stroke

Department of Neurology, UK 2. LFAleš TomekDecember 2010

Evidence based therapy of strokeČNS ČLS JEP – Czech guidelineswww.cmp.cz

ESO Guidelines ischemic 2009, ICH 2006 www.eso-stroke.org

AHA-ASA Guidelines ischemic 2009, SAH 2009, ICH 2010www.americanheart.org

Reading

Tomek et al. Neurointenzivní péče 2012

Školoudík et al. Neurosonologie 2003Uchino et al. Acute stroke care 2011Mohr, Choi, Grotta et al. Stroke 2008Caplan’s Stroke, 4th ed. 2009

Stroke typesSTROKE

Ischemic

TIA

RIND

Completed stroke

ICH

SAH

Venous thrombosis

3rd most frequent cause of death

11 640 200711 685 200812 192 200911 567 201032 deaths per day(Deaths – total in 2010 - 106 844

persons)

Epidemiology in Czech Rep.

www.uzis.cz 9/2012

Hospitalisations I60-6957 484 (2010)853 078 days

Hospitalizations

www.uzis.cz

Hlavní příznaky - FAST (Face Arm Speech Test) 1x

Clinical signs – minor (2x)Acute• Coma• Hemihypesthesia• Dysarthria• Hemianopia• Diplopia• Headache• Meningeal signs• Vertigo with nausea

Clinical examination and signs

FAST FaceArmSpeechTest

Internal Esp. cardio-

pulmonaryNeurological Consciousness Speech, mnestic

and cognitive, neglect

Cranial nerves Motoric and

sensory

Stroke scales COMA

GLASGOW COMA FOUR SCORE

ACUTE ISCHEMIC NIHSS

ICH ICH SCORE

SAH HUNT HESS WFNS (WORLD FEDERATION OF NEUROSURGEONS)

OUTCOME MODIFIED RANKIN SCALE

Prehospital care

ABCCorrect diagnosis or suspicion of

stroke (FAST)Do not lower blood pressure

(220/120) Immediate transportation to stroke

center

Situace u nás 2013

Tvorba sítě iktových center (Věstník 2 a 8/2010 MZd ČR), start 1.1.2011

KCC (komplexní cerebrovaskulární centrum) 10 center

IC (iktové centrum) 1. vlna - 23 center 2. vlna – 12 center

Soláň 13. - 14. 1. 2012

Ústecký krajI. MNULII. ChomutovII. DěčínII. Teplice Liberecký kraj

I. KN LiberecII. Česká Lípa

Jihočeský krajI. Nemocnice Č. BudějoviceII. Nemocnice Písek

Královéhradecký kraj I. FN Hradec KrálovéII. Obl.nem.Trutnov

Jihomoravský krajI. FNUSA + FN BrnoII. BřeclavII. Vyškov

Moravskoslezský krajI. FN Ostrava II. MN OstravaII. Vítkovická nemocniceII. KrnovII. Třinec II. Karviná

Olomoucký krajI. FN Olomouc

Kraj PrahaI. Nemocnice Na HomolceI. ÚVNII. FN Motol II. VFNII. FNKV + FTNsP

Plzeňský krajI. FN Plzeň

Karlovarský krajII. Nem. Sokolov

Zlínský krajII. Krajská nem. T. Bati Zlín

Kraj Vysočina

II. Nemocnice Jihlava

Středočeský krajII. KolínII. Kladno

Pardubický kraj II. PardubiceII. Litomyšl

Komplexní cerebrovaskulár

ní a iktová centra

Soláň 13. - 14. 1. 2012

Ústecký krajÚstí n. LabemChomutovDěčínTepliceNem. Litoměřice

Liberecký kraj KN LiberecČeská Lípa

Jihočeský krajI. Nemocnice Č. BudějoviceII. Nemocnice Písek

Královéhradecký kraj FN Hradec Králové Obl.nem.TrutnovObl. Nem. Náchod

Jihomoravský krajFNUSA + FN Brno BřeclavZnojmoVyškov

Moravskoslezský krajFN Ostrava MN Ostrava Vítkovická nemocniceKrnovTřinec Karviná

Olomoucký krajIFN OlomoucProstějov

Hl. m. PrahaNemocnice Na HomolceÚVNFN Motol VFNFNKV + FTNsP

Plzeňský krajI. FN Plzeň

Karlovarský krajNem. SokolovNem. Karlovy Vary

Zlínský kraj Zlín (T. Bati)Uh. Hradiště

Kraj Vysočina

JihlavaNové Město na Moravě

Středočeský krajKolínKladnoMladá BoleslavPříbram

Pardubický kraj Pardubice Litomyšl

Komplexní cerebrovaskulár

ní a iktová centra

TIA x ischemic stroke

TIA x RIND x completed stroke 35% of TIA’s have DWI MR lesions Same mortality and morbidity as

minor stroke AHA-ASA 2009 new definition of TIA:= tissue definition

No signs of acute MR or CT lesion

Stroke imaging - CT

• Gold standard• ischemic / hemorhagic + availability, speed, senzitivity for

hemorhagy,... - negative first 3-6 hours, poor for

brainstem

ischemie

hemorhagie

Early CT diagnostics of stroke

Native CT – markers of early ischaemia:

Early hypodenzityLower difference between gray x white matter Lost gyrification (SA space)Dense artery sign (MCA)

MR diagnostics of stroke More senzitive for smaller strokes

and for brainstem Early vs. Old ischemic stroke (DWI) Availability and duration of exam

ischemie

ischemie

akutní ischemie

Penumbra concept

Penumbra

Benign oligemia

Ischemic core

CBF < 10 ml/100g/min (< 20%)Cytotoxic oedema + neuronal cell deathCBV, CMRO2 decreased to zeroOEF 100%CBF 10-18 ml/100g/min

Cell death without reperfusionLoss of function of neuronsOEF 100% can not stop decline CMRO2

Normal tissue CBF 20-50 ml/100g/minSurvives without reperfusionElevated oxygen extraction fraction (OEF) Normal cerebral metabolic rate of oxygen (CMRO2)

CBF 50-60 ml/100g/minFunctional for CPP 60-130 mmH, changes CBV Warach S. Stroke 2001;32:2460-2461.

DWI PWI mismatch

24 hours later….

CT Perfusion

CT angiography

Ultrasound (TCD and carotid)

MR angiography

DSA – digital subtraction angiography

Strategy of ischemic stroke therapyRecanalizationNeuroprotectionTherapy of complications (oedema,

epilepsy, infection…)Secondary prevention of recurrent

strokeRestoration of function

(physiotherapy, occupational therapy

The only causal therapy - recanalization

Katzan et al, Arch Neurol 2004Thomas et al, N Engl J Med 2006

Intravenous

thrombolysisIntraarterial

thrombolysisMechanical

recanalizationSonothrombotrip

sy2 - 30% patients with stroke

IVT

“Time is brain”

NNT 2

NNT 7 (3,1)

NNT 14

Saver JL. Stroke 2006;37(1):263-6.Hacke W et al. NEJMN 2008;359:1317 29.

Every 1 minute: • 1 900 000 neurons• 14 000 000 000 synapsis• 12 km of myelinated fibers

90 minutes

180 minutes

270 minutes

rtPA (Actilyse) r-TPA (Actilyse)

0,9mg/kg, max. 90 mg t½= 3-8min

IVT limitations

CT or MR without bloodMax. 4,5 hours after beginningMin. 30 min of durationSerious disability NIHSS 4 – 25 (relative)Age 18-80 (relative)

Rescue therapy after IVT

Assessment of efficiency Examination in 60. minute Recanalized only in 40-50% cases, early

reocclusion, recanalisation does not mean clinical effect

Our goal: What happened during IVT? TCCS or NIHSS (40% points down) Ultimate DSA (after 30/60 minutes)

RESCUE = mechanical

Intraarterial thrombolysis – IATCombined IVT + IAT

Sonothrombotripsy

Mechanical recanalization MERCI

Experimental methods PTA balloon angioplasty and stenting +/- IAT laser microcavitation: LaTIS, EPAR Ultrasound cavitatione: Ekos, ACS Thrombus aspiration: AngioJet, Oasis, Neurojet

Solitaire FR

Solitaire FR

Solitaire FR

Stroke diagnosisIschemic 85%Before 4,5 hours

IVT

4,5 – 8 h w. penumbra

4,5-6 IA

4,5-8 IA, mech,

TT

After 4,5 hrs. Wo. penumbra

ICH 12-15%SAK 1%Correction of hemostasis and oedema

Timetable of stroke th.

Secondary prevention

Antithrombotic Antiplatelet Anticoagulation (VKA)

ACEI or AT1 blocker, diuretic

Statine

TOAST subtypes

TOAST, Adams et al, Stroke 1993N = incidence for 100 000 persons, Kolominsky-Rabas et al, Stroke 2001

Small vessel disease25.8/100 000

Large vessel disease15.3/100 000

Cardiogenic30.2/100 000

Other known2,1/100 000

Cryptogenic39,3/100 000

Cerebral veins (sinuses) thrombosis = CVT

Therapy of CVT

Anticoagulation (3, 6 months, chronic)

Lifestyle changes (smoking, hormonal, drinking)

Depends on etiology of thrombofilic state Inborn (Leiden, homocysteine…) Acquired (hormonal, posttraumatic, post

infection, surgery…etc)

Intracerebral hemorrhage (ICH)

Dynamics of ICH

**Kazui et al. Stroke. 1996;27:1783-1787.*Brott et al. Stroke. 1997;28:1-5

First 24 hrs– 20*-36%**volume progression(majority first 3 hours)

Treatment options in ICHTherapy

Stabilisation of hemostasis

Blood pressure correction

Surgery – treatment of mass effect and

of source of bleeding

Antioedematous therapy,

decompression

EVD, shunts

DiagnosticsCT

AngiographyMRI + MRA

RHB

Bleedingprogression

24hrs

Brain oedema3-5.day

Hydrocephalus

14 days

RHB

Hypertension

Goal – 140/90 Hypertonics Aim 120 MAP (160/100), maximum 180/105, no more than

than 20% Normotonisi – aim 110 MAP (150/90),

max.160/95 ABP monitoring , i.v. therapy (Urapidil,

Esmolol, Enalapril, Nitroprusid)

hemostasis APTT, Quick, trombocytes Trombocytes

treat <75 000, substitution in caso of antiplatelet medication

Warfarine INR <8 FP 2-3 TU INR >8 FP 6 TU Better concentrated prothrombin complex (fa. II, VII,

IX, X) Prothromplex Total TIM4 rFVIIa – best ever- 10 minutes (10-40 μg/kg) Vitamin K - after 6-12 hoours

Heparine protamine sulphate (1mg/100 IU, max. 50mg/10 min)

SurgeryCraniectomy (mass + source)Stereotactic – event. + rtPAExternal ventricular drainage

– event. + rtPA

Surgery yes: Cerebellar above 10ml (>3-4cm) + GCS

=<13 Lobar superficial (temporal lobe) 10-

40ml or with later clinical progression Typical BG initialy 10-30ml with good

clinical state and later worsening (first 24-48 hrs)

ICH score 3 and age under 50 years Ultimum refugium in case of cranio-

caudal deterioration

Secondary prevention of ICH

PRIMARY 80% Recurrence/ yearHypertensive microangiopathy 2%Amyloid angiopathy 10,5%AVM 18%Cavernous angioma 4,5%

SECONDARY 20%Tumors

Exclude the source of bleeding (if possible)HypertensionCorrection of bleeding disorders and exclusion of anticoagulantsLifestyle - smoking, alcohol

Subarachnoidal hemorrhage (SAH)

SAH diagnostics

Headache 97%Meningeal syndrome (after 6-24

hrs)Nausea, vomitting, loss of

conscioussness + neurological deficite

Grading by Hunta and Hess HH 1-5 or WFNS

Diagnostic problems with HH1 – CSF exam.

In the first 24 hours DSA – to find and treat source of bleeding

SAH: Coiling x Cliping

Specific complications of SAHRebleeding (7%)- Majority in the first two weeks (4% first

day, after that 1,5% daily for the first 2 weeks)

Hydrocephalus (20%)- Obstruction type acute (EVD),

hyporesorbtive type later (shunting)

Vasospasms (46%)- Max. 5. – 12. day- TCD daily