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Acute Stroke Management

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Acute Stroke Management Dr. FAWAZ AL-HUSSAIN FRCPC, MPH(HTA) May 25th/10 For Internal Medicine Residents * * * * * * * * * * Stroke In Saudi Arabia: No good studies ... – PowerPoint PPT presentation

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Title: Acute Stroke Management


1
Acute Stroke Management
  • Dr. FAWAZ AL-HUSSAIN FRCPC, MPH(HTA)
  • May 25th/10
  • For
  • Internal Medicine Residents

2
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?

3
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.

4
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)

5
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

6
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

7
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.

8
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.

9
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.

10
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.

11
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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19
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).

20
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.

21
  • 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.

22
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).

23
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).

24
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).

25
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).

26
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.

27
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.

28
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

29
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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