Acute Stroke Management

Dr. FAWAZ AL-HUSSAIN FRCPC, MPH(HTA)May 25th/10

For

Internal Medicine Residents

Stroke In Saudi Arabia:

No good studies Estimated to affect 40.000 annually 85% ischemic ½ large artery (cardiogenic or A-A) ½ lacunar Review traditional and non-traditional risk

factors. And which ones are modifiable?

Could it be a stroke?

60 y/o man with sudden difficulty in talking without focal weakness or numbness.

55 y/o lady with sudden diplopia. 25 y/o man with headache, N/V, P/P and Rt arm

weakness. 68 y/o man with sudden confusion. 52 y/o woman with sudden decrease vision in

both eyes.

Common acute stroke presentation based on arterial distribution:

ACA MCA M1 Supperior M2 Inferior M2 PCA Basilar Sup. Cerebellar artery Wallenberg (lateral medulary syndrome)AND 5 Kinds of lacunar strokes (motor, motor & sensory,

sensory, ataxic hemiparesis, and dysarthria-clumbsy hand syndrome)

Acute Stroke Care:

Prehospital management Emergency evaluation and diagnosis Acute treatment: thrombolytics and

endovascular intervention Anticoagulants/ antiplatelets General acute treatment, including hypertension Treatment of acute neurological complications Secondary stroke prevention

Pre-hospital Mx:

Guidelines for EMS Management of Patients withSuspected Stroke:

• Manage ABCs• Cardiac monitoring• Intravenous access• Oxygen (keep O2 sat >92%)• Assess for hypoglycemia• NPO• Alert receiving ED• Rapid transport to closest appropriate facility capable of treating acute stroke

Not Recommended:• Dextrose-containing fluids in non-hypoglycemic patients• Excessive blood pressure reduction• Excessive IV fluids

EMERGENCY EVALUATION AND DIAGNOSISOF ACUTE ISCHEMIC STROKE

Class I Recommendations:

1. Organized protocol for the emergency evaluation of pts

with suspected stroke. Goal is to complete evaluation

and decide treatment within 60 minutes of pt arrival in

ED (Head CT within 25 minutes of ED arrival, study

interpretation within 20 minutes). Careful clinical

assessment, including neuro exam.

2. Use of stroke rating scale, preferably NIHSS.

EMERGENCY EVALUATION AND DIAGNOSISOF ACUTE ISCHEMIC STROKE

Class I Recommendations:

3. Limited number of hematalogic, coagulation, andbiochemistry tests are recommended during initialemergency evaluation CBC, lytes, cr, INR,PTT, Trop.,glucose

• Time is critical: thrombolytic tx should not be delayedwhile waiting for results of PT/PTT or platelet count,unless bleeding abnormality/thrombocytopeniasuspected, pt taking warafarin and heparin, oranticoagulation use suspected.

EMERGENCY EVALUATION AND DIAGNOSISOF ACUTE ISCHEMIC STROKE

Class I Recommendations

4. Pts with clinical or other evidence of acute cardiac or pulmonary dz may warrant chest x-ray.

5. ECG recommended because of high incidence of heart disease in pts with stroke.

Emergency evaluation and diagnosis

Class I recommendations:

1. Imaging of brain recommended before initiating anyspecific tx to treat acute ischemic stroke

CT(brain) is still preferred availability, time, easier to R/O hgeLimitation: pregnancy

Class II recommendations:

1. Data insufficient to state (except for hemorrhage) thatany specific CT finding should preclude treatment ofTPA.

Acute stroke imaging:

Hypo-attenuation of brain tissues Loss of sulcal efffacement Insular ribbon sign Obscuration of lentiform nucleus Hyperdense sign (MCA>basilar>PCA)

THROMBOLYTICS: IV-TPA

Class I recommendations:

1 .IV-TPA is recommended for selected pts who may be

treated within 4 1/2 hours of onset of sxs of ischemic

stroke.

2 .Besides bleeding complications, physicians should be

aware of potential side effect of angioedema that may

cause partial airway obstruction (new

recommendation.)

THROMBOLYTICS: IV-TPA

Original NINDS trial:

• Absolute difference in favorable outcome of tPA versus

placebo was 11-13% across the scales

• Depending upon the scale, the increase in relative

frequency of favorable outcome in patients receiving tPA

ranged from 33% to 55%.

• The effect of tPA was independent of stroke subtype,

with beneficial effects seen in those with small vessel

occlusive, large vessel occlusive and cardio-embolic

induced ischemia.

Original NINDS trial:

• Approximately 6% of the r-tPa treated patients

sustained a symptomatic ICH within 36 hours following

treatment compared with 0.6% of patients receiving

placebo.

• Half of the tPA associated symptomatic hemorrhages

were fatal, however tPA treatment was not associated

with an increase in mortality in the three-month outcome

analysis.

THROMBOLYTICS: IV-TPA

Class I recommendations:

1. IA thrombolysis is an option for treatment of selected

patients who have major stroke of <6 hours’ duration

due to occlusion of MCA, and who are not otherwise

candidates for IV-TPA.

2. Tx requires pt to be at experienced stroke center with

immediate access to cerebral angiography and

qualified interventionalists (new recommendation).

THROMBOLYTICS: IA-TPA

Class I recommendations:

1. IA thrombolysis is an option for treatment of selected

patients who have major stroke of <6 hours’ duration

due to occlusion of MCA, and who are not otherwise

candidates for IV-TPA.

2. Tx requires pt to be at experienced stroke center with

immediate access to cerebral angiography and

qualified interventionalists (new recommendation).

THROMBOLYTICS: IA-TPA

Class II recommendation:

1. IA thrombolysis is reasonable in patients who have contraindication to use of IV-TPA, such as recent

surgery (new recommendation).

Mechanical Disruption:

Class II recommendations: MERCI device is reasonable intervention for extraction of intra-arterial thrombi in carefully selected patients, but

panel recognizes that utility of device in improving outcomes

after stroke is unclear (new recommendation).

Anticoagulation:

Class III Recommendations:

1. Urgent anticoagulation with goal of preventing early

recurrent stroke, halting neurological worsening, or

improving outcomes after acute ischemic stroke not

recommended.

2. Urgent anticoagulation not recommended for pts with

moderate to severe strokes because of increased risk

of serious ICH complications.

3. Initiation of anticoagulant tx within 24 hours of IV-TPA

not recommended.

Antiplatelet Rx:

Class I recommendation:

1. Oral administration of ASA 325 mg within 24 to 48

hours after stroke onset is recommended for tx of most

pts.

BP management:

For IV-tPA: follow NINDS guidelines

185/110 Not candidate for thrombolysis:

220/120

Use Labetalol IV 10 mg Q 30 min. PRN Avoid quick reduction in BP and look for bradycardia. Alternative: Hydralazine IV Avoid strong vasodialtors

Outcome with IV-t-PA:

Odds Ratios for Favorable Outcome

Time Odds Ratio 95% )CI) Interval

0-90 2.8 1.8 - 4.5

91-180 1.5 1.1 - 2.1

181-270 1.4 1.1 - 1.9

271-360 1.2 0.9 - 1.5