Guideline Guideline For Management Ischemic StrokeFor Management Ischemic Stroke

นายแพทยธติินายแพทยธติิ อึ้งอารีอึ้งอารี

Guideline For Ischemic StrokeGuideline For Ischemic Stroke

In the pastIn the past Stroke preventionStroke prevention

Supportive careSupportive careRehabilitationRehabilitation

1995 1995 NINDNINDSS ( National Institute of Neurological disorder and stroke )( National Institute of Neurological disorder and stroke )

rtpArtpA in Acute in Acute IschemicIschemic Stroke (FDA)Stroke (FDA)Medical emergency Medical emergency Treated early, few Treated early, few sequelaesequelae

๏๏ stroke occur while sleepingstroke occur while sleeping ๏๏ patient cannot call for helppatient cannot call for help ๏๏ unrecognized caregiversunrecognized caregivers

ECASSECASS (( EUROPEAN COOPERATIVE ACUTE STROKE STUDY EUROPEAN COOPERATIVE ACUTE STROKE STUDY ))

NINDSNINDS 624 pt,624 pt, 39 center39 center19911991--19941994

onset onset <=<= 33 hrhrCT brain exclude hemorrhageCT brain exclude hemorrhageBP >185/110BP >185/110Previous Previous IntracranialIntracranial hemorrhage, hemorrhage, recent stroke, head injury < 3 recent stroke, head injury < 3 momoreceived heparin, received heparin, anticaogulantanticaogulant < 48 hr< 48 hrBS > 400 mgBS > 400 mg

Rx Rx rtpArtpA0.9 mg/kg (90 mg.total) over 1 hr0.9 mg/kg (90 mg.total) over 1 hrSiginificantSiginificant increase full recovery,disabilityincrease full recovery,disability6.4% Symptomatic intracranial hemorrhage6.4% Symptomatic intracranial hemorrhage

ECASS IECASS I620 pt ,75 hospital620 pt ,75 hospital

onset <= 6 hronset <= 6 hrCT no hemorrhage, CT no hemorrhage, rtpArtpA dose 1.1 mg/kg (Max 100 mg)dose 1.1 mg/kg (Max 100 mg)no recent trauma, surgery, no recent trauma, surgery,

receiving anticoagulantreceiving anticoagulantMCA occlusion > 33% (1/3)MCA occlusion > 33% (1/3)

Significant increase recoverySignificant increase recovery

American Heart Association StrokeAmerican Heart Association StrokeCouncil guidelines, 1999Council guidelines, 1999Prevention after TIA/StrokePrevention after TIA/Stroke1. HT1. HT : maintain BP < 140/90: maintain BP < 140/902. Smoking2. Smoking : cessation: cessation3. DM3. DM : BS < 126 mg/dl: BS < 126 mg/dl4. Carotid 4. Carotid StenosisStenosis : surgery if > 70% : surgery if > 70% 5. AF5. AF : anticoagulant: anticoagulant6. Cholesterol6. Cholesterol : : statinstatin if LDL > 130 mg/dlif LDL > 130 mg/dl7. 7. AntiplateletAntiplatelet agentagent : if : if atherothromboticatherothrombotic8. Other8. Other : diet, exercise, alcohol: diet, exercise, alcohol

Royal Royal colladgecolladge of physicians of Londonof physicians of LondonNational clinical guideline for stroke 2000National clinical guideline for stroke 2000Guideline for Secondary prevention of Guideline for Secondary prevention of stroke (all patients)stroke (all patients)

(A)(A) ((MetaanalysisMetaanalysis or or randomisedrandomised controlled trial controlled trial evidence)evidence)All patientsAll patients HT persist > 1 HT persist > 1 momo RX RX All patientsAll patients ASA 50ASA 50--300 mg300 mg

or low dose ASA + or low dose ASA + dipyridamoledipyridamolemodified releasemodified release

ASA intolerantASA intolerant clopidogrelclopidogrel 75 mg75 mgAnticoagulant all AF unlessAnticoagulant all AF unless contraindicatedcontraindicated

Anticoagulant after brain imagingAnticoagulant after brain imaging14 days after acute stroke14 days after acute strokeno used in TIA no used in TIA (except cardiac emboli)(except cardiac emboli)

EndarterectomyEndarterectomy stenosisstenosis >70%>70%Specialist surgeon Specialist surgeon low complication < 3low complication < 3--5 %5 %

StatinStatin MIMICholesterol > 5 Cholesterol > 5 mmolmmol/l/l

(B)(B) All patients (descriptive study)All patients (descriptive study)assessed vascular risk factorassessed vascular risk factor

(C)(C) (Expert committee)(Expert committee)AnticoagulantAnticoagulant

MitralMitral valuevalueprosthetic valueprosthetic valueMI < 3 MI < 3 momo

Carotid ultrasound Carotid ultrasound carotid strokecarotid strokeEndarterectomyEndarterectomy

All patientsAll patientsLifestyle modificationLifestyle modification

European Stroke Initiative (EUSI) 2003European Stroke Initiative (EUSI) 2003

RecommendationRecommendationStroke patients should be treated Stroke patients should be treated

in stroke unitsin stroke unitsOnce stroke symptoms are suspectedOnce stroke symptoms are suspected,,patients or their proxies should call the patients or their proxies should call the EMS or a similar systemEMS or a similar system

Requirements for stroke managementRequirements for stroke management

Minimum RequirementsMinimum Requirements1. Availability of 241. Availability of 24--hr CT scanninghr CT scanning2. Established stroke treatment guidelines 2. Established stroke treatment guidelines

and operational proceduresand operational procedures3. Close co3. Close co--operation of neurologists, operation of neurologists,

internists and rehabilitation expertsinternists and rehabilitation experts4. Specially trained nursing personnel4. Specially trained nursing personnel

5. Early multidisciplinary rehabilitation 5. Early multidisciplinary rehabilitation including speech therapy, occupational therapy including speech therapy, occupational therapy and physical therapyand physical therapy

6. 6. NeurosonologicalNeurosonological investigations within 24 hr investigations within 24 hr ((extracranialextracranial vessels, vessels, colourcolour--coded duplex coded duplex sonographysonography))

7. ECG7. ECG8. Laboratory examinations 8. Laboratory examinations

(including coagulation parameters)(including coagulation parameters)9. Monitoring of blood pressure, ECG, 9. Monitoring of blood pressure, ECG,

oxygen saturation, blood glucose,body temperatureoxygen saturation, blood glucose,body temperature

Additional facilities recommendedAdditional facilities recommended1. MRI/MRA1. MRI/MRA2. Diffusion and perfusion MR2. Diffusion and perfusion MR3. CTA3. CTA4. ECG (4. ECG (transoesophagealtransoesophageal))5. Cerebral 5. Cerebral angiographyangiography6. 6. TranscranialTranscranial Doppler Doppler sonographysonography7. 7. SpecialisedSpecialised neuroradiologicalneuroradiological, , neurosurgicalneurosurgical

and vascular surgical consultationand vascular surgical consultation

Emergent diagnostic tests in acute strokeEmergent diagnostic tests in acute stroke1. CT1. CT2. ECG and chest X2. ECG and chest X--rayray3. Clinical chemistry3. Clinical chemistry

Complete blood count and platelet count, Complete blood count and platelet count, prothrombinprothrombin time, INR, PTTtime, INR, PTTSerum electrolytes, blood glucoseSerum electrolytes, blood glucoseCRP, sedimentation rateCRP, sedimentation rateArterial blood gas analysis, Arterial blood gas analysis, if if hypoxiahypoxia is suspectedis suspectedHepatic and renal chemical analysisHepatic and renal chemical analysis

4. Pulse 4. Pulse oxymetryoxymetry5. Lumbar puncture (only if CT is negative,5. Lumbar puncture (only if CT is negative,

CT and CT and subarachnoidalsubarachnoidal haemorrhagehaemorrhageis clinically suspected)is clinically suspected)

6. Duplex and 6. Duplex and transcranialtranscranial ultrasoundultrasound7. EEG7. EEG8. MRI and MRA/CTA8. MRI and MRA/CTA9. Diffusion MR and perfusion MR9. Diffusion MR and perfusion MR10. ECG (10. ECG (transthoracictransthoracic and and transoesophagealtransoesophageal))

Primary PreventionPrimary PreventionRecommendationsRecommendations1. Blood pressure should be lowered to normal1. Blood pressure should be lowered to normal

levels (<140/<90 mm Hg,levels (<140/<90 mm Hg,or <135/80 mm Hg in diabetics)or <135/80 mm Hg in diabetics)

2. Cholesterol 2. Cholesterol --lowering therapy (lowering therapy (simvastatinsimvastatin))is recommended for highis recommended for high--risk patientsrisk patients

3. Cigarette smoking should be discouraged3. Cigarette smoking should be discouraged4. Heavy use of alcohol should be discouraged, 4. Heavy use of alcohol should be discouraged,

light or moderate alcohol consumptionlight or moderate alcohol consumptionmay be protective against strokemay be protective against stroke

5. Regular physical activity is recommended5. Regular physical activity is recommended6. A low salt, low saturated fat, high fruit and 6. A low salt, low saturated fat, high fruit and

vegetable diet rich in vegetable diet rich in fibrefibre is recommendedis recommended7. Subjects with an elevated body mass index 7. Subjects with an elevated body mass index

should take a weightshould take a weight--reducing dietreducing diet8. Hormone replacement therapy should not be used 8. Hormone replacement therapy should not be used

for primary prevention of strokefor primary prevention of stroke9. Although aspirin does not reduce the risk 9. Although aspirin does not reduce the risk

of stroke in healthy subjects, it does reduce the riskof stroke in healthy subjects, it does reduce the riskof MI and can be recommendedof MI and can be recommendedin subjects with one or more vascular risk factorsin subjects with one or more vascular risk factors

10. 10. ClopidogrelClopidogrel, , ticlopidineticlopidine, , trifusaltrifusal and and dipyridamoledipyridamole have not been studied in have not been studied in asymptomaticasymptomaticsubjects and therefore cannot be recommended for subjects and therefore cannot be recommended for primary stroke preventionprimary stroke prevention

11. Long11. Long--tern oral tern oral anticogulationanticogulation therapy should be consideretherapy should be considerefor all AF patients at high risk of embolismfor all AF patients at high risk of embolism

12. Carotid surgery may be indicated for some 12. Carotid surgery may be indicated for some asymptomaticasymptomaticpatients with a 60patients with a 60--99% 99% stenosisstenosis of the ICA.of the ICA.The carotid The carotid endarterectomyendarterectomy (CEA) (CEA) --related risk ofrelated risk ofstroke or death must be less than 3%, stroke or death must be less than 3%, and patients with a life expectancyand patients with a life expectancyof least 5 years (or under the age of 80)of least 5 years (or under the age of 80)

Secondary prevention of StrokeSecondary prevention of Stroke

Risk factor ModificationRisk factor ModificationHTHT diuretic, ACEIdiuretic, ACEICholesterolCholesterol lowering lowering statinstatinSmokingSmoking stopstopHRTHRT no indication in post menopauseno indication in post menopause

Anti Anti thromboticthromboticASA 50ASA 50--325 mg325 mgASA 50 mg + long release ASA 50 mg + long release DipyridamoleDipyridamole200mg bid (recurrent)200mg bid (recurrent)

clopidogrelclopidogrel

ASA, ASA, DipyridamoleDipyridamole intoleranceintoleranceHigh risk patientsHigh risk patientsTIA or TIA or IschemicIschemic stroke + non Q MI or stroke + non Q MI or

unstable anginaunstable anginaRx ASA 75 mg + Rx ASA 75 mg + clopidogrelclopidogrel 75 mg75 mg

patient start with patient start with thinopyridinethinopyridinederivativeshouldderivativeshould receive receive clopidogrelclopidogrel(fewer side effect) (fewer side effect)

Oral anticoagulantOral anticoagulantINR 2INR 2--33not advice Epilepsy, dementianot advice Epilepsy, dementiaGI bleeding, fallGI bleeding, fall

ACCPACCP (American (American ColladgeColladge of Chest Physicians)of Chest Physicians)September 2004September 2004

Anti Anti thromboticthrombotic and and ThrombolyticThrombolytic Therapy for Therapy for IschemicIschemic StrokeStroke

IV IV tpAtpA in 3 hr of symptom onsetin 3 hr of symptom onsetIV 0.9 mg/kg (Max 90 mg)IV 0.9 mg/kg (Max 90 mg)10% initial bolus10% initial bolusremianderremiander infused > 60 mininfused > 60 minavoid (infarction >1/3 MCA)avoid (infarction >1/3 MCA)IV IV tpAtpA between between 33--66 hr o symptom onsethr o symptom onsetunselected patients not use IV unselected patients not use IV tpAtpAIV IV streptokinasestreptokinase between 0between 0--6 hr 6 hr of onset not useof onset not use

IntraIntra -- arterial arterial thrombolysisthrombolysis-- MCA occlusion no sign major infarctMCA occlusion no sign major infarct-- onset < 6 hronset < 6 hr-- basilarbasilar artery thrombosis artery thrombosis

without major infarctionwithout major infarctionAnticoagulant not Anticoagulant not digibledigible for for thrombolysisthrombolysis

iv,iv,scsc LMWHLMWHAnticoagulant prevent DVT, PEAnticoagulant prevent DVT, PE

(stable (stable intracerebralintracerebral hemorrhage in second day)hemorrhage in second day)

แนวทางการรักษาแนวทางการรักษาโรคหลอดเลือดสมองตีบหรืออุดตันโรคหลอดเลือดสมองตีบหรืออุดตัน

Clinical Practice Guidelines For Ischemic StrokeClinical Practice Guidelines For Ischemic Strokeสมาคมประสาทวทิยาสมาคมประสาทวทิยา -- ราชวทิยาลัยราชวทิยาลัยอายุรอายุรแพทยแพทย 25452545

แนวทางเวชปฏิบัตินี้แนวทางเวชปฏิบัตินี้ เปนเครื่องมือสงเสริมคุณภาพของเปนเครื่องมือสงเสริมคุณภาพของการบริการดานสุขภาพที่เหมาะสมกับทรัพยากรการบริการดานสุขภาพที่เหมาะสมกับทรัพยากร และเงื่อนไขของและเงื่อนไขของสังคมไทยสังคมไทย โดยหวังผลในการสรางเสริมโดยหวังผลในการสรางเสริม และแกไขปญหาสุขภาพและแกไขปญหาสุขภาพของคนไทยของคนไทย อยางมีประสิทธิภาพอยางมีประสิทธิภาพ และคุมคาและคุมคา ขอแนะนําตางๆในขอแนะนําตางๆในแนวทางเวชปฏิบัตินี้ไมใชขอบังคับของการปฏิบัติแนวทางเวชปฏิบัตินี้ไมใชขอบังคับของการปฏิบัติ ผูใชสามารถผูใชสามารถปฏิบัติแตกตางไปจากขอแนะนํานี้ไดปฏิบัติแตกตางไปจากขอแนะนํานี้ได ในกรณีที่สถานะการณในกรณีที่สถานะการณแตกตางออกไปหรือมีเหตุผลที่สมควรแตกตางออกไปหรือมีเหตุผลที่สมควร โดยใชวิจารณญาณที่เปนที่โดยใชวิจารณญาณที่เปนที่ยอมรับในสังคมยอมรับในสังคม

Acute ischemic stroke < 3 hrAcute ischemic stroke < 3 hrAcute ischemic stroke between 3Acute ischemic stroke between 3--72 hr72 hr

Sudden onset<3hrSudden onset<3hr (Neurosurgeon+CT brain(Neurosurgeon+CT brain))

Basic life supportBasic life support ABC,ABC,hypoglycamiahypoglycamia

Facility of Facility of thrombolyticthrombolytic drugdrug

NoNo YesYes

EmergencyEmergency Lab + Lab + CT brainCT brainCBC.FBS,Bun,CBC.FBS,Bun,CrCrE’lyteE’lyte,EKG,EKG

NonNon--StrokeStroke StrokeStroke

Appropriate RxAppropriate Rx

NormalNormal

IschemicIschemic StrokeStroke

ThrombolyticThrombolytic PXPX (Advice ญาติ(Advice ญาติ))

HypodensityHypodensity

Onset 3Onset 3--72 hr72 hr

HematomaHematoma

Appropriate Appropriate PxPx

Ability to transferAbility to transfercenter to obtain center to obtain thrombolyticthrombolyticin 3 hrin 3 hr

ReferRefer Onset3Onset3--72 hr72 hr

YesYes NoNo

IndicationIndication1. Onset < 3 hr.1. Onset < 3 hr.2. > 18 2. > 18 yr.yr.3. CT brain normal3. CT brain normal

ContraContra--indicationindication1.1. rapid recovery, Mild ataxia, dysphasiarapid recovery, Mild ataxia, dysphasia2. Seizure at onset2. Seizure at onset3. SBP>185, DBP>1103. SBP>185, DBP>1104. Previous cerebral 4. Previous cerebral hematomahematoma5. Head injury < 3 5. Head injury < 3 momo6. PT > 15 sec, INR > 1.76. PT > 15 sec, INR > 1.77. Stop heparin < 48 hr, prolong PTT7. Stop heparin < 48 hr, prolong PTT8. Platelet < 100,0008. Platelet < 100,0009. Major surgery < 14 days9. Major surgery < 14 days10. UGIH, 10. UGIH, hematuriahematuria < 21 days< 21 days11. BS < 50mg/dl, > 400 mg/dl11. BS < 50mg/dl, > 400 mg/dl12. Recent MI12. Recent MI

DoseDoserr--tpAtpA 0.9 mg/kg (Max 90)0.9 mg/kg (Max 90)10 % bolus, 90 % drip in 60 min10 % bolus, 90 % drip in 60 minObservationObservation1. Avoid 1. Avoid antiplateletantiplatelet, anticoagulant 24 hr., anticoagulant 24 hr.2. Avoid patient cerebral edema, large 2. Avoid patient cerebral edema, large infarctioninfarction3. Stop r3. Stop r--tpAtpA if suggest cerebral if suggest cerebral hematomahematoma4. 4. AvalableAvalable CT, MRI 24 hrCT, MRI 24 hr5. Avoid NG5. Avoid NG--tube, CVP, Atube, CVP, A--line in 24 hrline in 24 hr6. Avoid Foley’s 6. Avoid Foley’s cathcath in 30 minin 30 min7. Control SBP <180, DBP <1207. Control SBP <180, DBP <120

Onset3Onset3--72 hr72 hr

Basic lifeBasic life--SupportSupport

Emergency ,Lab CBC BUN, Emergency ,Lab CBC BUN, CrCr, , E’lyteE’lyte, BS, BS

Emergency CT brainEmergency CT brain

NonNon--strokestroke strokestroke

Appropriate Appropriate PxPx Normal/Normal/HypodensityHypodensityHyperdensityHyperdensity

Appropriate Appropriate PxPxGeneral management

Avoid antihypertensive except SBP>=220, DBP >=120Avoid intravenous glucose solution unless necessaryControl BS<180Treatment fever and concomitant conditions

Work up for Etiology of strokeWork up for Etiology of strokeGeneralGeneral

Lipid profile Lipid profile cholchol TG LDL HDLTG LDL HDLFBS, VDRLFBS, VDRLCardiac work up EKG, CXRCardiac work up EKG, CXR

Suggest cardiac embolismSuggest cardiac embolismEchocardiogramEchocardiogramHolterHolter monitoringmonitoring

Stroke in the youngStroke in the young(< 45 (< 45 yrs.yrs. , no DM, HT, smoking), no DM, HT, smoking)ESRESRANAANACoagulogramCoagulogram protein C,S, protein C,S, antithrombinantithrombin III, III,

anticardiolipinanticardiolipinVascular work upVascular work up

TCD, Carotid duplexTCD, Carotid duplexMRAMRACT CT angiographyangiography

Secondary preventionSecondary preventionAntiplateletAntiplatelet

ASA 60ASA 60--325 mg325 mgINTOLERANCEINTOLERANCE

TiclopidineTiclopidine 250 mg. Bid250 mg. Bid((thrombocytopeniathrombocytopenia, , NeutropeniaNeutropenia))clopidogrelclopidogrel 75 mg75 mgASA 25 + ASA 25 + DipyridamoleDipyridamole extended extended

release 200 mg bidrelease 200 mg bid

AnticoagulantAnticoagulantwarfarinwarfarin INR 1.5INR 1.5--3.03.0

Carotid Carotid endarterectomyendarterectomystenosisstenosis > 70%> 70%

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