Management of acute ischemic stroke (2013 aha

Bader Almasaad

Definition.

In 2008 stroke dropped from being 3rd

leading cause of death in the USA to the 4th

Less than 50% of calls to 911 were made within one hour of symptoms, less than 50% of those who called thought stroke was the diagnosis.

Public education is a priority

Patient or bystander recognition of stroke signs and symptoms

Detection

Immediate activation of 911 and priority EMS dispatch

dispatch

Prompt triage and transport to most appropriate stroke hospital and prehospitalnotification

delivery

Immediate ED triage to high-acuity areadoor

Prompt ED evaluation, stroke team activation, laboratory studies, and brain imaging

data

Diagnosis and determination of most appropriate therapy; discussion with patient and family

decision

Administration of appropriate drugs or other interventions

drug

Timely admission to stroke unit, intensive care unit, or transfer

disposition

Primary stroke centre(PSC)

Comprehensive stroke centre(CSC)

Acute stroke ready hospital (ASRH)

The biggest reduction in stroke morbidity and mortality is achieved by admission to a CSC.

TimeAction

<10 minsDoor to physician

<15 minsDoor to stroke team

<25 minsDoor to CT initiation

<45 minsDoor to CT interpretation

<60 minsDoor to drug

<3 hrsDoor to stroke unit admission

Selected patientsAll patients

TT and ECT if indicatedNon contrast brain CT or brain MRI

LFTBlood glucose

Toxicology screenOxygen saturation

Blood alcohol levelSerum electrolytes/renal function tests

Pregnancy testComplete blood count, including platelet count

ABG( if hypoxia suspected)Markers of cardiac ischemia

Chest x-rayProthrombin time/INR

LP (if SAH suspected after negative CT)

APTT

EEG (if seizures suspected)ECG

CT (plain)

MRI (DWI)

Contrast CT, MRI, angio

TCD

Hypoxia:

Up to 63% of hemiparetic patients develop hypoxia

Common causes found were:

• Partial airway obstruction

• Hypoventilation

• Aspiration

• Atelectasis

• Pneumonia

Central periodic breathing (cheyne-stokes respirations) associated with decreases in oxygen saturation

Hypoxia is detrimental to ischemic brain tissue and associated with poorer outcomes

Must be corrected (<94%) and continuously monitored for

Patient positioning: Can influence O2 sats, CPP, MCA mean flow velocity, ICP.

In the non hypoxic patient able to tolerate lying flat, the supine position is recommended.

Otherwise head up position at 15 to 30 degrees

Supplemental oxygen Supplemental oxygen should be provided via least invasive method to

provide o2 sats of >94% ( class I, level C)

Airway support and ventilatory assistance recommended for patients with decreased LOC or who have bulbar dysfunction that compromises the airway ( class I, level C)

Temperature control

Hyperthermia:• Associated with 2 fold increase in short term mortality in patients with

hyperthermia in the first 24 hours of hospitalization.

• Hyperthermia should be corrected and causes sought out (class I, level c)

Hypothermia:• No data available about the utility of induced hypothermia in stroke patients

at present

Blood pressure:

In patients with markedly elevated BP (consensus is that that is BP >220 / >120) not receiving fibrinolysis, a reasonable goal is to lower BP by 15% during the first 24 hours (class I, level C)

Initiation of anti-hypertensives within 24 hours of stroke is relatively safe including restarting medications for previously hypertensive patients ( class IIa, level B)

patient otherwise eligible for A.R.T except that BP is >185/110:

Labetalol 10-20mg IV over 1-2 mins, may repeat once

Nicardipine 5mg/hr IV up to maximum of 15 mg/hr

other agents (hydralazine, enalapril) may be considered

If BP is not maintained <185/110 do not administer rTPA

Management of BP during or after A.R.T at or below 180/105

Monitor BP every 15 mins for 2 hours post A.R.T, then ½ hourly for 6 hrs

If BP >180-230 or >105-120:

Labetalol 10mg IV followed by infusion 2-8 mg/min or;

Nicardipine 5mg/hr IV up to maximum of 15mg/hr

If BP not controlled of diastolic >140 consider sodium nitroprusside

Blood sugar

Persistent in-hospital hyperglycemia during the first 24 hours after stroke is associated with worse outcomes than normoglycemia so hyperglycemia should be treated to a target range of 8-10. (class IIa, level c)

Hypoglycemia has to be corrected

Approved by FDA in 1996.

Window is 3 hours, extended to 4.5 hours in selected patients.

Time is brain

In eligible patients treatment should be started as early as possible, with door to needle time of less than 60 minutes (class I, level A)

IV rTPA (0.9 mg/kg max. 90 mg) is recommended for eligible patients within 3 hours of symptom onset (class I, level A)

Physicians should be aware of and be prepared to treat complications of rtPA such as ICH and angioedema that may cause partial airway obstruction in 1-5% of patients.

The effectiveness of sonothrombolysis for treatment of stroke patients is not well established (class IIb, level B)

The use of IV rtPA in patients on direct thrombin inhibitors or direct factor Xa inhibitors is not recommended unless sensitive lab tests are normal or patient not received any of these drugs for more than 2 days (class III, level C)

Patients eligible for IV rtPA should receive it even if IA treatment is considered (class I, level A)

IA fibrinolysis is beneficial for selected patients with major ischemic strokes of <6 hours duration involving the MCA who are otherwise not candidates for IV fibrinolysis.(class I, level B)

Rescue IA fibrinolysis or mechanical thrombectomy may be reasonable approaches to re-canalization in patients with large artery occlusion not responsive to IV rtPA.( class IIb, level B)

Urgent anticoagulation with the goal of preventing early recurrent stroke, halting neurological worsening or improving outcome after acute ischemic stroke is not recommended (class III, level A)

Urgent anticoagulation for the management of non-cerebrovascular conditions is not recommended for patients with moderate to severe stroke because of increased risk of serious ICH complications. (class III, level A)

Initiation of anticoagulation within 24 hours of IV rtPA is not recommended (class III, level B)

Oral administration of aspirin (initial dose 325mg) within 24 to 48 hours is recommended. ( class I, level A)

The usefulness of clopidogrel for the treatment of acute ischemic stroke is not well established (class IIb, level C)

The administration of aspirin or other anti platelets as an adjunctive therapy within 24 hours of IV fibrinolysis is not recommended (class III, level C)

In exceptional cases with systemic hypotension producing neurological sequelae, a physician may prescribe vasopressors to improve cerebral blood flow under close observation ( class I, level C)

The administration of high dose albumin is not well established as a treatment for most patients with acute ischemic stroke (class IIb, level B)

Measures to reduce brain edema are recommended during the first days after stroke ( class I, level A)

Decompressive surgery should be considered urgently in all patients with cerebellar infarcts, and individualized but encouraged early (before signs of herniation) in all large volume supratentorial hemispheric infarcts ( mortality reduced from 78%-29%).

No studies to date have indicated a benefit of prophylactic anticonvulsants after ischemic stroke.

Prophylactic enoxaparin 40mg od is recommended in all ischemic stroke patients and studies show no increase risk of hemorrhagic transformation. Enoxaparin was found to be superior to UFH.

The risk of developing DVT after TBI in the absence of prophylaxis is 20%

Thrombi in the proximal lower limbs are more likely to embolize

Mechanical thromboprophylaxis intuitively carries less risk of ICH progression without affecting MAP, ICP or CVP however does carry risk of local skin injury.

Studies have shown that pharmacological thromboprophylaxis is more efficacious than mechanical.

Level III evidence supports use of graduated compression stockings for DVT prophylaxis in patients with severe TBI unless lower limb injuries prevent their use.

Level III evidence supports the use of prophylaxis with low dose heparin or LMWH for prevention of DVT in patients with severe TBI

Brain trauma foundation recommendations (2007)

Administration of SQ LMWH or UFH in patients with ICH and/or IVH for DVT prophylaxis in the acute or sub acute period(2-5 days) is generally safe.

Retrospective analysis, no prospective data available yet.

AHA/ASA recommendation in 2011