The modern management of s-t-r-o-k-e

Tom Hughes

Royal Glam

May 2014

Acknowledgements

• Neuroradiology colleagues (Shawn Halpin, Maggie Hourihan, Yogish Joshi)

• Neurology SpRs• Neurology colleagues• Radiographers and research pharmacists• Dr Hamsaraj Shetty, Dr Shak Ahmad, Dr Susan

White• Welsh Ambulance service• Dr Suzanne Wyatt and Dr Jo Mower (EU)• IST3 trial organisers

– Peter Sandercock, Karen Innes, Mat Williams

The lecture

• A review of thrombolysis• A review of the relevant anatomy and

pathology• I will try not to use the word S-T-R-O-K-E

Time to open up the dorma windows of the discussionThe ABCDE approach

ArteryBrainClinical FeaturesDiseaseEvidence

Three types of artery to consider in cerebrovascular disease

Large artery occlusions

Lenticulostriate perforators Leptomeningeal perforators

(small arrows)

The ABCDE approach: large artery

Artery Brain Clinical features

Disease Evidence

Large artery e.g. MCA

Cortex Cortical deficits e.g. Dysphasia, dyscalculia, apraxia etc.

Embolic Warfarin in AFEndarterectomyAntiplateletsStatinsBP treatment

Right and left cerebral cortex do different things

Cortex

The ABCDE approach: large artery

Artery Brain Clinical features

Disease Evidence

Large artery e.g. MCA

Cortex Cortical deficits e.g. Dysphasia, dyscalculia, apraxia etc.

Embolic Warfarin in AFEndarterectomyAntiplateletsStatinsBP treatment

CHADS2 Scoring Scheme

• C Congestive heart failure 1• H Hypertension 1• A Age > 75 years 1• D Diabetes Mellitus 1• S2 Prior Stroke or TIA 2

Annual Stroke Risk with Respect to CHADS 2 Score (1)

• CHADS2 Stroke Risk % 95% CI• 0 1.9 1.2-3.0• 1 2.8 2.0-3.8• 2 4.0 3.1-5.1• 3 5.9 4.6-7.3• 4 8.5 6.3-11.1• 5 12.5 8.2-17.5• 6 18.2 10.5-27.4

Anticoagulation based on CHADS2 score

Score Risk Anticoagulation therapy

0 Low Aspirin

1 Moderate Aspirin or Warfarin

2 or greater Moderate or High

Warfarin

CHA2DS2-VASc scoreIf 2 or above give warfarin, <2 think!

• Feature Score• Congestive Heart Failure 1• Hypertension 1• Age >75 years 2• Age between 65 and 74 years 1• Stroke/TIA/TE 2• Vascular disease (previous MI, peripheral arterial

disease or aortic plaque) 1• Diabetes mellitus 1• Female 1

The ABCDE approach: lenticulostriate

Artery Brain Clinical features

Disease Evidence

Lenticulostriate Internal capsule, basal ganglia

Pure motor and sensory

In-situ obliteration causing lacunes

Traditional secondary prevention?

Involvement of internal capsule and basal ganglia

The ABCDE approach: lenticulostriate

Artery Brain Clinical features

Disease Evidence

Lenticulostriate Internal capsule, basal ganglia

Pure motor and sensory

In-situ obliteration causing lacunes

Traditional secondary prevention?

The ABCDE approach: leptomeningeal perforators

Artery Brain Clinical features

Disease Evidence

Leptomeningeal perforators

Perventricular white matter

Gait apraxiaPreserved “bed cycling”Subcortical dementiaIncontinence

Leukoaraiosis Not clear

White matter tracts

Superior longitudinal fasciculusInferior longitudinal fasciculus

Arcuate fasciculusUncinate fasciculus

Things have changed!89-year-old female

We are changing things!

What is all the fuss about?

Cochrane

Death, dependency and good outcome in randomized trials of rt-PA given within

3 hours of acute ischaemic stroke

17.3

38.4

44.3

18.4

51.4

30.2

0

20

40

60

80

100

Thrombolysis Control

Alive andindependent

Alive butdependent

Dead

Differences/1000: 141 extra alive and independent (P<0.01)130 fewer dependent survivors (P<0.01)12 fewer deaths (NS)

Cochrane Library 2003

(3 trials, n=869)NNT 10

4.5 hours....it is difficult

• A perfect perfect clinical storm– A health service not used to dealing with stroke as an

emergency (3-6 hours)– No pain or bleeding, no spots or screaming, – Negative rather than positive signs– Common condition– Lots of mimics– An evolving story– Immature signs– Shortage of time– CT scan (plain) which is not always diagnostic (excludogram)– Dangerous treatment

But it is happening........

Inclusion criteria

• Inclusion Criteria used in the SITS-MOST study of relevance to the on-call general physician

• Male or female aged 18-80 years old• Clinical diagnosis of ischaemic s---e• Onset of symptoms within three hours/4.5hours

of predicted initiation of thrombolysis• S---e symptoms present for at least 30 minutes,

without significant improvement before commencement of therapy

Exclusion criteria used in the SITS-MOST study of relevance to the on-call general physician

• Evidence of intracranial haemorrhage (ICH) on the CT scan

• Duration of symptoms >3 hours/4.5hours from likely time of initiation of tPA infusion, or time of symptom onset not known

• Minor neurological symptoms or symptoms rapidly improving

• Severe s---e as assessed clinically or by appropriate imaging techniques

Exclusion criteria used in the SITS-MOST study of relevance to the on-call general physician

• Seizure onset at s---e onset• Symptoms suggestive of subarachnoid

haemorrhage, even if the CT scan is normal

• Administration of heparin within the previous 48 hours and a thromboplastin time exceeding the upper limit of normal

• Past history of s---e and concomitant diabetes (controversial)

Exclusion criteria used in the SITS-MOST study of relevance to the on-call general physician

• Previous s---e within last three months• Known platelet count of <100,000/mm3• Systolic blood pressure >185mmHg or

diastolic blood >110mmHg, or the need to treat aggressively with IV medication to achieve these levels.

• Blood glucose <50 or > 400mg/l • Known haemorrhagic diathesis

Exclusion criteria used in the SITS-MOST study of relevance to the on-call general physician

• Warfarin therapy (although it is considered appropriate if INR<1.4)

• Recent or current bleeding• Known history of or suspected intracranial

haemorrhage• Presenting symptoms and signs, or disability,

likely to be due to recent or past subarachnoid haemorrhage

• Known CNS disease e.g. neoplasm, aneurysm, past intracranial or spinal surgery

• Haemorrhagic retinopathy

Stop tPASeek immediate medical advice-recheck Bp in 5 mins if lowered –recommence Tpa BP stable if still elevated commence treatment If Systolic 185 mmHg or Diastolic 110mmHg

First Line:Labetalol 10mg IV over 2 minutes. May repeat or double every 10 minutes to a total dose of 150mgOr: give initial dose then infusion at 2mg/min, titrated to 8mg/min as neededSecond line: Administer GTN 10micrograms/min & titrate

Stop tPASeek immediate medical adviceAdminister oxygen if sats lowGive Hydrocortisone 200mg and Chlorpheniramine 10mg IVIf circulatory collapse and IV access give 100micrograms (1ml) to 200micrograms (2ml) of 1 in 10,000 IV Epinephrine then review response (NB no IM epinephrine)

Anaphylaxis

Hypertension

Suspected bleeding– Stop tPA!

• Suspect if headache, nausea and vomiting, fall in GCS, new focal neurological signs or acute hypertension

• Check bloods for APPT, INR, FBC, group and save and clotting screen • Arrange urgent CT scan• If Intracerebral or life - threatening systemic bleeding give the following:• Administer Fibrinogen Concentrate • A standard dose of fibrinogen for an average size person would be about 4gm

and then check the fibrinogen straight after the infusion.• In addition if severe beleeding consider an anti-fibrinolytic ie tranexamic acid

500mg IV 6 hourly in the acute phase. •  If platelets below 100 and life threatening bleed or ICH administer platelets • All available from Blood bank •  NB fibrinogen concentrate is not licensed in the UK and so would be on a

named patient basis

But what are we dealing with?

• Justification for not using the s---e word

Conclusions

• Think anatomy first• Then pathology

• Thank you