ABC Stroke Treatment 062408

8/8/2019 ABC Stroke Treatment 062408

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Stroke

Infarction Hemorrhage

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Immediate Diagnostic Studies

All patients

Cranial CTscan

ECG

Bloodglucose Serumelectrolytes

Renal functiontests

CBC + platelet

PT + INR

aPTT

Selected patients

Hepaticfunctiontests

Toxicology screen

Bloodalcoholdetermination

Pregnancy tests

ABG

CXR

Lumbarpuncture

EEG

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Cerebral infarction

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Cerebral infarction

Acute phasey Admissiontostroke unit

y ABCs

y Maintenanceofnormal physiologic parameters Measurestorestorecirculation

y Thrombolysis within3hoursofstrokeonset

y Permissivehypertension

y TreatmentofCerebral edemaandraisedICPy Antiplateletandanticoagulantagents

y Surgery forsymptomaticcarotidstenosis

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Physical Therapy & Rehabilitation

Measuresto preventstrokeyAspirinvsAnticoagulation

y Hypotensive agentsy MaintainsystemicBP,oxygenation,

intracranial bloodflow duringsurgicalprocedures,esp elderly

y Lifestylemodification: Discontinuesmoking Low cholesterol, low fatdiets

y Cholesterol loweringagents

Cerebral infarction

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Stroke Units

This is geographic area within the hospital designated

for stroke and stroke-like patients, who are in need of

rehabilitation services and skilled professional care (by

personnel with special interest on stroke) that such a

unit can provide.

.

M.DennisandP.Langhorne,BMJ1994

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The Stroke Unit - Team

NutritionistsSocial Workers

Home Care CaseManagers

Occupational Therapists Speech Pathologists

Nurses Medical Doctors Physiotherapists

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Stroke Units

Organized stroke care has been shown to reduce mortality by

about 30% and improve outcome.

A large number of RCTs have compared care on generalmedical or other wards with that in an organized SU & a

meta-analysis has shown a convincing benefit.Stroke UnitTrialistsCollaboration2002.

CochraneDatabaseSystRev1:CD000197

Patients treated in a hospital with an acute SU had significantly

lower odds ratio for death of 0.89 (95 % CI 0.850.93).JarmanB, AylinP,Bottle A..

BMJ2004;328:369

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Stroke units

reduceddeathsduetosecondary complications

y careful andsystematicassessmentofdysphagia

y reductioninthe useofurinary catheters

y moreaggressivemanagementofinfections

y Programsofearly activationandmobilization

reducedisability (dependency) afterstroke

y morecoordinatedandfocused programofrehabilitationinvolving

patientsandcaregiversy moreintensive physiotherapy andoccupational therapy input

y patientmotivationandmorale

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General supportive care

Airway andventilatory support

Blood pressuremanagement

Cardiacmonitoring Control offever

Bloodsugarregulation

Fluidandelectrolytes

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Respiratory monitoring

Adequateoxygenationisimportanttopreservethe penumbra

Mostcommoncausesofhypoxemiain

strokey Previous pulmonary disease

yAirway obstruction

yAcuteaspiration

y Hypoventilationdueto largehemisphericinfarct orbleed,brainsteminvolvement,seizure,heartfailureand pulmonaryembolism

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Respiratory monitoring

nodatafavorO2administrationtoall strokepatients

O2administrationisrequiredincaseof

hypoxemia ( O2sat


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Blood Pressure Management

Why treat?

Worsenscerebral bloodflow

PromoteshemorrhagictransformationandICHaftert-PA

Why withholdtreatment?

Precipitousdeclinemay worsen

ischemia

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Guidelines in BP Management in

Acute Ischemic Stroke (first 5 days)

Avoid precipitousdrop inBP; not > 20% of baselineMAP

Donot userapidactingsublingual agents e.g.Nifedipine

Useeasily titratableIVanti-HPNmedications e.g.Nicardipine,Esmolol

Treatifwithany oftheff:SBP > 220orDBP > 120orMAP> 130mmHg

StrokeSociety ofthePhil..2002

WHO-ISH,1999

AHA ScientificStatement,2003

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Anti hypertensive Medications

Indicatedfor:

y aorticdissection

y acutemyocardial infarction

y heartfailure

y acuterenal failure

y hypertensiveencephalopathy

y thrombolytictherapy

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Cardiac monitoring

Cardiacenzymesmay beelevatedafter

stroke

15%to40%ofstroke patientsmay

experience

arrhythmias (AF)

congestiveheartfailure

AMI

suddendeath

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Cardiac monitoring

Athospital entry:ECGandclinical chemistry to

checkforconcomitantMI

Continuouscardiacmonitoringinthefirst48hours

ofstrokeonsety Abnormal baselineECG

y previousknowncardiomyopathies

y History ofarrythmias

y Heartfailure

y Unstableblood pressure

y infarctintheinsularcortex

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Body temperature

Body temperatureincreasein50%ofpatients

Why treat?y Feverincreaseinfarctsize

y Highbody temperatureincreasestrokeprogressionandbadoutcome

Why withholdtreatment?y Inc.temperatureis partoftheacute phase

response

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Body Temperature

Treatmentisadvisableiftemperature

>37.5C

85%offeverinstrokearedueto

infectiousdisease

Searchforpossibleinfectionis

necessary tostartappropriatetreatment

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Fluid and Electrolyte

All acutestroke patientsneedhydration

y D5containingandhypotonicsolutions (NaCl 0.45%)

arecontraindicated:riskofbrainedema

y Glucosesolutionsarecontraindicated:detrimentaleffectofhyperglycemia

y PNSSat80cc/hour

Hypokalemiamay appearduringinsulininfusion

Hyponatremiamay beconsequentto Inadequateantidiuretichormonesecretionsyndrome

Cerebral salt wastingsyndrome

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Hyperglycemia in Stroke

Accountsfor25to50%ofpatients

Associated with worseoutcomey increasescerebral edema

y hemorrhagictransformationofischemicstrokes

y increasesmortality withBS > 130mg%

EUSIand AHA Recommendations:

- Treathypoglycemia- GiveInsulinforBloodGlucose > 300mg%

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Effective Acute Stroke Treatment

based on Evidence

Treatment

Aspirin w/in48hrs.

Stroke Unit

rTPA

overall

0-3hours

3-6hours

NNT

81.1

19.3

18.3

9.1

33.6

BussiereM,WiebeS,etal

Can. J.Neurol.Sci.2005;32:440-49

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IV tPA - Acute Ischemic Stroke Inclusion Criteria*

Age18through79 years

Clinical diagnosisofischemicstrokecausingameasurableneurologicdeficit.

Reliably timedonsetofsymptomsofischemicstroke within3hoursofthetimetoinitiationoftreatment withintravenoustPA

*Adaptedfromguidelines publishedby the AmericanHeart Associationand American Academy ofNeurology.Stroke1996;27:1711-1718.Neurology 1996;47:835-839

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IV tPA - Acute Ischemic Stroke

Exclusion Criteria

Symptomsrapidly improvingorvery minor

HemorrhageonCTscan glucose < 50or> 400,Hct 80 (unknown) Signsofavery severestroke Early ischemiaCTchanges

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NINDS tPA Stroke Trial

0

10

20

30

0

10

20

30

tPA tPAPlacebo Placebo

31

20 9

8

20

1

NIHSS Excellent

Recovery (%)Total Death

Rate (%)

Hemorrhagep < .05

NEJM,199526


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rTPA RULE of 3

ShouldbegivenduringtheFIRST3

HOURS

30% will improve (completerecovery or

milddeficit)

Improvementseenin3months

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Stroke: The Challenge

Only 1-3%ofall strokevictimsreceive

treatment withtPA inthe US

25%ofAcuteMI patientsreceivetreatment(lyticsorPTCA) inthe US

Meantimeto presentation

yAMI:

3hrs

yAcuteStroke:4-10hrs

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Early secondary prevention

RiskofrecurrentstrokefollowingstrokeorTIA was

thoughttobeabout10%.

Recentstudieshavesuggesteditismuchhigherthanthis withariskof:

first7days 812%

1month1 115%

3months 1718.5%

JohnstonSCetal.JAMA 2000;284:2901-2906.

LovettJK,etal.Stroke2003;34:e138-e140.

Coull AJ,etal.BMJ2004;328:326328

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EUSI and AHA:Heparin in Stroke

1.Norecommendationforgeneral useof heparin,LMWH

orheparinoidsafterischemicstroke (Level I)

2.Full doseheparinforselectedindicationssuchas AF,

othercardiacsources withhighriskofre-embolism,

arterial dissection,orhighgradearterial stenosis (LevelIV)

3.DVT-prophylaxis

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Aspirin in Acute Stroke

Recommendation:160to325mg/day within24to48hours

Avoidin potential candidatesforthrombolytictherapy

Delay forat least24hoursaftertheadministrationofrtPA

Donotadminister prehospital (i.e. pre-CT)

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Antiplatelet & Anticoagulant therapy

Aspirin reduces the risk of recurrent ischemic stroke byb

18 %. Aspirin is as effective or more effective than anticoagulation in

non-cardioembolic stroke prevention.

Warfarin is not recommended for non-cardioembolic strokes.

.

.

AntithromboticTrialistsCollaboration.

BMJ2002;324:71-86

MohrJP,etal.NEJM2001;345:14441451.

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CAPRIE trialy Patients treated with clopidogrel had a 5.32%

annual risk of ischemic stroke, myocardial infarctionor vascular death whereas patients treated withaspirin had a 5.83% annual risk of the same events.

.

ESPS2 study

y dipyridamole + ASA may be more effective than

aspirin alone

y criticized for the low dose of aspirin used

CAPRIESteeringCommittee.Lancet1996;348:13291339

DienerHC,etal.

JNeurol Sci1996;143:1-13.

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Warfarin is the treatment of choice in patients withAF

b 60% reduction of stroke in the primary preventionof stroke in AF

.

All patients with AF should be considered for

warfarin therapy unless there are

contraindications. A similar benefit is found in the secondary

prevention of stroke in patients with AF..

HartRG,etal.

AnnInternMed1999;131:492-501

EAFT (European Atrial Fibrillation

Trial) Study Group.Lancet1993;342:1255

1262

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Any agentisbetterthannoagent!!

IfBP > 20/10abovegoal,initiate Rx with 2

medications!!

Thechoiceofspecificdrugsandtargetsshouldbe

individualizedonthebasisofrevieweddataand

considerationofspecific patientcharacteristic (ex,DM,

renal impairment,etc)

Antihypertensive treatmentAntihypertensive treatment

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Diabetes control

Morerigorouscontrol ofHTNanddyslipidemiashouldbeconsideredin patients withDM (BPtargetsof130/80mmHg)

AC

EIsand ARB

sarerecommendedasfirst-choicemedicationsforpatients withDM

Glucosecontrol isrecommendedtonearnormoglycemiclevelstoreducemicrovascularcomplicationsandpossibly macrovascularcomplications

Hemoglobin A1cgoal


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Statin therapy

Statin therapy q risk of vascular events (including

myocardial infarction, cardiovascular death, and

stroke) by b 25 %

.

AmarencoP,etal.CerebrovascDis2004;7(Suppl

1):8188.

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Revascularization procedure

Endarterectomy forpatients with

symptomaticcarotidartery stenosis

>70%effectiveinreducingincidenceof

ipsilateral hemispheral stroke

Carotidangioplasty andstenting

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Intracerebral hemorrhage

Accountsfor10-

30%ofall stroke

hospital admissions

30day Mortality~35-52%;halfinthe

first2days

Only 20%ofICH

patientsfunctionallyindependentat6

monthsBroderick J et al. Stroke 2007; 38: 2001-23

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ICH score

0

13

26

72

97100

0

10

20

30

40

50

60

70

0

90

100

30DM

ortlity

%

0 1 2 3 4 5

IC Score

Component Points

GCS

3-4

5-12

13-15

2

1

0

IC vol>30

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Management Goals

Stop orslow initial bleedingduringfirsthoursafteronset

Removebloodfrom parenchymaor

ventriclestoeliminatemechanical andchemical factorscausingbraininjury

Managementofcomplicationsofbloodinthebrain (increasedICP,decreased

cerebral perfusion) General supportivemanagement

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ICH related to Anticoagulation

Occurs withafrequency of0.3-0.6% peryearin patientsonchronic warfarintx

OAT useincreasesriskforICH, worsenstheseverity ofICHandsignificantlyincreasesthe likelihoodofdeath whenICHoccurs

Hematomaexpansionmaybebemorecommonandoccurovera longertime

frame Riskfactors:age,history ofhypertension,

intensity ofanticoagulation,associatedconditionssuchasCAA, leukoaraiosis

Hart RG, et al. Stroke 2005; 36: 1588-93

SteinerT, et al. Stroke 2006; 37: 256-62

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EUSIRecommendations

NormalizationofINR (1.5,considerredosing w/ reduceddose

y FFP 10ml/kg will reduceanINRof4.2to2.4,anINRof3.0

to2.1,oranINRof2.4to1.8

ToreduceanINRof4.2to1.4 wouldrequire40ml/kg

y VitamineK 1-2x5-10mgPO orIV

Cerebrovasc Dis 2006; 22: 294-31643


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EUSIRecommendations

NormalizationofPTTafterheparin

y Protaminesulphate

1.0-1.5ml protaminesulfateinactivates1000

IU heparinofthetotal amountapplied withinthe last4hrs

PreventionofDVT

y Compressionstockings

y Low doseheparin/heparinoids

Cerebrovasc Dis 2006; 22: 294-31644


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ICH related to Fibrinolysis

SymptomaticICH

y 3-9%ofpatientstreated w/ IVtPA

y 6%ofpatientstreated w/ IV + IA tPA

y 10.9% w/ IA prourokinase

y 30Dmortality >60%

Noreliabledatare:treatment

Currentrecommendedtherapy:y Plateletinfusion (6-8U) andcryoprecipate

Broderick J et al. Stroke 2007; 38: 2001-23

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Management Goals

Stop orslow initial bleedingduringfirsthoursafteronset

Removebloodfrom parenchymaor

ventriclestoeliminatemechanical andchemical factorscausingbraininjury

Managementofcomplicationsofbloodinthebrain (increasedICP,decreased

cerebral perfusion) General supportivemanagement

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Surgical Treatment ofICH

Craniotomy

Minimally invasivesurgery

y Endoscopicaspirationofhematoma

y Stereotactic placementofflexiblecatheter

followedby administrationofthrombolytic

agents

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STICH

Early surgery vsinitial conservativetherapy

N = 1033

Inclusioncriteriay CTevidenceofspontaneoussupratentorial

ICH w/in72hours

y Neurosurgeon uncertainofbenefitsofeither

treatmenty Minhematomadiameter2cm & GCS > 5

Mendelow AD, et al. Lancet 2005; 365: 387-397

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STICH


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Surgical Treatment ofICH

Cerebellarbleed

y No prospectiveRCT

y Patients w/ cerebellarhemorrhage >3cm

whoaredeterioratingneurologically orwhohavebrainstemcompressionand/or

hydrocephalusfromventricularobstruction

shouldhavesurgical removal ofthe

hemorrhageassoonas possible


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Treatment ofoICP

Headofbedelevation

CSFdrainage

Analgesiaandsedation

Neuromuscularblockade

Osmotictherapy

Hyperventilation

Barbituratecoma

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Hyperosmolar therapy

Studiesonmannitol,glycerol,and

steroidshavebeendisappointing

Therapy shouldbedirectedat patients

withdeteriorationsecondary tomass

effectorhydrocephalus

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Brain supportive therapy

Blood pressuremanagement

Ventilatory support

Glucosecontrol

Fevercontrol

Managementofseizures

Nutritional supplement

ProphylaxisforDVT

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Guidelines for BP management

SBP >200orMAP >150

yAggressiveBP lowering w/ IVantiHPN, w/

BPmonitoringq5min

SBP >180orMAP >130y w/ o ICP monitorICPandreduceBP w/

intermittentorIVmedstokeep CPP >60-80

y w/ normal ICP reduceBPtoMAP=110or

BP160/90 usingintermittentorIVmeds;

monitorpatientq15min


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Brain supportive therapy

Antiepilepticdrugs

y SeizuresafterICH

occurredatonsetin4%ofpatients

30day riskofseizure postICH- 8%

y cEEGabnormal in28%in1st 72hrs

Associated w/ higherNIHSSscoresandmidlineshift

trendtowards pooroutcome

y Lobarhematomasassociated withearly seizures

y NoRCTre: prophylactic AED use

Passero et al. Epilepsia 2002; 43 (10): 1175-80

Vespa et al. Neurology 2003; 60: 1441-6

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MariaLeticia Araullo,MDFPNA

Neurologist Psychiatrist

Documents

ABC Stroke Treatment 062408