Stroke Society of the Philippines - The Filipino Doctor Acute Stroke Treatment.pdf · Stroke Society of the Philippines 13 Board of Trustees President 1st Vice-President 2nd Vice-President

Stroke Society of the Philippines

13

Board of Trustees

President 1st Vice-President

2nd Vice-PresidentSecretaryTreasurer

P.R.O

Members

Rm. 101 Medicine Bldg., UERM, Aurora Blvd., Quezon CityTelephone No: 715-0861/62 Loc 287

Joven R. Cuanang, MDDante D. Morales, MDAbdias V. Aquino, MDEster S. Bitanga, MDBetty D. Mancao, MDRenato Q. Sibayan, MD

Honorata Baylon, MDCarlos L. Chua, MDWilliam T. Chua, MDFatima R. Collado, MDFlorimond A. Garcia, MDSimeon M. Marasigan, MDMa. Socorro C. Martinez, MDJose C. Navarro, MDEnrique T. Ona, MD

Department of HealthDepartment of Non-Communicable Disease Service

Desiree M. Narvaez, MD, MPH Florante Trinidad, MD, MPH

Working Committees:

Prevention: Dante Morales, MD Florante Trinidad, MD Fatima Collado, MD Artemio Roxas, MD Jose Tablante, MD

Treatment: Abdias Aquino, MD Jose Navarro, MD Robert Gan, MD Ester Bitanga, MD Carlos Chua, MD Joven Cuanang, MF Alejandro Diaz, MD Renato Sibayan, MD Roel Romero, MD

Rehabilitation: Betty Dy-Mancao, MD Josephine Bundoc, MD

Overall Coordinator: Roel Romero, MD

Panel of Reactors to the First Congress on Brain Attack: Thinking Globally, Acting Locally

Members: Norman Bitanga Esperanza Cabral Primitivo Cammayo Rogelio Chua George Bernardo Conde Romeo Divinagracia Ferdinand Floreindo Melissa Gozum Manolete Guerrero Policarpio Joves Amado Layno Rogelio Libarnes Reynaldo “Rey” Matias Eduardo Mercado Martesio Perez Jose Bonifacio Rafanan Roel Romero Renato Sibayan Winnie Shiao Eduardo Tordesillas

CPM 5TH EDITION ACUTE STROKE TREATMENT

Guidelines for Acute Stroke Treatment

1

Stroke

TIA & mild stroke?

2

Y

N

3

TIA: - deficits resolved within 24 hrs incl transient blindness in one eye (transient monocular blindness)

4

Alert patients with any of the ff:a. mild pure motor weakness of one

side of the body defined as can raise arm above shoulder, clumsy hand, or can ambulate without assistance

b. pure sensory deficitc. slurred speech but intelligibled. vertigo with incoordination, like

gait disturbance, unsteadiness, or clumsy hand

e. visual field defects alonef. combination of (a) and (b)

5

Moderate stroke?

Y

6

See Fig. 2

Awake patient with signifi-cant motor &/or sensory &/or language &/or visual deficit orDisoriented, drowsy, or stuporous patient but with purposeful response to painful stimuli

See Fig. 3

7

Severestroke

8Comatose patient with non-purposeful response, decorticate, or decerebrate posturing to painful stimuli (appendix I)

orComatose patient with no response to painful stimuli

See

Fig. 4

FIGURE 1

N

Definition of “Stroke”- Sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathology.

ACUTE STROKE TREATMENT CPM 5TH EDITION

Guidelines for Transient Ischemic Attack (TIA) and Mild Stroke

1

TIA & mild stroke

2

3Emergent Diagnostics• Complete blood count (CBC)• Blood sugar (CBG, HGT, or

RBS)• Electrocardiogram (ECG)• PT/PTT (if EKG shows atrial

fibrillation or possible cardi-oembolic source)

• Plain CT scan of brain as soon as possible

4Early Specific

Treatment (Appendix IV)

5

CT scan confirmed?

Y

6

CT scan not available• No specific emergent drug treatment recommended• Neuroprotection (appendix IVD)• Consult a neurologist, or neurosurgeon• Early supportive rehabilitation

N

See Fig. 2A

Management PrioritiesAscertain clinical diagnosis of stroke or TIA - history & physical exam very important • Exclude common stroke mimickers (appendix IIA and IIB)Monitor & manage blood pressure, treat if SBP >220 or DBP >120 or MAP >130 (appendix IIIA). Precautions:• Avoid precipitous drop in BP >20% of baseline MAP• Do not use rapid-acting sublingual agents; when needed use oral or

easily titratable IV anti-hypertensive medications (appendix IIIB)Ensure appropriate hydration. If IV fluid is needed, use 0.9 NaCl

FIGURE 2


1

Ischemic?Y

4

Hemorrhagic

N

2Non-cardi-oembolic

(Thrombotic, Lacunar)?

Y

Cardioem-bolic

N

• Aspirin 160-325 mg/day start as early as possible and continue for 14 days (for secondary prevention, see below under delayed manage-ment)• Neuroprotection (appendix IVD)• Early rehabilitation within 72 hrs.

5

Y

N

• Anticoagulation with IV heparin or subcutaneous low molecular weight heparin (LMWH), or• Aspirin 160-325 mg/day (if heparin & PTT, or LMWH not available)• Neuroprotection (appendix IVD)• Early rehabilitation within 72 hrs.*If infective endocarditis is sus-pected, give antibiotics & do not anticoagulate

TIA

8

FIGURE 2A

Figure 2

3

6

9• Aspirin 160-325 mg/day• If crescendo TIA (multiple events within hours, increasing severity & duration of deficits), consider anticoagulation with intravenous heparin.

7• If there is suspicion of non- hypertensive cause for intracerebral hemorrhage (e.g. AVM, aneurysm), refer to neurosurgeon• Neuroprotection (appendix IVD)• Early rehabilitation within 72 hrs.

Place of Treatment (Appendix VII)

Admit to Hospital (Stroke Unit)1. Stroke onset within 48 hrs.2. Patients requiring specific active interventions for any of the following: a. BP control, monitoring, and stabilization b. Cardiac stabilization, incl. atrial fibrillation, CHF, acute MI c. Hydration d. Anticoagulation, if bleed ruled out by CT scan3. Rapidly worsening deficits4. >4 TIA's in 2 weeks prior to consult5. 1-4 TIA's in 2 weeks with high risk (multiple events within hours, increasing severity and duration of deficits,

cardiac arrhythmia, carotid bruit)

Urgent Outpatient Work-up1. Single TIA more than 2 weeks ago2. 1-4 TIA's in 2 weeks but not high risk (no change in severity and duration of deficit, cardiac arrhythmia,

carotid bruit)3. Transient monocular blindness alone4. Stable mild strokes occuring >48 hrs not requiring specific active intervention.

*Advise immediate re-consult if there is worsening of deficit


1

Delayed Management & Treatment

(Secondary Prevention) (Appendix VIII)

2

CT scan confirmed?

Y

10

CT scan not available• No specific emergent drug treatment recommended• Neuroprotection (appendix IVD)• Consult a neurologist, or neurosurgeon• Early supportive rehabilitation

N

3

Ischemic?Y

6

Hemorrhagic

N

4

Thrombotic/ Lacunar?

Y

N

• Control of risk factors (see Risk Factor section)• Antiplatelets (aspirin, ticlopidine, clopidogrel, dipyridamole, cilostazol)• Carotid ultrasound If this reveals >70% steno-sis, refer to neurologist for decision-making regarding carotid endar-terectomy.

5

8• Long-term blood pressure monitoring and treatment• Consider CT angiography, MRA, or angiography in aneurysm or AVM suspects.

7

Cardio-em-bolic

9• Echocardiography and/or cardi-ology consult• If age <75 and PT/INR avail-able, anticoagulation with coumadin (target INR 2-3)• If age >75, aspirin 80-325 mg/day or coumadin with target INR 2-2.5 (if PT/INR available).

FIGURE 2B

Place of Treatment (Appendix VII) - See Figure 2A


Guidelines for Moderate Stroke

1

Moderate stroke

2

3Emergent Diagnostics• Complete blood count (CBC)• Blood sugar (CBG, HGT, or RBS)• PT/PIT• Serum Na+ and K+

• Electrocardiogram• Plain CT scan of brain as soon as possible

4Early Specific

Treatment (Appendix IV)

5CT scan

confirmed?(Appendix

VIA)

Y

6

CT scan not available• Use scoring system (Appendix VIB)

N

See Fig. 3A

Management PrioritiesNeuro-vital signs: BP, PR, CR, RR, Temp, Pupils, Glasgow Coma Scale (Appendix X)Basic emergent supportive care (ABC of resuscitation)Monitor and manage blood pressure, treat if SBP>220 or DBP>120 or MAP>130 (Appendix IIIA). Precautions:

• Avoid precipitous drop in BP>20% of baseline MAP • Do not use rapid-acting sublingual agents; when needed use oral or

easily titratable IV anti-hypertensive medication (Appendix IIIB)Ascertain clinical diagnosis of stroke-history and physical exam very important

• Exclude common stroke mimickers (Appendix II)Identify co-morbidities (cardiac disease, gastric ulcer, etc.)Recognize and treat early signs and symptoms of increased ICP (Ap-pendix IX)

7

Likely ischemic?

Y

N

8

• No specific emergent drug treatment recommended• Neuroprotection (appendix IVD)• Refer to specialist• Early supportive rehabilitation

9

Likely hemorrhagic

10• Refer to neurologist/ neurosurgeon for further diagnostic work-ups &/or subsequent surgery• Neuroprotection (Appendix IVD)• Early supportive rehabilitation

FIGURE 3


1

Ischemic?Y

4

Hemorrhagic

N

2Non-cardi-oembolic


Y

N

• If within 3 hours of stroke onset, consider rtPA treatment and refer to specialist• Aspirin 160-325 mg/day start as early as possible• Neuroprotection (Appendix IVD)• Early supportive rehabilitation

3

6• Supportive treatment:1. Mannitol 20% 0.5 mg/kg BW q 6h

for 2-5 days2. Neuroprotection (Appendix IVD)• Neurosurgery consult for hematomas distorting or displacing 4th

ventricle• Within 12-24h, recommend surgery for hematoma:1. size 10-30 cc (non-dominant sub-

cortical frontal or temporal)2. size >30 cc (subcortical, putami-nal,

cerebellar)• Early supportive rehabilitation

5

Cardio-em-bolic

(Appendix V)

7• If within 3 hours of stroke onset, consider rtPA treatment and refer to specialist• Aspirin 160-325 mg/day start as early as possible• If source of embolism can be demonstrated, consider early anticoagulation• Neuroprotection (appendix IVD)• Early supportive rehabilitation*If infective endocarditis is sus-

pected, give antibiotics & do not anticoagulate

Figure 3

FIGURE 3A

Place of Treatment (Appendix VII): Hospital - Intensive Care Unit or Stroke Unit

2

Ischemic?Y

5

Hemorrhagic

N

3

Y

N

• Control of risk factors (see Risk Factor section)• Antiplatelets (aspirin, ticlopidine, clopidogrel, dipyridamole, cilostazol)• Carotid ultrasound If this reveals >70% stenosis, refer to neurologist for decision-making regarding carotid endarterectomy.

4

7• Long-term blood pressure monitoring and treatment• Consider CT angiography, MRA, or angiography in aneurysm or AVM suspects

6

Cardio-embolic

8• Echocardiography and/or cardiology consult• If age <75 and PT/INR available, anticoagulation with coumadin (target INR 2-3)• If age >75, aspirin 80-325 mg/ day or coumadin with target INR 2-2.5 (if PT/INR available)


FIGURE 3B

Delayed Management & Treatment (Secondary Prevention) (Appendix VIII)

1

Mild stroke


Guidelines for Severe Stroke

1

Severe stroke

2

3Emergent Diagnostics• Complete blood count (CBC) • Blood sugar (CBG, HGT, or

RBS) • PT/PTT • Serum Na+ and K+

• Electrocardiogram (ECG) • Plain CT scan of brain

4

Early SpecificTreatment

(Appendix IV)

Management Priorities• Basic emergent supportive care (ABC of resuscitation)• Neuro-vital signs: BP, PR, CR, RR, Temp, Pupils, Glasgow Coma Scale (Ap-

pendix X)• Recognize & treat early signs & symptoms of increased ICP (Appendix IX)• Monitor and manage blood pressure, treat if SBP>220 or DBP>120 or

MAP>130 (appendix IIIA). Precautions: - Avoid precipitous drop in BP >20% of baseline MAP - Do not use rapid-acting sublingual agents; when needed use oral or easily

titratable IV anti-hypertensive medication (appendix IIIB)• Ascertain clinical diagnosis of stroke-history and physical exam very impor-tant - Exclude common stroke mimickers (appendix II)

FIGURE 4

5CT scan con-

firmed(Appendix VIA)

6

Ischemic?

9

Hemorrhagic

N

Y

7Non-cardi-oembolic

(Thrombotic)?Y

N

• May give aspirin 160-325 mg/day• Neuroprotection (Appendix IVD)• If cerebellar infarct, consult neurosurgeon as soon as possible• Early supportive rehabilitation

8

10

Cardio-embolic

(Appendix V)

11• May give aspirin 160-325 mg/day• Neuroprotection (Appendix IVD)• If cerebellar infarct, consult neurosurgeon as soon as possible• Early supportive rehabilitation12

• Supportive treatment:1. Mannitol 20% 0.5 mg/kg BW q 6h for 2-5 days2. Neuroprotection (appendix IVD)• Neurosurgery consult if:1. Patient not herniated, bleed located in putamen, subcortical area,

or cerebellum, and goal is reduction of mortality2. Herniated patient but family is willing to accept consequences

of high mortality or irreversible coma and persistent vegetative state

3. ICP monitoring contemplated and salvage surgery is considered• Early supportive rehabilitation


APPENDICES FOR ACUTE STROKE TREATMENTS

Appendix II

Differential Diagnosis of Stroke

A. The presence of any of the following should alert the physician to consider conditions other than stroke:

- Gradual progressive course and insidious onset - Pure hemifacial weakness including forehead - Trauma - Fever prior to onset of symptoms - Recurrent seizures - Weakness with atrophy - Recurrent headaches

B. Conditions that mimic stroke in the emergency de-partment (according to decreasing frequency):

1. Seizures 2. Systemic infection 3. Brain tumor 4. Toxic-metabolic 5. Positional vertigo 6. Cardiac 7. Syncope 8. Trauma 9. Subdural hematoma 10. Herpes encephalitis 11. Transient global amnesia 12. Dementia 13. Demyelinating disease 14. Cervical spine fracture 15. Myasthenia gravis

16. Parkinsonism 17. Hypertensive encephalopathy 18. Conversion disorder

Other conditions to consider: - Bell's palsy - Migraine - Toxins

References:

1. Libman RB, Wirkowski E, Alvir J, Rao H. Conditions that mimic stroke in the emergency department. Arch Neurol 1995;52:1119-1122.

2. The Brain Matters Stroke Initiative. Acute Stroke Management Workshop Syllabus. Basic Principles of Modern Management for Acute Stroke.

Appendix III

Blood Pressure Management

A. If SBP is 185-220 mmHg or DBP is 105-120 mm Hg, emergency therapy for blood pressure control should be deferred unless there is left ventricular failure, aortic dissection, or acute myocardial ischemia. Patients who are potential candidates for rtPA therapy but who have persistent elevations in SBP >185 mm Hg or DBP >110 mm Hg may be treated with small doses of IV anti-hypertensive medication to maintain the BP just below these limits.

B. Mean Arterial Pressure (MAP):

MAP = Systolic BP + 2(Diastolic BP) 3

NicardipineHCI

Hydralazine HCI

Nitroglycerin

Esmolol

Most hypertensive emergencies except acute heart failure; caution with coronary ischemia

Eclampsia

Coronary ischemia

Supraventricular tachycardia, hyperten-sion

Tachycardia, headache, flushing, local phlebitis

Tachycardia, flushing, headache, vomiting, in-creased angina

Headache, vomiting, meth-emoglobinemia, tolerance with prolonged use

Hypotension, bradycardia, peripheral ischemia, agita-tion, confusion, headache, vomiting

5 - 15 mg/h 5-10IV min 1-4 h

10 - 20 mg 10 - 20IV min 3 - 8 h10 - 50 mg 20 - 30IM min

5 - 100µg/min as IV 2 - 5 min 3 - 5 mininfusion

0.5 - mg/kgbolus IV over30 sec. or 2 - 10 10 - 300.05/kg/min min mininfusion

C. Locally available intravenous anti-hypertensives used in acute stroke:

Onset of Duration Special Drug Dose Action of Action Adverse Effects Indications

CPM 5TH EDITION ACUTE STROKE TREATMENT References: 1. The Brain Matters Stroke Initiative. Acute Stroke Management

Workshop Syllabus. Basic Principles of Modern Management for Acute Stroke.

2. Marler JR, Jones PW, Emr M (eds). Setting New Dimensions for Stroke Care. Proceedings of a national symposium on rapid iden-tification and treatment of acute stroke. The National Institute of Neurological Disorders and Stroke, National Institutes of Health. Bethesda, MD. August 1997.

Appendix IV

Acute Stroke Treatments

References: Same as Appendix III

A. Risk of treating patient with mild stroke with anti-thrombotics:

- 1% of TIAs are not due to ischemic stroke - 3 to 14% of mild strokes are hemorrhagic

References:

1. The Amaurosis Fugax Study Group. Current management of amau-rosis fugax. Stroke 1990;21:201-208.

2. Anzalone N, Landi G. Non-ischaemic causes of lacunar syndromes: prevalence and clinical findings. J Neurol Neurosurg Psychiatry 1989;52:1188-1190.

3. Bamford J, Sandercock P, Jones L, Warlow C. The natural history of lacunar infarction: The Oxfordshire Community Stroke Project. Stroke 1987;18-545-551.

4. Bamford JM, Warlow CP. Evolution and testing of the lacunar hy-pothesis. Stroke 1988;19:1074-1082.

5. Bogousslavsky J, Van Melle G, Regli F. The Lausanne Stroke Reg-istry: Analysis of 1,000 consecutive patients with first stroke. Stroke 1988;19:1083-1092.

6. Brown RD Jr, Evans BA, Wiebers DO, Petty GW, Meissner I, Dale AJD. Transient ischemic attack and minor ischemic stroke: An algo-rithm for evaluation and treatment. Mayo Clin Proc 1994;69:1027-1039.

7. Chimowitz MI, Furlan AJ, Sila CA, Paranandi L, Beck GJ. Etiology of motor or sensory stroke: A prospective study of the predictive value of clinical and radiological features. Ann Neurol 1991;30:519-525.

8. Mori E, Tabuchi M, Yamadori A. Lacunar syndrome due to intracer-ebral hemorrhage. Stroke 1985;16:454-459.

B. Thrombolytic Therapy - Thrombolytics is not recommended in mild

strokes. - Streptokinase and Urokinase are not currently

recommended in acute stroke - Recombinant tissue plasminogen activator (rtPA)

given within 3 hours of stroke onset may reduce disability by a third at three months

Guidelines: 1. Dose of rtPA is 0.9 mg/kg (maximum 90 mg)

- 10% of total volume given as bolus, rest as infusion over 60 minutes.

2. RtPA is recommended as treatment within 3 hours of onset of ischemic stroke. The benefit of IV rtPA for acute ischemic stroke beyond 3 hours from onset of symptoms is not established. Intravenous rtPA is not recommended when the time of onset of stroke cannot be ascertained reliably, including

strokes recognized upon awakening. 3. Thrombolytic therapy is not recommended unless

the diagnosis is established by a physician with expertise in diagnosis of stroke and CT of the brain is assessed by physicians with expertise in reading this imaging study. If CT demonstrates early changes of a recent major infarction such as sulcal effacement, mass effect, edema or pos-sible hemorrhage, thrombolytic therapy should be avoided.

4. Thrombolytic therapy cannot be recommended for persons with any of the following (NINDS Study):

a. current use of oral anticoagulants or a pro-thrombin time >15 seconds (INR >1.7)

b. use of heparin in the previous 48 hours or a prolonged partial thromboplastin time

c. a platelet count less than 100,000 mm3

d. another stroke or a serious head injury in the previous 3 months

e. major surgery within the preceding 14 days f. pretreatment systolic blood pressure greater

than 185 mm Hg or diastolic BP> 110 mm Hg (rtPA) may be given if BP is controlled using recommendation in Table 1)

g. rapidly improving neurological signs h. isolated, mild neurological deficits, such as

ataxia alone, sensory loss alone, dysarthria alone, or minimal weakness

i. prior intracranial hemorrhage j. blood glucose <50 mg/dl or >400 mg/dl k. seizure at the onset of stroke l. gastrointestinal or urinary bleeding within the

preceding 21 days m. recent myocardial infarction 5. Thrombolytic therapy should not be given unless

the emergent ancillary care and the facilities to handle bleeding complications are readily avail-able.

6. Caution is advised before giving rtPA to persons with:

a. Severe stroke (NIH Stroke Scale Score >22) b. Age >77 c. Obtunded patients d. Major infarct on CT e. Acute pericarditis f. Recent trauma g. Infectious endocarditis h. High probability of left heart thrombus i. Significant hepatic disease j. DM retinopathy or hemorrhagic ophthalmo-

pathy k. Pregnancy l. Bleeding hazards 7. Because the use of thrombolytic drugs carries the

real risk of major bleeding, whenever possible the risks of potential benefits of rtPA should be discussed with the patient and his or her family before treatment is initiated.


Reference:

1. NINDS rt-PA Stroke Study Group Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-1587.

C. Antithrombotic therapy

1. International Stroke Trial (IST) - Multicenter randomized clinical trial of 19,435

patients - Regimen: Aspirin 300-325 mg/day vs. no aspirin Heparin subcutaneous vs. no heparin 5,000 units bid or 12,500 units

bid - Started within 48 hours of stroke onset for 14

days or until discharge - Results: a. Aspirin - fewer recurrent stroke within 14 days - fewer deaths and dependency at 6

months b. Heparin - no benefit even at 6 months - if use, should not exceed 5,000 units

bid 2. Chinese Acute Stroke Trial (CAST) - 21,106 patients randomized - Aspirin 160 mg/day vs. placebo - Started within 48 hours of stroke onset - Results: Risk of recurrent stroke or vascular death: Aspirin 5.3% Placebo 5.9% (p=0.03) 3. 846 patients in the IST and 2,521 patients in the

CAST (total 3,367 patients) did not have a CT scan done. Giving aspirin within 48 hours of stroke onset among these patients without CT scan did not significantly affect outcome at 4 weeks (recurrent stroke, CAST) and at 6 months (functional status, IST)

References:

1. Chinese Acute Stroke Trial Collaborative Group. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. Lancet 1997;349:1641-1649.

2. International Stroke Trial Collaborative Group. The International Stroke Trial: a randomised trial of aspirin, subcutaneous heparin, both or neither among 19,435 patients with acute ischemic stroke. Lancet 1997;349-1569-1581.

4. A trial on the use of nadroparin (Fraxiparine) started within 48 hours of stroke onset given at 0.4 cc subcutaneously once or twice a day for 10 days showed improvement in functional outcome at 6 months compared to placebo.

Reference:

1. Kay R, Wong KS, Yu YL, et al. Low-molecular-weight heparin for the treat-ment of acute ischemic stroke. N Engl J Med 1995;333:1588-1593.

D. Neuroprotection

1. Avoid hypotension, hypoxemia (aspiration pneu-monia), hyperglycemia, hyponatremia, and fever during acute stroke in an effort to “salvage” the ischemic penumbra.

2. Several neuroprotectants for acute ischemic stroke have been investigated or are currently under investigation. Some results have been encourag-ing.

References: 1. Clark WM, Warachi SJ, Pettigrew LC et al for he Citicoline Stroke

Study Group. A randomized dose-response trial of citicoline in acute ischemic stroke patients. Neurology 1997;29-671-678.

2. De Deyn PP, Reuck JD, Deberdt W et al for the Piracetam in Acute Stroke Study Group. Treatment of acute ischemic stroke with pira-cetam. Stroke 1997;28-2347-2352.

3. Mohr JP, Orgogozo JM, Harrison MJG, et al. Meta-analysis of oral nimodipine trials in acute ischemic stroke. Cerebrovasc Dis 1994;4:197-203.

E. Treatment of intracerebral hemorrhage (ICH)

1. Surgical treatment: Role depends on size, loca-tion, and extent of hematoma

a. There is definite evidence of increase in hematoma size (26-107%); about half of which is attributable to impaired coagulation (patients with liver disease, alcoholics, etc.). Early hematoma removal contributes to overall improvement or morbidity and mortality.

b. There is good evidence of functional recovery after surgery of hematoma size 10-30 cc with reversible hemiplegia or severe hemiparesis.

c. There is available evidence to show that about 1/3 of patients with significant hematoma size (30 cc) will deteriorate and may die (47% mortality) from ischemia (perifocal) and not from clot enlargement.

d. There is acceptable evidence to show that mor-tality rate in patients with larger hematomas but not herniated can be reduced with surgery.

2. Medical Treatment: Goal is to prevent complica-tions and careful management of blood pressure

a. Maintain MAP <130 i. Sustained hypertension may alter cerebral

autoregulation, promote progression of bleed, and increase edema

ii. Hypotension may result in cerebral hypoper-fusion especially in the setting of increased intracranial pressure (ICP)

b. Manage increased ICP accordingly (see ap-pendix X)

c. Consider prophylactic use of anticonvulsants. i. There is higher incidence of seizures in ICH

especially in lobar hematomas ii. Role of prophylactic anticonvulsants in

deep hemorrhages is unclear. It is justified


to withhold anticonvulsants until clinically indicated.

d. Prevention and treatment of respiratory com-plications

i. Prevention and treatment of infections e. Maintenance of adequate nutrition f. Early rehabilitation once stable, bedsore pre-

cautions, DVT prophylaxis (Ted hose stockings or compression boots)

g. Neuroprotectants, like calcium channel block-ers, might be useful in reducing tendency to perifocal edema, although evidence is experi-mental.

References:

1. Aver LM, et al. Endocscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neu-rosurg 1989;70:530-535.

2. Barnett HJM, Mohr JP, Stein BM, Yatsu FM (eds). Stroke - Patho-physiology, Diagnosis, and Management, 2nd edition. Churchill Livingstone, New York, 1992.

3. Broderick JP, et al. Ultra-early evaluation of intracerebral hemor-rhage. J Neurosurg 1990;72:195-199.

4. Brott T, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997;28:1-5.

5. Caplan L. Intracerebral hemorrhage revisited. Neurology 1988;38:624-7.

6. Fujii Y, et al. Hematoma enlargement in spontaneous intracerebral hemorrhage. J Neurosurg 1994;80-51-57.

7. Juvela S, et al. The treatment of spontaneous intracerebral hemor-rhage: randomized clinical trial. J Neurosurg 1989;70-755-788.

8. Kazui S, et al. Enlargement of spontaneous intracerebral hemorrhage: incidence and time course. Stroke 1996;27:1783-1787.

9. Mayer SA, Sacco RI, Shi T, Mohr JP. Neurologic deterioration in noncomatose patients with supratentorial intracerebral hemorrhage. Neurology 1994;44-1379-84.

10. Mendelon AD. Mechanisms of ischemic brain damage with intrac-erebral hemorrhage. Stroke 1993;24 (Suppl 12):1115-1117.

11. Sacco RL, Wolf PA, Bharucha NE, et al. Subarachnoid and intracer-ebral hemorrhage: Natural history, prognosis, and precursive factors in the Framingham Study. Neurology 1984;34:847-54.

12. Welch KMA, Caplan LR, Reis DJ. Siesjo BK, Weir B (eds). Primer on Cerebrovascular Diseases. Academic Press. San Diego, 1997.

Appendix V

Cardiogenic Sources of Embolism

1. Atrial fibrillation/flutter2. Valvular heart disease (including Rheumatic heart

disease)3. Bacterial endocarditis4. Cardiac thrombus5. Cardiomyopathy6. Recent myocardial infarction7. Atrial myxoma8. Right-to-left shunts9. Pulmonary vein thrombosisReferences:

1. Foulkes MA, Wolf PA, Price TR, Mohr JP, Hier DB. The Stroke Data Bank: design, methods, and baseline characteristics. Stroke 1988;19:547-54.

2. Mohr JP, Caplan LR, Melski JW, et al. The Harvard Cooperative

Stroke Registry: A prospective registry. Neurology 1978;754-762.

A. Requirements for intravenous anticoagulation of patients with cardiogenic source of embolism:

1. Heparin sodium in D5W 2. Infusion pump, if available 3. Activated partial thromboplastin time (PTT) or

clotting time

B. Procedure a. Start intravenous infusion at 800 units heparin/

hour ideally using infusion pump. b. Monitor infusion closely. If using soluset instead

of infusion pump, intensive monitoring is re-quired.

c. Perform aPTT as often as necessary, every 6 hours if need, to keep aPTT at 1.5 - 2.3 times control. Risk for major hemorrhage, including intracranial bleed, progressively increases as the aPTT becomes prolonged above 80 sec-onds.

d. Intermittent intravenous heparin administration is not recommended.

e. Infusion may be discontinued once oral anti-coagulation with coumadin is adequate or once antiplatelet medication is started for secondary prevention. See section on stroke prevention (page 11, IV Atrial Fibrillation) and secondary prevention (appendix VIII).

C. If using low-molecular-weight heparin (LMWH), give nadroparin (Fraxiparine) at 0.4 cc (4,100 units) subcutaneously once or twice a day for 10 days. There is no need for aPTT monitoring.

Appendix VI

Differentiating Ischemic from Hemorrhagic Stroke

A. Gold standard is plain CT scan - Hyperdense (bright) lesion = bleed or intracer-

ebral hemorrhage - Normal = Acute infarction or TIA - Hypodense (dark) - Infarction

B. Scoring systems have been used in the absence of CT scan

- Not recommended for use in mild stroke - False negative rate for bleed most probably high

in mild strokes

DIAz STROKE SCALE sensitivity 100% specificity 86% accuracy 93%

A. Vomiting +4

B. Level of Consciousness


Unarousable +4 Drowsy - arousable +2 Awake 0

C. Fever +3

D. Respiratory Pattern Ataxic or apneustic (rapid irregular) +3 Hyperventilation (rapid regular) +2 Cheyne-Stokes (slow irregular) +1 Normal or regular 0

E. Upper GI Bleeding +3

F. Neurologic deficit maximal at onset +3

G. Headache +2

H. Nuchal rigidity +2

I. Diastolic Blood Pressure (mmHg) <90 -2 91 - 99 0 >100 +2

J. Systolic Blood Pressure (mmHg) <150 -2 151-169 -1 170-180 0 181-199 +1 >200 +2

TOTAL SCORE

Interpretation: Score >7 = 90% probability of bleed Score <7 = probably infarct

ILANO SCORING SYSTEM

I. History

1. Vomiting Present 2 Absent 0

2. Headache Present 1 Absent 0

3. Loss of Present 1 consciousness Absent 0

II. Physical Examination

1. Systolic BP >200 mm Hg 5 160-200 mm Hg 1 <160 mm Hg 0

2. Diastolic BO >90 mm Hg 2 <90 mm Hg 0

3. Level of Stuporous-coma 3 consciousness Drowsy 1 Awake 0

4. Nuchal rigidity Present 2 Absent 0

5. Preferential gaze Present 1 Absent 0

TOTAL SCORE

Interpretation: Score 11-17 = definitely hemorrhagic 8-10 = most probably hemorrhagic 0-7 = unlikely hemorrhagic

SIRIRAj SCORE sensitivity 68% specificity 64% accuracy 64%

Consciousness (X 2.5) Alert 0 Drowsy, stupor 1 Semicoma, coma 2

Vomiting (X 2) No 0 Yes 1

Headache within No 02 hours (X 2) Yes 1

Diastolic blood pressure DBP X 0.1

Atheroma markers (X 3): None 0diabetes, angina Once or more 1intermittent claudication

Constant - 1 2

TOTAL SCORE

Interpretation: Score <1 = infarct >1 = hemorrhage

ALLEN (GUY'S sensitivity 70-88%HOSPITAL) SCORE specificity 64-78% accuracy 64-82%

Apoplectic onset None 0 Loss of consciousness 2 or more 21.9 Headache within 2 hrs Vomiting Neck stiffness

Level of consciousness 24 Alert 0 hours after admission Drowsy 7.3 Unconscious 14.6

Plantar response Both flexor or single extensor 0 Both extensor 7.1

Diastolic blood pressure DBP X24 hours after admission 0.17

Atheroma markers: None 0 diabetes, angina One or more -3.7 intermittent claudicationHypertension Present -4.1 None 0Previous event: TIA Any no. of -6.7 previous event

Heart disease None 0 Aortic or mitral murmur -4.3 Cardiac failure -4.3 Cardiomyopathy -4.3 Atrial fibrillation -4.3 MI within 6 months -4.3

CPM 5TH EDITION ACUTE STROKE TREATMENT Constant -12

T O T A L S C O R E

Interpretation: Score <4 = infarct 4-24 = uncertain >24 = hemorrhage

References: 1. Allen CMC. Clinical diagnosis of the acute stroke syndrome. Quar-

terly J Med, New Series LII 1983;208:515-523.2. Diaz A. A scoring system to differentiate cerebral hemorrhage from

infarction. Santo Tomas J Med 1986;35-168-174.3. Ilano F, Yu C. A clinical score system to differentiate hemorrhagic

from non-hemorrhagic strokes. MJDLSU 1993;9:47-53.4. Poungvarin N, Viryavejakul A. Komontri C. Siriraj stroke score and

validation study to distinguish supratentorial intracerebral hemor-rhage from infarction. BMJ 1991;302:1565-1567.

5. Sandercock PAG, Allen CMC, Corston RN, Harrison MJG, Warlow CP. Clinical diagnosis of intracranial hemorrhage using Guy's Hos-pital score. BMJ 1985;291:1675-1677.

6. Weir CJ, Murray GD, Adams FG, Muir KW, Grosset DG, Lees KR. Poor accuracy of stroke scoring system for differential clinical diag-nosis of intracranial hemorrhage and infarction. Lancet 1994;334:999-1002.

Appendix VII

Place of Treatment

A. Mayo algorithm for management of TIA's and minor stroke.

Reference:

1. Brown RD Jr, Evans BA, Wiebers DO, Petty GW, Meissner I, Dale AJD. Transient ischemic attack and minor ischemic stroke: An algo-rithm for evaluation and treatment. Mayo Clin Proc 1994;69:1027-1039.

B. Admission to an organized Stroke Unit or manage-ment by a Stroke Team has been shown to:

- improve functional outcome - reduce mortality and morbidity by 21-28% - hasten recovery after a stroke - shorter hospital stay

References: 1. Indredavik B, Slordahl SA, Bakke F, Rokseth R, Haheim LL. Stroke

1997;28:1861-1866.2. Langhorne P, Williams BO, Gilchrist W. Do stroke units save lives?

Lancet 1993;342:395-398.3. Ronning OM, Guldvog B. Stroke unit versus general medical wards,

II: Neurological deficits and activities of daily living. Stroke 1998;29-586-590.

4. Stroke Unit Trialists' Collaboration. How do stroke units improve patient outcome? Stroke 1997;28-2139-2144.

C. Requirements for a Stroke Team 1. WHY (Objectives) To reduce mortality and morbidity of stroke

through efficient delivery of effective therapy for acute stroke after urgent transport and evalu-ation.

2. WHAT (Components) a. Facilities:

- Nursing: Vital signs, suction, IV hydration, intubation, ventilation, cardiac monitor

- Diagnostics: CT scan, EKG, laboratory for hematology, chemistry, coagulation

- Therapy: Pharmacy, stroke treatment area/unit

b. Guidelines: - Guidelines on Acute Brain Attack as pub-

lished by the Stroke Society of the Philip-pines and Department of Health Non-com-municable Disease Service

c. Communication system: - Early warning system by direct communica-

tion link 3. WHO (Personnel) a. Neurologists/neurosurgeon or stroke physi-

cians b. Stroke nurses c. Radiologist or physician experienced in reading

CT scans in acute stroke

References:

1. Grotta J. How to organize a stroke team. American Academy of Neurology Syllabus on Disk 1998.

2. Rudd A, Wolfe CDA. Developing a district stroke service. Cerebrov-asc Dis 1996;6:89-96.

Appendix VIII

Secondary Prevention for Stroke

A. Antithrombotics 1. Aspirin • Antiplatelet Trialists Collaboration: - 145 trials with almost 100,000 patients - 23% risk reduction for stroke, myocar-

dial infarction (MI), and vascular death

2. Ticlopidine • Canadian American Ticlopidine Study (CATS) - 23% risk reduction vs. placebo for

stroke, MI, or vascular death • Ticlopidine Aspirin Stroke Study (TASS) - 12% risk reduction vs. aspirin for stroke

or death at 3 years 3. Clopidogrel • Clopidogrel vs. Aspirin in Patients at Risk of

Ischemic Events (CAPRIE) - 19,185 patients with prior stroke, MI, or

PVD - Clopidogrel 75 mg/day vs. Aspirin 325

mg/day - 8.7% relative risk reduction in stroke,

MI, and muscular death over aspirin 4. Cilostazol • Cilostazol Stroke Prevention Study (CSPS) - 1,095 patients with cerebral infarction at


1-6 months - Cilostazol 100 mg bid vs. placebo - Relative risk reduction of 41.7% 5. Dipyridamole • European Stroke Prevention Study 2 6,602 patients randomized to: - Aspirin 25 mg bid - Dipyridamole 200 mg bid - Aspirin 25 mg bid + Dipyridamole 200 mg bid - Placebo Results: - Aspirin better than placebo - Dipyridamole better than placebo - Combination aspirin and dipyrida-

mole better than either one alone

References: 1. Antiplatelet Trialists' Collaborative overview of randomized trials

of antiplatelet therapy, I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994;308-81-106.

2. Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A. European Stroke Prevention Study 2. Dipyridamole and acetyl-salicylic acid in the secondary prevention of stroke. J Neurol Sci 1996;143:1-13.

3. Gent M, Blakely JA, Easton, JD, et al. The Canadian American Ticlo-pidine Study (CATS) in thromboembolic stroke. Lancet 1989;1:1215-1220.

4. Hass WK, Easton JD, Adams HP, et al. A randomized trial com-paring ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients. N Engl J Med 1989;321:501-507.

5. CAPRIE Steering Committee. A randomized, blinded trial of clopi-dogrel versus aspirin in patients at risk of ischemic events (CAPRIE). Lancet 1996;348:1329-1339.

6. Gotoh F, Tohgi H, Hirai S, et al. Secondary prevention of cerebral infarction with cilostazol - a multicenter, double-blinded, placebo controlled, long term, randomized study (Cilostazol Stroke Preven-tion Study, CSPS) (abstract). Presented at the International Stroke Society Regional Meeting, Yokohama, Japan, April 22-24, 1999.

B. Carotid endarterectomy The North American Symptomatic Carotid Endar-

terectomy Trial (NASCET), European Carotid Sur-gery Trial (ECST), and the Veterans Administration Symptomatic Carotid Surgery Trial all showed benefit in reducing risk of recurrent stroke in patient with severe internal carotid artery stenosis (>70%) who had a TIA or minor stroke.

References:

1. European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: Interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 1991;337:1235-1243.

2. Mayberg MR, Wilson SE, Yatsu F, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA 1991;266-32893294.

3. North American Symptomatic Carotid Endarterectomy Trial Col-laborators. Beneficial effect of carotid endarterectomy in symp-tomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-453.

C. Anticoagulant The benefit of oral anticoagulation with coumadin

(target INR=2.0-3.0) has been shown in patients with non-valvular atrial fibrillation who are at high risk (hypertension, poor left ventricular function, previous TIA, stroke, or thromboembolic events).

See also page 11 (IV. Atrial Fibrillation)

References:

1. Ezekowitz MD, Levine JA. Preventing stroke in patients with atrial fibrillation. JAMA 1999;281:1830-1835.

2. Quality Standards Subcommittee of the American Academy of Neurology. Practice Parameter: Stroke prevention in patients with non-valvular atrial fibrillation. Neurology 1998;51:671-673.

Appendix IX

Increased Intracranial Pressure (ICP)

A. Signs and symptoms of increased ICP: • Deteriorating sensorium • Cushing's triad 1. Hypertension 2. Bradycardia 3. Bradypnea (late)

B. Management options for increased ICP: 1. Manage combative behavior and agitation - search for source of pain, e.g. bladder disten-

tion - appropriate sedation if necessary 2. Elevate head to approximately 30o from horizon-

tal 3. Hyperventilate to pCO2 of low 30's (maximum

of 6 hours) 4. Osmotic agents: goal is serum osmolality of

310-320 Mannitol 0.25 - 2.0 gm/kg bolus; may give 0.25

- 0.5 mg/kg every 3 - 5 hours - expect response in 20 minutes - effect may last for 6 hours - difference of <10 between measured and com-

puted osmolality means additional doses are needed

computed = 2 (Na+) + glucose + BUN osmolality 18 2.8 5. Other options (use with caution): - Furosemide + albumin - Hypertonic saline 3% (50 mL in 5 min) - Pentobarbital 10-20 mg/kg loading dose then

1-3 mg/kg/hr

References: 1. Wijdick EFM. Neurology of Critical Illness. F.A. Davies, Philadelphia


PA: 1995.2. Davis SM (ed). Interventional Therapy in Acute Stroke. Blackwell

Science, Inc. Carlton, Victoria: 1998.

Appendix X

Glasgow Coma Scale

Category Score

Eye opening Spontaneous 4 To speech 3 To pain 2 None 1

Best motor response Obeys 6 Localizes 5 Withdraws 4 Abnormal flexion 3 Abnormal extension 2 None 1

Best verbal response Oriented conversation 5 Confused coversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1

Circle one score in each category; add the three scores to obtain total score. Lowest possible GCS score is 3. Highest score is 15.

Reference:

1. The Brain Matters Stroke Initiative. Acute Stroke Management Workshop Syllabus. Basic Principles of Modern Management for Acute Stroke.


Drugs Mentioned in the Treatment GuidelineThis index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing Information of these drugs can be found in the Philippine Pharmaceutical Directory (PPD) and the Philippine Pharmaceutical Directory Review (PPDr).

Ace InhibitorsBenazepril CibacenCaptopril Capoten Captace Drugmaker's Biotech Captopril Novopharm Captopril Primace Tensoril VasostadCilazapril Vascace Vascace Plus*Delapril CupressinEnalaprilmaleate Co-Renitec Renitec VasopressFosinopril BPNorm SaprilImidapril Norten VascorLisinopril Zestoretic* ZestrilMoexipril UnivascPerindopril

Coversyl Preterax*Quinapril AccuprilRamipril TritaceSpirapril WandopresTrandolapril Odace

Angiotensin II AntagonistsCandesartan BlopressIrbesartan AprovelLosartan Cozaar

Hyzaar*/ Hyzaar DS*Telmisartan Micardis/ Micardis Plus* PritorValsartan Co-Diovan*Anticoagulants/AntiplateletsThrombolyticsAbciximab ReoproActilyseAspirin Asaped Aspilets Astrix Bayer Aspirin Cor-30Cilostazol Pletaal Clopidogrel Plavix Dalteparin FragminDipyridamole Drugmaker's Biotech

Dipyridamole Persantin Prexin RidamolDL-lysineacetylsalicylate KardegicEnoxaparin ClexaneEptifibatide IntegrilinHeparin Leo Heparin Pharmacia Heparin

SodiumNadroparin Fraxiparine Fraxiparine ForteTiclopidine TiclidTirofiban Aggrastat

Warfarin Coumadin

ß-blockersAtenolol Atestad Nif-Ten* RiteMED Atenolol Serten Tenoretic* Tenormin TherablocBetaxolol KerloneBisoprolol ConcoreCarteolol MikelanCarvedilol DilatrendEsmolol BreviblocMetoprolol Betaloc Betazide* Betazok Cardiosel Cardiostat Logimax* Metostad RiteMED Metoprolol SanergPindolol Viskaldix* ViskenPropranolol Asterol Bedranol Drugmaker's Biotech

Propranolol Duranol Inderal Phanerol Phoenix Propranolol RiteMED Propranolol Servol


Calcium AntagonistsAmlodipine NorvascDiltiazem Cordazem Dilatam Diltac Diltelan Dilzem/Dilzem SA/

Dilzem SR Drugmaker's Biotech

Diltiazem Mono-Tildiem Novoptin RiteMED Diltiazem Servazen Tildiem ZandilFelodipine Logimax* Plendil ERIsradipine Dynacirc Icaz SROLacidipine LacipilManidipine Caldine MinadilNicardipine CardepineNifedipine Adalat Calcheck Calcibloc Calcibloc OD Darat Denkifed Nelapine Nif-Ten* Nifelan Nifestad Servidipine 10 Nimodipine NimotopVerapamil Hinorm Isoptin/Isoptin SR Verelan

Centrally-Acting DrugsClonidine Catapres/Catapres TTS Melzin

Guanfacine EstulicMethyldopa Aldomet Dopetens Meldopa Mendonil UL MethyldopaMoxonidine Cynt PhysiotensReserpine Brinerdin/Brinerdin Mite* Rauverid Ser-Ap-Es*Rilmenidine Hyperdix

CNS Stimulants/NeurotonicsCiticoline Nicholin SomazinePiracetam NootropilPyritinol Encephabol/ Encephabol ForteRivastigmine ExelonSulbutiamine ArcalionDiureticsAcetazolamide DiamoxBumetanide BurinexCilazapril Vascace/ Vascase PlusFurosemide Aquadrine Drugmaker's Biotech

Furosemide Europharma Furosemide Flexamide Frusema Furoscan Injection Lasix PharmixIndapamide Natrilix SR Preterax*Reserpine Brinerdin/ Brinerdin Mite* Rauverid Ser-Ap-Es

Spironolactone Aldactone Aldazide*

Osmotic AgentsMannitol Lacryvisc* Osmofundin 20%

Parenteral Ele ctrolytes0.9NaCl Braun NaCl 0.9% Soln Braun NaCl 0.9% Soln

for Inj Hizon 0.9% Sodium

Chloride LVP S9

VasodilatorsDoxazosin CarduranHydralazine Apresoline Ser-Ap-Es*Prazosin MinipressReserpine Brinerdin/Brinerdin Mite* Rauverid Ser-Ap-Es*

Documents

Stroke Society of the Philippines - The Filipino Doctor Acute Stroke Treatment.pdf · Stroke Society of the Philippines 13 Board of Trustees President 1st Vice-President 2nd Vice-President