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1
Management of
STROKE Kalkidan Gulilat , Sujin Kim (MMC 2nd yr)
2
Outline• Objective• Introduction and prevalence of stroke• Types and Risk factors of stroke• Primary and secondary prevention• Management and Rehabilitation• Summary• References
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Objective• know the different types of stroke
• Identify the signs and symptoms of stroke
• Describe the pathophysiology of both types of stroke
• Describe the primary and secondary prevention methods
• Identify the acute management of stroke
4
Introduction – Stroke
• apoplexy, cerebrovascular accident (CVA)
• is a sudden interruption of the blood supply to the
brain.
• a medical emergency
5
The Global burden of stroke
Source: http://www.world-stroke.org/advocacy/world-stroke-campaign - 2016
STROKE
15 million have a sroke
5th cause of death in 15- 59years old
2ND leading cause of
death >60 years old
six million die
• Every 53 sec some one will have a
stroke
• Every 3.3 min someone will die of stroke
6Source: World Health Statistics 2007
Trends in Global Deaths 2002-30
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Stroke in Ethiopia
http://www.cdc.gov/globalhealth/countries/ethiopia/ 2016 Data
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Time lost is brain lost!!
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Types of stroke
85%15%
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Embolic - cardiogenic sources such as atrial fibrillationThrombotic - associated with atherosclerotic plaque
Ischemic Stroke
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Ischemic stroke symptoms
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• ‘‘mini-strokes’’
• symptoms resolve completely (<24hr) and the person
returns to normal
Transient Ischemic Attack (TIA)
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Risk Factors for IS
Oral contraceptives, HRT
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Pathophysiology of IS
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Hemorrhagic Stroke
• weakened regions of blood
vessels rupture as a result of
increased pressure
• HTN, cocaine,Amphetamine
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Risk Factor of HS
Brain Aneurism
Arteriovenous malformation
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Type of Hemmorhagic stroke
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SSx of HS
• depressed level of
consciousness,
• higher initial blood
pressure,
• or worsening of
symptoms after onset
favor Hs
“Worst headache of my life”
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Remember
• determine cause of stroke before you start treatment
• emergency head CT scan
• No reliable clinical findings separate ischemia from
hemorrhage
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Management of a Stroke
21General Picture of Tx
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Primary and secondary prevention
• A- antiplatelet and anti coagulants
• B- blood pressure lowering medication
• C- cholesterol lowering, cessation of smoking
• D- diet
• E- exercise
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Asprin• Antiplatelet agent, irreversible COX inhibitor
• Prevent adhesion and aggregation of platelets
• dose of 81 mg enteric-coated aspirin is usually
started
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Platelet aggregation inhibitors• Abiciximab
• Clopidogrel, Ticlopidine
• Dipyridamole
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Warfarin• Oral anticoagulant
• Slow onset
• Narrow therapeutic index, teratogenic
• Drug- drug interaction – Inducers - phenytoin, rifampin, barbiturates
– Inhibitors – amiodarone,SSRI, cimetidine
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Lipid lowering drugs• ↓LDL
• Atorvastatin, Cholestyramine,
Ezetimibe
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Antihypertensive dugs• Diuretics- thiazide• ACE inhibitors – Enalapril• CCB, beta blockers
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Acute management
Harrison 19th ed. 2015 pg. 2560
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Treatment fall into 6 categories(1) Medical support (2) Intravenous thrombolysis(3) Endovascular techniques(4) Antithrombotic treatment(5) Neuroprotection(6) Stroke centers and rehabilitation
Acute management for IS
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(1) Medical support
•ABC •IV fluid•Cardiac monitoring & treat arrhythmia•Antipyretics
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• Should be normoglycemia (90-140 mg/dL) : Treat hypoglycemia(D50) & hyperglycemia(insuline)
• Candidates for IV fibrinolytic treatment Plus BP >185 /110 mmHg
First, labetalol, nitroglycerin paste, or IV nicardipine
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(2)Intravenous thrombolysis• Restore blood flow to ischemic regions of the brain
• “< 3H” : prevent neurologic deficits
tPA – the major tx of IS
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Exclusion Criteria for tPA Use
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(3) Endovascular techniquesOcclusions of large arteries(MCA, ICA, BA)
involve a large clot volume
failure to open with IV tPA alone.
thrombolytics via an intra-arterial route
• concentration of drug at the clot site
• systemic bleeding complications
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(4) Antithrombotic treatmentAsprin• Only antiplatelet agent
effective for the acute treatment of IS
• Use within 48 h of stroke onset : recurrence risk and mortality
Rivaroxaban• Selective inhibitor of factor Xa• “bridging anticoagulation”
Abiciximab, Ancrod (clinical trials)
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(5) Neuroprotection•NMDA receptor antagonist
Dextrorphan
•GABA agonistClomethiazole
•Free radical scavenger tirilazad
•Hypothermia, calcium channel blockers
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Treatment of Hemorrhagic stroke
Supportive therapy (no direct therapy)
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•Stablize vital signs
•Intubation and hyperventilation•Stop any medication that could increase bleeding (e.g. warfarin, aspirin).
•Evacuate the hematoma
•Measure and control the pressure within the brain
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Cont…• ICP
osmotic diuretics – mannitol Loop diuretics – furosumide
• Anti hypertensive : Beta blocker
• Vitamin K, Fresh frozen plasma• Acetaminophen : to reduce fever and headache
• Antiemetic agents : Promethazine
• Anti acids : for stress ulcers
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Rehabilitation
• Mobility
• Activity of daily living
• Communication
• Swallowing
Focuses on improving
• Shoulder pain
• Spasticity
42
Medical Interventions
• Skeletal muscle relaxants– Botulinum Toxin – regional nerve block– Diazepam, Baclofen, Dantrolene – systemic
• Anti depressant
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Tx of Stroke in Ethiopia• ABC, non contrast and contrast CT then• For IS:
• No rtPA (But it is on the Ethiopian Treatment Guideline)
• Asprin (80mg or 300 mg)• Heparin (first loading dose 10,000 IU and
then maintenance 5,000 IU)• Warfarin
• For HS: • Treat the HTN• No surgery unless the hemorrhage is
massive – blood enter in to the ventricles• For SAH = Nimodipine injection 1 mg/5mlSource:- Standard Treatment Guideline For General Hospitals, 2010- MCM physicians
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Summary• There are two types of stroke: Ischemic and Hemorragic.• The most common cause of
– ischemic stroke (IS) is cerebral infraction caused by thrombi or emboli.
– hemorrhagic stroke (HS) is hypertension.• The treatment goal is to restore cerebral perfusion (IS)
and to decrease the hypertension (HS)• The primary and secondary preventions aimed at
decreasing the risk factors.
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Reference• Harrisons principles of internal medicine, 19th edition, 2015• Applied Therapeutics: The Clinical Use of Drugs, 9th edition• Standard Treatment Guideline For General Hospitals, 2010• Pharmacology: Examination & Board Review, 10th edition• Lippincott illustrative Review of pharmacology; 6th ed., 2015• http://emedicine.medscape.com/• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585721/1/• http://
www.medicaldaily.com/birthcontrolpillsincreaseriskischemicstrokeonlycertainwomenstudy353634
• http://www.world-stroke.org/advocacy/world-stroke-campaign
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THANK YOU!