Stroke

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Stroke

• Supischa Theerasasawat

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Epidemiology

• The second most common cause of death (9 of all
  death)

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Classification

• Hemorrhagic stroke
• Acute ischemic stroke
• Large artery atherosclerosis
• Cardiac embolism
• Small vessel occlusion
• Stroke of other determined cause
• Stroke of undetermined cause

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Risk factors for ischemic stroke

• Genetic, gender
• Race
• Age
• Family history

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Risk factors for ischemic stroke

• Cardiac disease, prior stroke, TIA, DM, HT,DLP
• Obesity, smoking, alcohol consumption, oral
  contraception

• Carotid bruits/stenosis, aortic arch
  atheromatosis
• Elevate fibrinogen, homocysteine, anticardiolipin
  antibody, low serum folate

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TIA

• A sudden, focal neurological deficit of presumed
  vascular origin with symptoms lasting lt 24 hr.
• A transient episode of neurological dysfunction
  cause by focal brain, spinal cord, or retinal
  ischemia, without acute infarction

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ABCD2 score

• Age gt60 y.
• BP gt 140/90 mmHg
• Clinical speech impairment without weakness
  (1), focal weakness (2)
• Duration - lt10 min. (0), 10-59 min (1), gt 60 min.
  (2)
• DM

If score gt 3 consider to admission
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Pathophysiology
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Evolution of Atherosclerosis
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Atherosclerosis and Thrombus Formation
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Ischemic Penumbra
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Ischemic Penumbra

• Impaired neuronal function
• lt 22 ml/100 gm/min for monkeys (40)
• lt 35 ml/100 gm/min for cats and rats
• Irreversible damage
• lt 18 ml/100 gm/min for monkeys
• lt 10 ml/100 gm/min
• In human (PET study, 5-18 hours after onset)
• 8-20 ml/100 gm/min ? potential reversibility
• lt 8 ml/100 gm/min ? irreversible damage

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Ischemic cascade
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Transverse section through the lower pons
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Lateral Medullary syndrome
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INTRACEREBRAL HEMORRHAGE

• headache and vomiting
• meningismus
• decreased level of consciousness
• contralateral sensory-motor deficits
• higher level cortical dysfunction
• brainstem dysfunction
• Ataxia, nystagmus, and dysmetria

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Guidelines for the Early Management of Adults
With Ischemic Stroke
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Class I Recommendations

• An organized protocol for the emergency
  evaluation of patients with suspected stroke is
  recommended
• (Class I, Level of Evidence B). The goal is to
  complete an evaluation and to decide treatment
  within 60 minutes of the patients arrival in an
  ED.
• The use of a stroke rating scale, preferably the
  NIHSS, is recommended (Class I, Level of Evidence
  B). Hospitals (ie, administration) must provide
  the necessary resources to use such a scale.

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Class I Recommendations

• A limited number of hematologic, coagulation, and
  biochemistry tests are recommended during the
  initial emergency evaluation
• (Class I, Level of Evidence B).
• Patients with clinical or other evidence of acute
  cardiac or pulmonary disease may warrant chest
  x-ray
• (Class I, Level of Evidence B).
• An ECG is recommended because of the high
  incidence of heart disease in patients with
  stroke
• (Class I, Level of Evidence B).

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Class III Recommendations

• Most patients with stroke do not need a chest
  x-ray as
• part of their initial evaluation (Class III,
  Level of Evidence B). This is a change from the
  previous guideline.
• Most patients with stroke do not need an
  examination of the CSF(Class III, Level of
  Evidence B).

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Class I Recommendations

• Imaging of the brain is recommended before
  initiating any specific therapy to treat acute
  ischemic stroke (Class I, Level of Evidence A).
• In most instances, CT will provide the
  information to make decisions about emergency
  management (Class I, Level of Evidence A).

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Class I Recommendations

• Airway support and ventilatory assistance are
  recommended for the treatment of patients with
  acute stroke who have decreased consciousness or
  who have bulbar dysfunction causing compromise of
  the airway
• (Class I, Level of Evidence C).
• Hypoxic patients with stroke should receive
  supplemental oxygen
• (Class I, Level of Evidence C).

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Class I Recommendations

• It is generally agreed that sources of fever
  should be treated and antipyretic medications
  should be administered to lower temperature in
  febrile patients
• with stroke
• (Class I, Level of Evidence C).
• 4. It is generally agreed that cardiac monitoring
  should be performed during the first 24 hours
  after onset of
• ischemic stroke (Class I, Level of Evidence B).

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Class I Recommendations

• The management of arterial hypertension
• remains controversial. Until more definitive
  data are available, it is generally agreed that a
  cautious approach to the treatment of arterial
  hypertension should be recommended
• Patients who have elevated BP and are otherwise
• eligible for treatment of rtPA may have their BP
  
• lowered so that their SBP is lt 185 mm Hg and
  their
• DBP is lt110 mm Hg
• (Class I, Level of Evidence B)

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Class I Recommendations

• 7. A reasonable goal would be to lower BP by 15
  during the first 24 hours after onset of stroke.
  Consensus exists that medications should be
  withheld unless the SBP is gt220 mm Hg or the DBP
  is gt120 mm Hg
• (Class I, Level of Evidence C).

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Class II Recommendations

• 1. It is generally agreed that antihypertensive
  medications should be restarted at 24 hours for
  patients who have preexisting HT and are
  neurologically stable
• (Class IIa, Level of Evidence B).
• 2. The minimum threshold described in previous
  statements likely was too high, and lower serum
  glucose concentrations (possibly gt140-185 mg/dL)
  probably should trigger administration of insulin
  (Class IIa, Level of Evidence C).

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Class I Recommendations

• Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg)
  is recommended for selected patients who may be
  treated within 3 hours of onset of ischemic
  stroke
• (Class I, Level of Evidence A).

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Class III Recommendations

• The intravenous administration of streptokinase
  for
• treatment of stroke is not recommended
• (Class III, Level of Evidence A).
• The intravenous administration of ancrod,
  tenecteplase, reteplase, desmoteplase, urokinase,
  or other thrombolytic agents outside the setting
  of a clinical trial is not recommended
• (Class III, Level of Evidence C).
• This recommendation is new.

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Class I Recommendations

• Intra-arterial thrombolysis is an option for
  treatment of selected patients who have major
  stroke of lt 6 hours duration due to occlusions of
  the MCA and who are no otherwise candidates for
  intravenous rtPA
• (Class I, Level of Evidence B).

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Class I Recommendation

• The oral administration of aspirin (initial dose
  is 325
• mg) within 24 to 48 hours after stroke onset is
  recommended for treatment of most patients
• (Class I, Level of Evidence A).

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Class III Recommendations

• 1. The administration of clopidogrel alone or
  in combination with aspirin is not recommended
  for the treatment of acute ischemic stroke
• (Class III, Level of Evidence C).
• The panel supports research testing the
  usefulness of emergency administration of
  clopidogrel in the treatment of patients with
  acute stroke.

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Endothelial uptake
Thromboxane A2
ADP
Adenosine
Cilostazol
Dipyridamole
Clopidogrel
P2Y1
P2Y12
Thromboxane A2
ATP
ASA
Ca
cAMP
Dipyridamole
Arachidonic a.
Cilostazol
Activation
AMP
Abxicimab Tirofiban
fibrin
Gp IIb-IIIa
Platelet fibrin complex
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Guidelines for the Management of spontaneous
intracerebral hemorrhage
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Recommendations for Emergency Diagnosis and
Assessment of ICH

• Class I
• 1. CT and magnetic resonance are each
  first-choice initial imaging options (Class I,
  Level of Evidence A)

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Treatment of Acute ICH/IVH

• Overall Approach to Treatment of ICH
• Airway
• Breathing
• Circulation
• Treatments of ICH include stopping , slowing
  the initial bleeding during the first hours after
  onset, removing blood from the parenchyma or
  ventricles
• Management of complications of blood in the
  brain increased ICP and decreased cerebral
  perfusion

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Blood Pressure Management

• Primary ICH, little prospective evidence exists
  to support a
• specific BP threshold.
• The recommendation was to maintain a systolic
  blood
• pressure 180 mm Hg and/or MAPlt 130 mm Hg.

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Recombinant Activated Factor VIIfor Acute
Intracerebral Hemorrhage

• 69 of placebo treated patients died or were
  severely
• disabled (as defined by a mRS of 4 to 6),
  compared with 55, 49, and 54 of the patients
  who were given rFVIIa 40, 80, and 160 µg/kg,
  respectively (P0.004 for comparison of the 3
  rFVIIa groups with the placebo group).
• The rate of death at 90 days was 29 for patients
  who received placebo versus 18 in the 3 rFVIIa
  groups combined (P0.02).
• Serious thromboembolic adverse events, mainly
  myocardial or cerebral infarction, occurred in 7
  of rFVIIa-treated patients versus 2 of those
  given placebo (P0.12).

N Engl J Med 2005352777-85.
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Recommendations for Initial Medical Therapy

• Class I
• 1. Monitoring and management of patients with an
  ICH should take place in an intensive care unit
  setting because of the acuity of the condition,
  frequent elevations in ICP and blood pressure,
  frequent need for intubation and assisted
  ventilation, and multiple complicating medical
  issues
• (Class I, Level of Evidence B).
• 2. Appropriate antiepileptic therapy should
  always be used for treatment of clinical seizures
  in patients with ICH
• (Class I, Level of Evidence B).

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Recommendations for Initial Medical Therapy

• Class I
• 3. It is generally agreed that sources of fever
  should be treated and antipyretic medications
  should be administered to lower temperature in
  febrile patients with stroke (Class I, Level of
  Evidence C).
• 4. As for patients with ischemic stroke, early
• mobilization and rehabilitation are
  recommended in patients with ICH who are
  clinically stable
• (Class I, Level of Evidence C).

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Recommendations for Initial Medical Therapy

• Class II
• 1. Treatment of elevated ICP should include a
  balanced and
• graded approach that begins with simple
  measures, such as elevation of the head of the
  bed and analgesia and sedation. More aggressive
  therapies to decrease elevated ICP, such as
  osmotic diuretics (mannitol and hypertonic saline
  solution), drainage of CSF via ventricular
  catheter, neuromuscular blockade, and
  hyperventilation, generally require concomitant
  monitoring of ICP and blood pressure with a goal
  to maintain CPP gt70 mm Hg
• (Class IIa, Level of Evidence B).

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Warfarin-related ICHTreatment

• Vitamin K1 IV 10 mg.
• at least 6 hrs for normalize the INR
• FFP 15 to 20 mL/kg
• several hours to be infused, may lead to
• volume overload and heart failure, variable
  of clotting factors in FFP
• Prothrombin complex concentration(eg.
  Profilnine)
• requiring smaller volumes of infusion than
  
• FFP and correcting the coagulopathy faster

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ICH that result from the use of iv heparin

• Protamine sulfate dose is 1 mg per 100 U
  heparin,
• If heparin is stopped for 30 to 60 min, dose is
  0.5 to 0.75 mg per 100 U heparin,
• 60 to 120 minutes ? 0.375 to 0.5 mg per 100 U
  heparin
• gt120 minutes? 0.25 to 0.375 mg per 100 U heparin
• Protamine sulfate is given by slow intravenous
  injection, not to exceed 5 mg/min, with a total
  dose not to exceed 50 mg.
• A faster rate of infusion can produce severe
  systemic hypotension.

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Recommendations for Surgical Approaches

• Class I
• 1. Patients with cerebellar hemorrhage gt3 cm who
  are deteriorating neurologically or who have
  brain stem compression and/or hydrocephalus from
  ventricular obstruction should have surgical
  removal of the
• hemorrhage as soon as possible
• (Class I, Level of Evidence B).

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Recommendations for Surgical Approaches

• 2. Although theoretically attractive, the
  usefulness of
• minimally invasive clot evacuation utilizing a
  variety
• of mechanical devices and/or endoscopy awaits
  
• further testing in clinical trials therefore,
  its current
• usefulness is unknown
• (Class IIb, Level of Evidence B).
• 3. For patients presenting with lobar clots
  within 1 cm of
• the surface, evacuation of supratentorial ICH
  by
• standard craniotomy might be considered
• (Class IIb, Level of Evidence B).

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Recommendation for Decompressive Craniectomy

• Class II
• Too few data currently exist to comment on the
  potential of decompressive craniectomy to
  improve outcome in ICH
• (Class IIb, Level of Evidence C).

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Neuroprotective agents

• Decrease glutamate release lubeluzole
• Block glutamate receptor CCB, Mg
• Decrease O2 free radical Tirilizad
• Membrane stabilizer citicholine
• Decrease inflammation statin
• GABA agonist barbiturate
• Revascularization - thrombolytic