LOGO 1 โดย นศ. ภ. กชกร คำอินต๊ะ นสภ. พฒนพงศ์...

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LOGO

โดยนศ.ภ . กชกร คำ� อิ�นต๊�ะ

นสภ . พฒนพงศ� ทร�พย�พ�ร�ยะอิ น�นต๊�

Academic in servicePrinciple of

pharmacotherapy in Stroke

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Stroke

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Stroke

Stroke is a "Brain Attack"

Stroke is an emergency!

Time is brain

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Stroke’s Outline

IntroductionClassificationCause of strokeTreatment & Prevention

Ischemic stroke Homorrhagic stroke

Stroke scale and clinical Assessment tools

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Introduction

Cause of hemiplegic and decrease the quality of life

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Classification of Stroke

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Cause of stroke

Large vessel occlusion : 32%Cerebral embolism : 32%Small vessel occlusion ,lacuna : 18%Intracerebral hemorrhage : 11%Subarachnoid hemorrhage : 7%

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Ischemic stroke

Risk factor Unmodified risk factor

•Age ,race ,sex and family history Modifiable risk factor

•Hypertension•Heart disease•Smoking•DM•Hyperlipidemia•Elevated fibrinogenlevel

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Early Management

Airway, Ventilatory Support, and Supplemental Oxygen

Temperature Cardiac Monitoring and Treatmen

t Arterial Hypertension Hypoglycemia and

HyperglycemiaACC/AHA 2007 Guidelines for the Early Management of Adults With

Ischemic StrokeA Guideline From the American Heart Association/America n Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovas

cular Radiology and Intervention Council, and the Atherosclerotic Periphe ral Vascular Disease and Quality of Care Outcomes in Research Interdiscip

linary Working Groups

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Medication

Intravenous ThrombolysisAnticoagulants Antiplatelet Agents Volume Expansion, Vasodilators,

and Induced Hypertension Neuroprotective Agents Surgical Interventions

ACC/AHA 2007 Guidelines for the Early Management of Adults With Ischemic StrokeA Guideline From the American Heart Association/America

n Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovas cular Radiology and Intervention Council, and the Atherosclerotic Periphe

ral Vascular Disease and Quality of Care Outcomes in Research Interdiscip linary Working Groups

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Class I reccommendation 09Intravenous rtPA ( . mg/kg, maximum dose

90mg) is recommended for selected patients w 3ho may be treated within hours of onset of isch

eeee eeeeee eeeeee ee eeeee ee eeeeeeee ee New recommendation : rtPA should be administe

red to eligible patients who can be treated in the time period of 3 to 4 .5 hours after stroke (Cl

ass I Recommendation, Level of Evidence B).

exclusioncr i t er i a:• 80Patients older than years• wwww ww wwwwwwwwwwwww wwwwwwwwww wwwww www1.7• ww wwwwww wwwwww wwwww wwwww ww 25• history of stroke and diabetes.

Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intr avenous Tissue Plasminogen Activatorใ Stroke2009

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Class I reccommendation

The oral administration of aspirin (initial dose is 325 mg) within 24

to 48 hours after stroke onset is r ecommended for treatment of mo

ee eeeeeeee ee eeee ee eeeee ee eeeee nce A)

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Secondary prevention

Antiplatelet Therapy 50 325Aspirin ( to mg/d) monothe

www wwwwwwwwwww ww wwwwwww www wwwwwwww-wwwwwww ww, pyridamole, andcl opi dogr el monot her apy ar e al l ac ceptableopt i ons f or i ni t i al t her apy ( Class I , Level of Evidence A

wwwwwwwwwwwwwww www wwwwwwwwwww ww wwwwwww www :- extendedr el ease di pyr i damol e i s r ecommende wwww wwwwwww wwwww w( Class I, Level of

Evidence B). Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or

Transient Ischemic Attackใ Stroke -200637577 617

Update to the AHA/ASA Recommendations for the Prevention of Stroke in Patients With Stroke and Transient I

schemic Attackใ Stroke -2008391647165; ;2

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Secondary prevention (cont.)

Anticoagulant for Cardioembolic Stroke Types Long term anticoagulant ;target INR 2.0-3.0

• Persistent or paroxysmal AF (class I, level of evidence A)

• Acute MI and LV thrombus (class IIa, level of evidence B)

• Cardiomyopathy (class IIb, level of evidence C)• Rheumatic mitral valve disease (class IIa, level of

evidence C)• Bioprosthetic heart valve (class IIb, level of

evidence C) Long term anticoagulant ;target INR 2.5-3.5

•Patients with mechanical heart valve

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Secondary prevention (cont.)

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Modifiable Behavioral Risk Factors

Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack Stroke 2006;37;577-617

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Hemorrhagic stroke

Hemorrhagic stroke Intracerebral Hemorrhage (ICH)

•Hypertension•Cerebral amyliod angiopathy•Vascular abnormality•Other nonhypertensive cause

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults 2007 Update A Guideline From the American Heart Association/American Stroke Ass

ociation Stroke Council, High Blood Pressure Research Council, and the Quality of Ca re and Outcomes in Research Interdisciplinary Working Group. Stroke200738; ;

-20012023

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Hemorrhagic stroke (cont.)

Subarachnoid Hemorrhage (SAH)•Hypertension•Substances abuse

(alcohol,tobacco,cocaine)•Oral contraceptive use •Pregnancy • lumbar puncture and cerebral

angiography•Unrupture aneurysms •Advanced age Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults

2007 Update A Guideline From the American Heart Association/American Stroke Ass ociation Stroke Council, High Blood Pressure Research Council, and the Quality of Ca

re and Outcomes in Research Interdisciplinary Working Group. Stroke200738; ;-20012023

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Early management Recommendations for Initial Medical Therapy Class I

Monitoring and management of patients with an ICH should take place in an intensive care unit setting becau

se of the acuity of the condition, frequent elevations in I CP and blood pressure, frequent need for intubation and

assisted ventilation, and multiple complicating medical i ssues (Class I, Level of Evidence B).

Appropriate antiepileptic therapy should always be used for treatment of clinical seizures in patients with ICH (Cla

ss I, Level of Evidence B). It is generally agreed that sources of fever should be

treated and antipyretic medications should be administe red to lower temperature in febrile patients with stroke (

Class I, Level of Evidence C). As for patients with ischemic stroke,93 early

mobilization and rehabilitation are recommended in pati ents with ICH who are clinically stable (Class I, Level of E

vidence C) Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults

2007 Update A Guideline From the American Heart Association/American Stroke Ass ociation Stroke Council, High Blood Pressure Research Council, and the Quality of Ca

re and Outcomes in Research Interdisciplinary Working Group. Stroke200738; ;-20012023

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Early management (cont.)

More aggressive therapies to decrease elevated ICP, such as osmotic diuretics (mannitol via vent

ricular catheter, neuromuscular blockade, and hy perventilation, generally require concomitant mo

nitoring of ICP and blood pressure with a goal to maintain CPP >70 mm Hg (Class IIa, Level of Evid

ence B) Evidence indicates that persistent hyperglycemi

a (>140 mg/dL) during the first 24 hours after str oke is associated with poor outcomes , and thus it

is generally agreed that hyperglycemia should b e treated in patients with acute stroke



-20012023

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Control BP



-20012023

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Secondary prevention

Recommendations for Prevention of Recu rrent ICH

Class I Treating hypertension in the nonacute settin

g is the most important step to reduce the ris k of ICH and probably recurrent ICH as well (

Class I, Level of Evidence A) Smoking, heavy alcohol use, and cocaine

use are risk factors for ICH, and discontinuati on should be recommended for prevention of ICH recurrence (Class I, Level of Evidence B)



-20012023

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Stroke scale and clinical Assessment tools

Facial Droop Normal : Bot h

si des of f ace move equal l y

Abnormal :One side of face does not move at all

Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.” - Ann Emerg Med 1999 Apr;33(4):373 8

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Stroke scale and clinical Assessment tools (cont.)

Arm Drift Normal :

Both arms m ove equally

or not at all Abnormal :

One arm drifts compared to the other

Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.” - Ann Emerg Med 1999 Apr;33(4):373 8

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Stroke scale and clinical Assessment tools (cont.)

Speech Normal : Pat i ent uses cor r ect wor

ds wi t h no sl ur r i ng Abnormal : Slurred or inappropriate

words or muteTime

FAST track Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke

Scale: reproducibility and validity.” - Ann Emerg Med 1999 Apr;33(4):373 8

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FAST track If you suspect that

someone is having a stroke, think F.A.S.T. F = FACE Ask the person

to smile. Does one side of the face droop?

A = ARM Ask the person to raise both arms. Does

one arm drift downward?

S = SPEECH Ask the per son to repeat a simple

phrase. Does the speech sound slurred or strange

? T = TIME If you observe

any of these signs, it’s - -time to call 9 1 1

http://www.nsmc.partners.org/web/press_room_detail/news_item=e6a11420-a0bd-4860-88e4-01fc60fbf000

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Our trip

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LOGO 1 โดย นศ. ภ. กชกร คำอินต๊ะ นสภ. พฒนพงศ์...

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