Acute Stroke Management

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Acute Stroke Management

• Dr. FAWAZ AL-HUSSAIN FRCPC, MPH(HTA)
• May 25th/10
• For
• Internal Medicine Residents

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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?

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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.

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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)

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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

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Pre-hospital Mx

• Guidelines for EMS Management of Patients with
• Suspected Stroke
• Manage ABCs
• Cardiac monitoring
• Intravenous access
• Oxygen (keep O2 sat gt92)
• 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

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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.

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EMERGENCY EVALUATION AND DIAGNOSISOF ACUTE
ISCHEMIC STROKE

• Class I Recommendations
• 3. Limited number of hematalogic, coagulation,
  and
• biochemistry tests are recommended during initial
• emergency evaluation? CBC, lytes, cr, INR,PTT,
  Trop.,glucose
• Time is critical thrombolytic tx should not be
  delayed
• while waiting for results of PT/PTT or platelet
  count,
• unless bleeding abnormality/thrombocytopenia
• suspected, pt taking warafarin and heparin, or
• anticoagulation use suspected.

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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.

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Emergency evaluation and diagnosis

• Class I recommendations
• 1. Imaging of brain recommended before initiating
  any
• specific tx to treat acute ischemic stroke
• CT(brain) is still preferred? availability, time,
  easier to R/O hge
• Limitation pregnancy
• Class II recommendations
• 1. Data insufficient to state (except for
  hemorrhage) that
• any specific CT finding should preclude treatment
  of
• TPA.

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Acute stroke imaging

• Hypo-attenuation of brain tissues
• Loss of sulcal efffacement
• Insular ribbon sign
• Obscuration of lentiform nucleus
• Hyperdense sign (MCAgtbasilargtPCA)

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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).

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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.

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• 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.

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THROMBOLYTICS IV-TPA

• Class I recommendations
• 1. IA thrombolysis is an option for treatment of
  selected
• patients who have major stroke of lt6 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).

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THROMBOLYTICS IA-TPA

• Class I recommendations
• 1. IA thrombolysis is an option for treatment of
  selected
• patients who have major stroke of lt6 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).

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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).

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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).

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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.

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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.

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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

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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

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