Management of ischemic and hemorhagic stroke

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

3

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

7

Stroke in Ethiopia

http://www.cdc.gov/globalhealth/countries/ethiopia/ 2016 Data

8

Time lost is brain lost!!

9

Types of stroke

85%15%

10

Embolic - cardiogenic sources such as atrial fibrillationThrombotic - associated with atherosclerotic plaque

Ischemic Stroke

11

Ischemic stroke symptoms

12

• ‘‘mini-strokes’’

• symptoms resolve completely (<24hr) and the person

returns to normal

Transient Ischemic Attack (TIA)

13

Risk Factors for IS

Oral contraceptives, HRT

14

Pathophysiology of IS

15

Hemorrhagic Stroke

• weakened regions of blood

vessels rupture as a result of

increased pressure

• HTN, cocaine,Amphetamine

16

Risk Factor of HS

Brain Aneurism

Arteriovenous malformation

17

Type of Hemmorhagic stroke

18

SSx of HS

• depressed level of

consciousness,

• higher initial blood

pressure,

• or worsening of

symptoms after onset

favor Hs

“Worst headache of my life”

19

Remember

• determine cause of stroke before you start treatment

• emergency head CT scan

• No reliable clinical findings separate ischemia from

hemorrhage

20

Management of a Stroke

21General Picture of Tx

22

Primary and secondary prevention

• A- antiplatelet and anti coagulants

• B- blood pressure lowering medication

• C- cholesterol lowering, cessation of smoking

• D- diet

• E- exercise

23

Asprin• Antiplatelet agent, irreversible COX inhibitor

• Prevent adhesion and aggregation of platelets

• dose of 81 mg enteric-coated aspirin is usually

started

24

Platelet aggregation inhibitors• Abiciximab

• Clopidogrel, Ticlopidine

• Dipyridamole

25

Warfarin• Oral anticoagulant

• Slow onset

• Narrow therapeutic index, teratogenic

• Drug- drug interaction – Inducers - phenytoin, rifampin, barbiturates

– Inhibitors – amiodarone,SSRI, cimetidine

26

Lipid lowering drugs• ↓LDL

• Atorvastatin, Cholestyramine,

Ezetimibe

27

Antihypertensive dugs• Diuretics- thiazide• ACE inhibitors – Enalapril• CCB, beta blockers

28

29

Acute management

Harrison 19th ed. 2015 pg. 2560

30

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

31

(1) Medical support

•ABC •IV fluid•Cardiac monitoring & treat arrhythmia•Antipyretics

32

• 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

33

(2)Intravenous thrombolysis• Restore blood flow to ischemic regions of the brain

• “< 3H” : prevent neurologic deficits

tPA – the major tx of IS

34

Exclusion Criteria for tPA Use

35

(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

36

(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)

37

(5) Neuroprotection•NMDA receptor antagonist

Dextrorphan

•GABA agonistClomethiazole

•Free radical scavenger tirilazad

•Hypothermia, calcium channel blockers

38

Treatment of Hemorrhagic stroke

Supportive therapy (no direct therapy)

39

•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

40

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

41

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

43

44

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

45

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.

46

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

47

THANK YOU!