Stroke Management Edited

8/8/2019 Stroke Management Edited

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STROKE MANAGEMENT

Adapted from source



STROKE

Third commonest cause of all mortality

48000 new strokes annually

Direct cost 2 billion dollars annually Incidence increasing set to double by 2030



STROKE

Sudden onset of neurological deficit

Clinical diagnosis

Imaging is supportive Emergency (brain attack)



STROKE

Definitions:

± TIA

±

CVA ± Syncope

± Hypoxic ischaemic encephalopathy



TYPES OF STROKE

ISCHAEMIC 85%

± Cardioembolic 17%

± Carotid atherosclerosis 4%

± Other 64%

HAEMORRHAGIC 15%

Aneurysmal SAH 4%

Hypertensive ICH 7%Other 4%



STROKE

Initial assessment:

ABC

Level of consciousness

Maintain BP Blood panel

Hydrate

Identify pyrexia and hyperglycaemia

ECG Brain CT scan



STROKE

Common causes of ischaemic stroke ± Thrombosis

± Lacunar

± Cardio-emboli

± Dehydration

± AF

± mechanical valves

± MS

±MI

± Bacterial endocarditis

± Intra-cardiac shunts



STROKE

Left MCA ischaemic stroke



STROKE

Right MCA ischaemic CVA



STROKE

Thrombolysis

± NINDS rtPA Stroke Study 1995; used 0.9mg/kg produced insignificant4% reduction of mortality(21% to 17%) but produced 12% ARR(32%from 44%) in mortality and minimal disability. Bleeding risk was6.4%(0.6% for placebo )

± ECASSI used 1.2mg/kg of rtPA up to 3hr produced similar results

± ECASSII used 0.9mg/kg up to 6hrs produced small additional benefit

± ATLANTIS tested NIND between 3-5hrs; produced no extra benefit



STROKE

THROMBOLYSIS



ISCHAEMIC CVA

Thrombolysis with rtPA

Indications:

±

Clear indication of ischaemic CVA ± Onset of symptoms to needle <3 hrs

± CT scan showing no he or oedema>1/3 of MCA

territory

± Age 18 and over

± consent



STROKE

Thrombolysis with rtPA:

Contraindications ± BP>185/110

± Platelet <100000: HCT<25%, BSL<4or >20mmol/L

± Use of heparin within 48hr and prolonged PTT or raised INR

± Rapidly improving symptoms ± Prior stroke of TBI within 3/12

± Prior ICH

± Major surgery in preceding 2/52

± Minor stroke symptoms

± GI bleed in past 3/52

± Recent MI ± Coma or stupor



STROKE

Precise efficacy of rtPA not clear due to variability

between patients

Risk of haemorrhage increases with:

± Large stroke

± High dose of TPA

± Longer time of treatment from onset



STROKE

Intra-arterial thrombolysis:

PROACT used urokinase in acute MCA

occlusion up to 6hrs after onset rtPA now used

High risk of bleeding

Beneficial in selected patients



STROKE

Anti-platelet agents:

1. Aspirin; most used,

± IST used 300mg within 48hrs of CVA produced insignificant reductionin mortality in first 2/52(9% from 9.4) but significant reduction in

recurrence (3.9% to 2.8%) ± CAST used 160mg of Aspirin produced small reductions in

mortalitiy(0.6%), recurrence(0.5%), death and dependency(1.1%).

± Aspirin is safe; need to treat 1000 pts to prevent 9deaths andrecurrence in first few weeks and 13 deaths and dependency in 6/12

± Asasantin



STROKE

Anti-platelet agents:

2.Clopidogrel no extra benefit in combination

with Aspirin (MATCH, Pluto-Stroke) 3.Glycoprotein IIb/IIIa promising but still

under study



STROKE

Ace inhibitors:

PROGRESS 28% RR

HOPE 32% RR



STROKE

Anti-coagulants:

Role unclear

±

TOAST demonstrated no extra benefit fromWarfarin vs. Aspirin

± IST showed on benefit but increased bleeding risk

± No data to support use in crescendo TIAS



STROKE

Neuroprotection:

± Under study; useful in animal studies

± SAINT 1(Stroke-Acute Ischaemic NXY Treatment); 1800

patients showed improvement in reduction of disability at3/12 but no improvement in other outcome measures

± Magnesium

± Erthropioten



STROKE

PREVENTION:

Risk Factors:Factor RRR # needed to treat

primary Secondary

Hypertension 38% 100 100

AF (Warfarin) 68% 60 13

AF (Aspirin) 21%

Smoking 50%

Carotid

Sten(asympt) 53% 85 N/A

Carotid 70-99% 65%(2yrs) N/A 12

Sten(sympt)

Carotid 50-69% 29%(5yrs) N/A 77

Sten(sympt)

Hyperlipidaemia 20%



STROKE

Prevention:

Atrial fibrillation:

Non-valvular AF commonest cause

20% cardio-embolic

Mainly lodges in MCA and PCA

Average annual risk of CVA 5% but ranges 0.5-

15%



Atrial Fibrillation

ACC/AHA/ESC 2006 Guidelines: Risk Factors for Stroke

Less Validated/Weaker Risk

Factors

Moderate Risk

Factors

High Risk Factors

Female gender Age 75 yrs Previous stroke, TIA, or

embolism

Age 65-74 yrs Hypertension Mitral stenosis

Coronary artery disease Heart failure



Atrial Fibrillation

ACC/AHA/ESC 2006 Guidelines: Risk Factors for Stroke

Weak Moderate High

Female Age>75 H/ CVA,TIA,

Age 65-74 Hypertension embolism

CAD CCF MS

Thyrotoxicosis LVEF,35% Prosth Valve

Diabetes



Atrial Fibrillation

ACC/AHA/ESC 2006 Guidelines: Recommended Therapies According toStroke Risk

Risk Category Recommended Therapy

No risk factors Aspirin,81-325 mg daily

One moderate factor Aspirin, 81-325 mg daily,or Warfarin

Any high risk factor Warfarin

> 1 moderate risk factor Warfarin (INR 2.0-3.0, target 2.5)*



CHADS 2

CCF

Hypertension

Age DM

Stroke



STROKE

stroke prevention in asymptomatic CAS:

1. Anti-platelet agents

2. Statins: HPS 25% RRR, SPARCL 17%RRR

3. Risk factor modification



STROKE

TIA

Neurological symptoms of <24 hrs

40% have real infarcts Risk of CVA 10% in first 3/12



STROKE

TIA

Prevention

±

Treat risk factors ± Anti platelet agents

± Anti-coagulants

± Statins

± ACE inhibitors



STROKE

Intracranial haemorrhage:

Causes:

Hypertension

TBI

Ischaemic transformationAneurysm

Metastasis

Coagulopathy

Drugs

Amyloid angiopathyAngioma

Telengectasia



STROKE

Haemorrhagic CVA

SAH

± TBI is commonest cause

±

Aneurysm is second, prev 2%, 20% multiple, usuallyasymptomatic until rupture

± Presents with acute sudden symptoms

± 95% diagnosed on brain CT

± Mortality 45%, 50% of survivors have significant neurodeficit



STROKE

SAH:

Initial supportive therapy; ± ABC

± Elevate head

± Hyperventilation

± Treat hypertension ± Haemodilution

± Mannitol

± Nimodipine for vasospasm

± Treat hydrocephalus

± Phenytoin for seizures

± Early surgical intervention, preferably coiling (ISAT) ± Look out for late neuro deterioration (re-rupture, vasospasm, hydrocephalus,

hyponatraemia)



STROKE

Rehabilitation

Stroke units

Restraint therapy

Stroke Management Edited

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