3 months
Arterial puncture at a noncompressible site in the previous 7 days
For treatment from 3 to 4.5 hours,
additional relative exclusions (where the risk/benefit ratio is less clear) are age >80 years and/or a combination of both previous stroke and diabetes mellitus
Intravenous Thrombolysis
AHA/ASA Stroke 2007; 38:1655.
N Engl J Med 2008; 359:1317. AHA/ASA Stroke 2009 May 28
Exclusion criteria
Clinical
Spontaneously clearing stroke symptoms
Seizure at the onset of stroke is an exclusion if the residual impairments are
due to postictal phenomenon
Symptoms of stroke suggestive of subarachnoid hemorrhage
Persistent blood pressure elevation (systolic ≥185 mmHg, diastolic ≥110
mmHg)
Active bleeding or acute trauma (fracture) on examination
For treatment from 3 to 4.5 hours,
additional relative exclusions (where the risk/benefit ratio is less clear) is an NIH Stroke Scale score of >25
Intravenous Thrombolysis
AHA/ASA Stroke 2007; 38:1655.
N Engl J Med 2008; 359:1317. AHA/ASA Stroke 2009 May 28
Exclusion criteria
Laboratory
Platelets <100,000/mm3**
Serum glucose <50 mg/dL (<2.8 mmol/L)
International normalized ratio (INR) >1.7 if on oral
anticoagulant**
Elevated partial thromboplastin time (aPTT) if on heparin**
For treatment from 3 to 4.5 hours,
additional relative exclusions (where the risk/benefit ratio is less clear) is oral anticoagulant use regardless of INR
Intravenous Thrombolysis
AHA/ASA Stroke 2007; 38:1655.
N Engl J Med 2008; 359:1317. AHA/ASA Stroke 2009 May 28
Exclusion criteria
Head CT scan
Evidence of hemorrhage
Evidence of a multilobar infarction with hypodensity involving
>33 percent of the cerebral hemisphere
Intra-Arterial Thrombolysis
Recombinant prourokinase
is an option for treatment of selected patients who have major
stroke of < 6 hours’ duration due to occlusions of the MCA and
who are not otherwise candidates for intravenous rtPA
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Antiplatelet Agents
The oral administration of aspirin (initial dose is 325
mg) within 24 to 48 hours after stroke onset is recom-
mended for treatment of most patients
The administration of clopidogrel alone or in
combination with aspirin is not recommended for the
treatment of acute ischemic stroke
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Anticoagulants
early administration of either heparin or a LMW
heparin/danaparoid is associated with an increased
risk of bleeding complications
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Volume Expansion
Hemodilution with or without venesection and
volume expansion is not recommended for treatment
of patients with acute ischemic stroke
The only possible exception for the use of
hemodilution is in stroke patients with severe
polycythemia
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Neuroprotective Agents
At present, no intervention with putative neuroprotec-
tive actions has been established as effective in improv-
ing outcomes after stroke
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Surgical Interventions Carotid Endarterectomy: Data on the safety and
effectiveness of carotid endarterecto-my and other operations for
treatment of patients with acute ischemic stroke are not sufficient
to permit a recommendation
Stenting and Clot Extraction: MERCI device is a
reasonable intervention for extraction of intra-arterial thrombi in
carefully
selected patients, the panel also recognizes that the
utility of the device in improving outcomes after stroke
is unclear
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
MERCI device
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Conclusion of Mx Admission (Class I, Level of Evidence A)
water swallow test performed at the bedside (Class
I, Level of Evidence B)
mobilization begins as soon as the patient’s
is considered stable (Class I, Level of Evidence C)
rtPA (Class I, Level of Evidence A) or Recombinant
prourokinase (Class I, Level of Evidence B)
ASA within 24-48 hrs. (Class I, Level of Evidence A)
Incorporating rehabilitation (Class I, Level of Evidence A)
Stroke. 2007;38:1655-1711; originally published online April 12, 2007
Prevention
Aggressive risk-factor management
10 risk factors
1. hypertension
2. current smoking,
3. a high waist-to-hip ratio
4. a high dietary risk score
5. lack of regular physical activity
6. diabetes mellitus
7. excess alcohol consumption
8. psychosocial stress or depression
9. cardiac causes
10. high ratio of apolipoprotein B to apolipoprotein A1
N Engl J Med 366;20 nejm.org may 17, 2012
Secondary prevention 1. blood-pressure lowering
2. cholesterol lowering with Statins
3. antiplatelet therapy
N Engl J Med 366;20 nejm.org may 17, 2012
Blood-Pressure Lowering The PROGRESS trial showed a greater reduction
in the risk of stroke and other vascular outcomes among
patients treated with a combination of an ACE inhibitor
and a diuretic than among those treated with an ACE
inhibitor alone
N Engl J Med 366;20 nejm.org may 17, 2012
Cholesterol Lowering Statin therapy with intensive lipid-lowering effects is
recommended to reduce risk of stroke and cardiovascular events
among patients with ischemic strokeor TIA who have evidence of
atherosclerosis, an LDL-C level >100 mg/dL, and who are
without known CHD
For patients with atherosclerotic ischemic stroke or
TIA and without known CHD, it is reasonable to target
a reduction of at least 50% in LDL-C or a target LDL-C
level of <70 mg/dL
Stroke; published online Oct 21, 2010
Cholesterol Lowering Cholesterol lowering with statin drugs, which is
effective in primary stroke prevention, has also
proved effective in secondary prevention after
stroke or TIA
simvastatin (at a dose of 40 mg per day)
atorvastatin (at a dose of 80 mg per day)
Despite the overall benefit, statins have been associated with a slightly
increased risk of intracerebral hemorrhage, and their use may be
contraindicated in patients with the disorder
N Engl J Med 366;20 nejm.org may 17, 2012
Antiplatelet Therapy Low doses of aspirin (ranging from 75 to 325 mg
per day) appear to be as effective as higher doses in
reducing the risk of stroke, with a lower risk of
gastrointestinal toxic effects
Current guide-lines indicate that
Aspirin alone (50 mg/d to 325 mg/d) or
Clopidogrel (75 mg/day)
combination of aspirin 25 mg and extended-release
dipyridamole 200 mg twice daily
N Engl J Med 366;20 nejm.org may 17, 2012
Antiplatelet Therapy The addition of aspirin to clopidogrel increases
the risk of hemorrhage and is not recommended for
routine secondary prevention after ischemic stroke
For patients who have an ischemic stroke while
taking aspirin, there is no evidence that increasing the
dose of aspirin provides additional benefit
Stroke; published online Oct 21, 2010
Carotid Endarterectomy and Carotid-Artery Stenting
Carotid endarterectomy is indicated for the
treatment of patients with a history of TIA or
nondisabling ischemic stroke who have
high-grade (70 to 99%) carotid stenosis or
selected cases,moderate (50 to 69%) stenosis
N Engl J Med 366;20 nejm.org may 17, 2012
Atrial Fibrillation and Anticoagulation
Dose-adjusted warfarin has been the mainstay of
therapy
For patients with ischemic stroke or TIA with
paroxysmal (intermittent) or permanent AF, antico-
agulation with a vitamin K antagonist (target INR 2.5;
range, 2.0 to 3.0) is recommended
Stroke; published online Oct 21, 2010
Atrial Fibrillation and Anticoagulation
Newer oral anticoagulant strategies, which do
not require monitoring, are now available and are
likely to replace warfarin in many cases
N Engl J Med 366;20 nejm.org may 17, 2012
Take home messages Always R/O Stroke Mimics
Last seen normal, NOT first seen abnormal!
oral administration of aspirin (initial dose is 325
mg) within 24 to 48 hours after stroke onset
combination antiplatelet therapy was
recently terminated
secondary prevention: BP lowering,cholesterol lowering, and antiplatelet therapy
Stroke; published online Oct 21, 2010
Thank you