Management of acute ischemic

stroke

To feed the flame!

László Csiba

MI and stroke

cases 1st year

(M Ft)

2nd year

(M Ft)

MI 16 000 5 052 444

Stroke 42 000 15 360 1 416

In acute stroke :CT or MRI Ischemia 80% Bleeding 10-15%

3

Subarachnoidal Bleeding

2-4%

After MI 70-80%

Normal lifestyle

After Stroke 10%

4

Diagnosis in stroke

From blood

•BSR, counts

•glucose, ions

•hemostasis

•lipids, homocsyt.

•Immunological

(in youngs)

Blood gases

Heart

Functional •BP monitoring

•ECG

•Holter ECG

Morphological •TTE

•TEE

TEE

Carotid, vertebral •ultrasound

•CT AG

•MRA

•DSA

Brain imaging •CT •MRI

•Diff. WI •Perf. WI

•TCD •Angiogr.(DSA, MRA) •SPECT, PET

EBM in stroke

• Stroke unit

• Iv. thrombolysis

• aspirin

• Hemicraniectomy in malignant MCA infarct

On site activity in acute stroke 1

Airway

Breathing

Circulation

Disability

Exposure

-nvironment

-vents

-valuation

On site activity in acute stroke

2: ABCDE

Diagnosis

Lab+Imaging etc.

Gen.+Neurol. exam

Observation

Autoanamnesis

Heteroanamnesis

1.Hetereoanamnesis

Hőmérséklet?

4.1.Consciousness? (alert-somnolent-stupor-coma?)

4.2.Aphasia?

4.3. Eye, mouth, nose ear

Coniugated eyes?

• Anisocoria?

• Tongue biting?

• Rest of medicaments?

• Lip-cyanosis?

4.7.position?

Babinski?

Severity of paresis?:

• Upper extr.?

• Lower extr?

• total-medium-mild?

ANY CHANGE DURING THE OBSERVATION PERIOD?

TIME OF ONSET OF PARESIS??

4. Examination

4.4.Bruit?

On site activity in acute stroke 3

3.Observation 2. Autoanamn.

4.5.RR

Pulse

Fever

auscult

4.6.Defense

Bladder?

Peristalt?

Sore?

Suspect for…..

• ischemia: – vascular risk factors,

– carotid bruit,

– onset in the morning, disturbance of consciousness is rare,

– RR slightly elevated breath normal

• bleeding – hypertension

– onset at dailly activity

– severe symptoms, plethora

– somnolent, forced breathing

• embolic origin • sudden onset, maximal quickly improving symtoms

• arhythmia, cardiac problems (eg. AF)

• previous stroke in the other hemipsh.

• vitium (heart)

80% hemiparesis

-upper extr.?

-lower. extr? -Hemihypaesth

-hemianopia

-tongue deviation

-diff-nasolabial fold

-cadaver position

-aphasia

Supratentorial

Vertebrobasilar

20% -vertigo? -ataxia? -dysarthria? -double vision? -swallowing? -paresis?

The differential diagnosis

– seizure with postictal paralysis

– Hypoglycemia

– brain tumor

– Migraine

– head trauma

– brain abscess

– Encephalitis

Blood sugar

• No routinous iv. or per os glucose!

• First measure!

• Hypo- or hyperglycemia? (< 2,7 mmol/l or >11

mmol/l), please correct!

• Avoid hyperglycemia!!

Most important question?

Is he/she a candidate for

thrombolysis or not?

ESO 2008

•

• ..Priority transport with

advance notification ...

• .. personnel be trained

to recognise stroke

using simple

instruments such as the

Face-Arm–Speech-

Test …

Modified Cincinnati Prehospital Stroke Scale

(CPSS)

Evaluation

Facial paresis

X

Upper extr. paresis

X

Lower extr. paresis

Speech

ESO 2008

• • ..helicopter transfer..

• ….telemedicine ….

• …suspected TIA be

referred without delay..

Activity during transport?

• Pulsoximetry

• ECG

• Blood sugar? Strip

• (if possible blood sampling)

• BP at 5-10 min

• Change of consciousness, paresis?

• If stable condition→directly to CT!!!

In the hospital

Immediate CT!!!!!

Quick labs!

Rapid onset of therapy

Awareness of

stroke

In-hospital

pathways

Stroke Unit

Well-

organised

transfer

The success of stroke care depends on the

stroke chain

Awareness

of stroke

In-hospital

pathways

Stroke Unit

Well-

organised

transfer

•Stroke day

•press, local TV

•Family physician

Awareness of

stroke

In-hospital

pathways

Stroke Unit

Well-

organised

transfer

•Every acute pt. from our region

to our stroke ICU

•„hotline” to ambulance

•7/24 two neurol. on the ward!!!

Awareness of

stroke

In-hospital

pathways

Stroke Unit

Well-

organised

transfer

The success of stroke care depends on the

stroke chain

16% of delay

Awareness of

stroke

In-hospital

pathways

Stroke Unit

Well-

organised

transfer Alert, stable stroke

directly to CT!!! Neurol. exam there!

Quick blood sampling for Lab!!!

Stroke care in Debrecen

Alert

Cardioresp.stabil

CT

CT angio

somnolent

Cardioresp.instabil EMD CT

Stroke unit

Lysis?

72 h

Monit.

BP

EKC

O2

reha

Thrombus location and likelihood of its

recanalization with systemic tPA.

Alexandrov , J Int. Medicine 267; 209–219 2010.

Stroke-care:Team-work

Neuropsychol Social worker

Cardiologist

Radiologist Logopedist

Stroke nurse Strokologist Physiotherapeuta

Prof. Kaste 32

Time is brain!

• 700 km axon/hour

• 2 mi neuron/min

• Every hour of stroke →3.6 yrs↓

Infarct

infarktus infarktus

Survival or death? hours

Lysis as soon as possible….

(Lancet 2004; 363: 768-74)

min

Ra

tio

of

su

cc

es

s

2,0

2,5

3,0

3,5

4,0

1,5

1,0

0,5

0 60 90 120 150 180 210 240 270 300 330 360

4 9 21 45

NNT for 1 symptom-free?

60’ 2!!

2003 februárban az agyi érbetegek kórházi felvételének száma

188161

529

436

383356

330

181176

515

435408403

366

204

148

515

456430

383365

173176

502

405440

364388

0

100

200

300

400

500

600

20

03

.02

.01

20

03

.02

.03

20

03

.02

.05

20

03

.02

.07

20

03

.02

.09

20

03

.02

.11

20

03

.02

.13

20

03

.02

.15

20

03

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.17

20

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.19

20

03

.02

.21

20

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.23

20

03

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.25

20

03

.02

.27

Week-end Week-end

Stroke during the week end week-end

36

Week-end Week-end

„Táguló” időablak: 4,5 h

Intravenous Alteplase Absolute contraindications

Evidence of intracranial hemorrhage on pretreatment evaluation

• Suspicion of SAH

• Recent (within 3 mo) intracranial or intraspinal surgery,

• serious head trauma, or previous stroke

• History of intracranial hemorrhage

• Uncontrolled hypertension at time of treatment (> 185 mm Hg systolic or >

110 mm Hg diastolic blood pressure)

• Active internal bleeding

• Intracranial neoplasm, AVM or aneurysm

• oral anticoagulants (e.g., warfarin sodium) if INR 1.7 or a prothrombin time

15 seconds

• heparin within 48 hours before the onset of stroke and an elevated activated

partial thromboplastin time at presentation

•

t-PA (alteplase)

• alteplase dose 0.9 mg/kg (maximum 90 mg), with a bolus of 10% of the dose administered over 1 minute, and the remainder infused over 60 minutes

• Significant drug interactions – OAC and AP increase the bleeding risk.

– The greatest risk sympt intracranial bleeding

– therapeutic heparin, antithrombotics, and OAC are contraindicated within 24 hours after administration of alteplase.

• Sc. heparin at a daily dose of 10,000 units or less without increased bleeding

• laryngeal and orolingual angioedema <1%, but urgent airway stabilization.

• orolingual angioedema was 1.7% (95% confidence interval [CI] 0.2–5.9%) with angiotensin-converting enzyme (ACE) inhibitor

Patient Evaluation and Management

in the Emergency Department • blood glucose level,

• serum electrolyte level,

• complete blood cell count,

• platelet count,

• renal function studies,

• prothrombin time,

• activated partial thromboplastin time,

• continuous oxygen therapy with oxygen saturation

• cardiac monitoring.

• with a cardiac history electrocardiography

Misbelieves in in acute stroke

• Early signs of ischaemia on CT excludes lysis

within the first 3 h NOT TRUE!

• Hyperdense MCA sign excludes thrombolysis.

NOT TRUE!

• Present anticoagulation excludes lysis . NOT

TRUE! except INR≥1.7

• Epileptic seizure excludes thrombolysis

NOT TRUE!

Control of intracranial bleeding from

fibrinolytic

– infusion of platelets 6–8 units and cryoprecipitate that contains factor VIII to rapidly correct the fibrinolytic state

– 10 units of cryoprecipitate be administered rapidly because cryoprecipitate contains fibrinogen, the most specific reversal agent for fibrinolytics

– To obtain cryoprecipitate, a type and screen is necessary.

– Neurosurgical evacuation may be warranted.

lysis ESO 2008

• New!

…Intra-arterial treatment

of acute MCA occlusion

within a 6-hour time

window is

recommended as an

option..

• Mechanical

Embolus

Removal in

Cerebral

Ischemia

MERCI

ESO 2008 MERCI

• Mechanical Embolus Removal in Cerebral

Embolism (MERCI)

• Recanalisation in 48% (68/141) within 8

hours

http://www.eso-

stroke.org/ppt/ESO08_Slides_25thApril.

PPT#444,11,Classification of Evidence

Therapy if NO lysis…..

Stroke unit

Neurosurgery

lysis

Op.

Isch/ICH

CT!!!

CT+AG!!

Neu. Status

labs

5-10%

80%

If BP >220mmHg use…

• α- and/or β-receptor-blocking (eg. urapidil,

metoprolol), careful monitoring of BP (measuring at

5-10 min)

• Stabilize at 160 Hgmm

If NO lysis… ESO 2008

• aspirin (160–325 mg loading dose) be given within 48 hours after ischemic stroke

If NO thrombolysis… in acute stroke

• NOT(!) recommended in acute phase:

– Early UFH,

– low molecular weight heparin or heparinoids

• meta-analysis of 22 trials,

– 9 ↓ recurr isch strokes per 1000 treated pts

– BUT 9/1000 in sympt intracranial

hemorrhages (Cochrane 2006].

Incr ICP ESO 2008

• New!

Surgical decompressive therapy within 48 hours up to 60 y with evolving malignant MCA infarcts

• New!

No recommendation can be given regarding hypothermic therapy in patients with space-occupying infarctions

Dept. of Neurology

Debrecen, Hungary

Basilar artery occlusio:. Intraarterial or iv. thrombolysis till 12 hours, if the

patient worsens

Intraarterial lysis is an option in MCA till 6 hours, but start with

iv.

iv.. thrombolysis 3 h –new time 4.5 hours with iv. t-PA

3-4,5 hour interval is NOT valid: 80y 1/3 MCA infarct, 25 NIHS, combin.

Of prior stroke+diabetes

Acute ischemic stroke therapy

Ih NO lysis :

100 mg aspirin, if NO lysis

2-4 lit/min oxygen

if BP 220 Hgmm decrease!!!

idő

Mechanical thrombus removal (eg.. MERCI, Penumbra etc) MCA occlusion 8

hours