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Early Early Management of Management of Ischemic Stroke Ischemic Stroke DR SANJAY JAISWAL, MD,DM DR SANJAY JAISWAL, MD,DM Member world stroke Member world stroke organization organization Consultant Neurologist Consultant Neurologist Jaiswal Hospital and Neuro Jaiswal Hospital and Neuro Institute Institute

Acute management of Stroke By Dr Sanjay jaiswal Neurologist sept2012

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Page 1: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Early Early Management of Management of Ischemic StrokeIschemic Stroke

DR SANJAY JAISWAL, MD,DMDR SANJAY JAISWAL, MD,DM

Member world stroke Member world stroke organizationorganization

Consultant NeurologistConsultant Neurologist

Jaiswal Hospital and Neuro Jaiswal Hospital and Neuro InstituteInstitute

Kota ,Rajasthan.Kota ,Rajasthan.

Page 2: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

ReferenceReference

Guidelines for the Early Guidelines for the Early Management of Adults With Management of Adults With Ischemic Stroke Ischemic Stroke Stroke Stroke 2007;38;1655-17112007;38;1655-1711

Acute ischemic stroke Acute ischemic stroke N Engl J N Engl J Med 2007; 357:572-579, Aug 9, Med 2007; 357:572-579, Aug 9, 2007 2007

Page 3: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Brain Attack!Brain Attack! Acute stroke = ‘brain Acute stroke = ‘brain

attack’attack’ Every minute matters: Every minute matters:

‘time is brain’‘time is brain’ Combat therapeutic Combat therapeutic

nihilismnihilism

Page 4: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Time is Brain…why?Time is Brain…why?The typical patient loses 1.9 million The typical patient loses 1.9 million

neurons each minute in which stroke is neurons each minute in which stroke is untreateduntreated

The ischaemic penumbraThe ischaemic penumbra

Page 5: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

WHO DEFINITION OF WHO DEFINITION OF STROKESTROKE

A NEUROLOGICAL DEFICIT OFA NEUROLOGICAL DEFICIT OF SuddenSudden onset onset WithWith focal focal rather than global rather than global

dysfunctiondysfunction In which, after adequate In which, after adequate

investigations, symptoms are investigations, symptoms are presumed to be of non-traumatic presumed to be of non-traumatic vascular originvascular origin

and last for and last for >24 hours>24 hours

Page 6: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

New definition of TIANew definition of TIA A brief episode of neurological A brief episode of neurological

dysfunction caused by focal brain or dysfunction caused by focal brain or retinal ischaemia with clinical retinal ischaemia with clinical symptoms lasting less than one hour symptoms lasting less than one hour without evidence of infarctionwithout evidence of infarction

Page 7: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Types of StrokeTypes of Stroke

85% Ischemic

15 % hemorrhagic

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•Language loss (aphasia)•Right hemiparesis•Right hemisensory loss•Right visual field cut•Left gaze preference

Left MCA SyndromeLeft MCA Syndrome

Page 9: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Right MCA SyndromeRight MCA Syndrome•Left hemi-neglect

visual,spatial,•Left hemiparesis•Left hemisensory loss•Left visual field cut•Neglect of deficits

“anasgnosia”

Page 10: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Stroke is due to sudden vascular Stroke is due to sudden vascular occlusionocclusion

ACA

MCA

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•50-70% of all stroke is due to embolism (cardiogenic and artery-to-artery) •80 % of acute strokes are due to MCA territory ischemia• Arterial occlusion is seen in 80-90% within 6-24° of symptom onset• Spontaneous recanalization seen in ~ 20% within 6 ° of symptoms

Vascular occlusion causes stroke Vascular occlusion causes stroke symptomssymptoms

Page 12: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Stroke Risk Factors Non-Stroke Risk Factors Non-modifiablemodifiable

AGEAGE Gender -maleGender -male Race – Blacks > Asians or Race – Blacks > Asians or

Hispanics> Hispanics> WhitesWhites Family Hx. Family Hx. Coagulation DisordersCoagulation Disorders Cardiac Disease Cardiac Disease

Page 13: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Stroke Risk Factors ModifiableStroke Risk Factors Modifiable

HypertensionHypertension Diabetes mellitusDiabetes mellitus HypercholesterolemHypercholesterolem

iaia Elevated LDL or Elevated LDL or

Low HDLLow HDL Elevated Elevated

homocysteinhomocystein SmokingSmoking Drug abuseDrug abuse

Alcohol AbuseAlcohol Abuse Oral ContraceptivesOral Contraceptives PregnancyPregnancy Migraine HeadachesMigraine Headaches ObesityObesity Sleep apneaSleep apnea Carotid stenosisCarotid stenosis

A combination of A combination of these risk factors these risk factors will increase risk of will increase risk of stroke!stroke!

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Many Causes of StrokeMany Causes of Stroke

Page 15: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

THE BURDEN OF STROKE THE BURDEN OF STROKE Anually more than 15 million people world Anually more than 15 million people world

wide suffer a stroke, 5.5 million die and 5 wide suffer a stroke, 5.5 million die and 5 million are left with permanent disability.million are left with permanent disability.

Stroke is 2nd most common cause of Stroke is 2nd most common cause of death(9.7%).death(9.7%).

Incidence of stroke is on the increase in India Incidence of stroke is on the increase in India and other developing countries.and other developing countries.

More than 80% of stroke occurs in More than 80% of stroke occurs in underdeveloped and developing countries.underdeveloped and developing countries.

Cruide annual incidence rate for first ever Cruide annual incidence rate for first ever stroke (FES) is 145 per 100,000 Persons.stroke (FES) is 145 per 100,000 Persons.

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Case fatality rate at 28 days after FES was Case fatality rate at 28 days after FES was 29.8%.29.8%.Of the surviving patients 38.5% had moderate Of the surviving patients 38.5% had moderate to severe disability. Hypertension (BP>140/90 alone or to severe disability. Hypertension (BP>140/90 alone or in various combination) was present in 82.8% cases. in various combination) was present in 82.8% cases. (dalal et al, Mumbai stroke registry,2005-2006).(dalal et al, Mumbai stroke registry,2005-2006).

WHO estimated that in 1990 ,out of a total 9.4 million WHO estimated that in 1990 ,out of a total 9.4 million deaths in India , 619,000 deaths were due to stroke. deaths in India , 619,000 deaths were due to stroke. This gives stroke mortality rate of 73 per 100,000 This gives stroke mortality rate of 73 per 100,000 population. population. 1880 people die every day in India due 1880 people die every day in India due to stroketo stroke..

In 1990 the estimated no of death due to stroke were In 1990 the estimated no of death due to stroke were 22 times that due to malaria,1.4 times that due to 22 times that due to malaria,1.4 times that due to tuberculosis,4 times that due to RHD, and almost tuberculosis,4 times that due to RHD, and almost equal to IHD.equal to IHD.

Stroke mortality rate is declining in USA and other Stroke mortality rate is declining in USA and other developed countries it is likely to increase in India.developed countries it is likely to increase in India.

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Stroke is a treatable Stroke is a treatable condition.condition.

IV tPA is approved for use within 3 hours ( 4.5 IV tPA is approved for use within 3 hours ( 4.5 hours) .(NINDS)hours) .(NINDS)

Intra-arterial therapy has proven to be safe Intra-arterial therapy has proven to be safe and effective within 6 hours (PROACT II) and effective within 6 hours (PROACT II)

Combined IV/IA may be more effective than IV Combined IV/IA may be more effective than IV t-PA (Interventional Management of Stroke -t-PA (Interventional Management of Stroke -IMS)IMS)

Mechanical and laser catheter technologies Mechanical and laser catheter technologies are showing great promise (Angio-Jet)are showing great promise (Angio-Jet)

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Stroke: The ChallengeStroke: The Challenge

Only 1-3% of all stroke victims Only 1-3% of all stroke victims receive treatment with tPA in the receive treatment with tPA in the US . US .

25% of Acute MI patients receive 25% of Acute MI patients receive treatment (lytics or PTCA) in the US treatment (lytics or PTCA) in the US ..

Mean time to presentation Mean time to presentation AMI: 3hrsAMI: 3hrs Acute Stroke: 4-10hrs.Acute Stroke: 4-10hrs.

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Reasons for lack of Reasons for lack of treatment:treatment:1.1. Patient’s inability to recognize stroke symptomsPatient’s inability to recognize stroke symptoms

40% of stroke patients can’t name a single 40% of stroke patients can’t name a single sign or symptom of stroke or stroke risk sign or symptom of stroke or stroke risk factor.factor.

75% of stroke patients misinterpret their 75% of stroke patients misinterpret their symptomssymptoms

86% of patients believe that their symptoms 86% of patients believe that their symptoms aren’t serious enough to seek urgent carearen’t serious enough to seek urgent care

2.2. Physician’s lack of experience with stroke Physician’s lack of experience with stroke treatment and therefore reluctance to “risk” treatment and therefore reluctance to “risk” treatmenttreatment

3.3. Lack of organized delivery of care in many Lack of organized delivery of care in many medical centers throughout the country.medical centers throughout the country.

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Current Status of Specific Treatment Current Status of Specific Treatment for Acute Ischemic Strokefor Acute Ischemic Stroke

YesYes 1. Tissue plasminogen activator 1. Tissue plasminogen activator

within 3-4.5 hrs.within 3-4.5 hrs. 2. Aspirin within 48 hrs.2. Aspirin within 48 hrs. 3. Management in SCU3. Management in SCUMay BeMay Be 1. Neuroprotection1. NeuroprotectionNo ?No ? 1. Heparin, Heparinoids1. Heparin, Heparinoids 2. Hemodilution2. Hemodilution 3. Steroids3. Steroids

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Page 22: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Acute Stroke Acute Stroke TreatmentsTreatments

% patients % patients that can that can benefitbenefit

Prevention Prevention death/dependency per death/dependency per

100 treated100 treated

Prevention Prevention death/dependency per death/dependency per

100 admitted100 admitted

Stroke UnitStroke Unit 90%90% 55 4.54.5

ThrombolysisThrombolysis0-3hr0-3hr

10% 10% ischaemic ischaemic

strokesstrokes1212 11

AspirinAspirin0-48hr0-48hr

65% 65% ischaemic ischaemic

strokesstrokes11 0.50.5

HemicraniectomyHemicraniectomy0-48hr0-48hr

0.5%0.5%Ischaemic Ischaemic

strokesstrokes2222 0.10.1

Slide by Prof G Ford, presented at UKCRN 21.11.2007 ,adapted from Gilligan et al 2005

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Pre of hospital recognition of Pre of hospital recognition of stoke. FASTstoke. FAST

FFacial Weaknessacial Weakness Can person smile Can person smile Has mouth droppedHas mouth dropped

AArm Weaknessrm Weakness Can person raise both armsCan person raise both arms

SSpeech problemspeech problems Can person speak clearly Can person speak clearly

and understand what you sayand understand what you say

TTest all three symptomsest all three symptoms

Stroke Association Stroke Association campaign to raise campaign to raise awarenessawareness

Practice staff should be Practice staff should be trained to inform doctor trained to inform doctor immediately if patient immediately if patient calls with symptoms calls with symptoms identifiable identifiable

Ambulance crews now Ambulance crews now trained to use FAST trained to use FAST score to prioritise Calls score to prioritise Calls and dispatch.and dispatch.

Act FAST call 108 Act FAST call 108 ambulance.ambulance.

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Section 1 Slide 30

Onset to Entry (By referral method)

ASIST data 1999

0

10

20

30

40

50

60

70

0-<1 1-<2 2-<3 3-<4 4-<5 5-<6 6-<9 9-<12 12-<24 >=24

Hours

Pt

Nu

mb

ers 999

GP

Other

GP+999

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Page 26: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Pre Hospital carePre Hospital care Ambulance services ,health care Ambulance services ,health care

professionals and general public should professionals and general public should receive education concerning the importance receive education concerning the importance of early recognition of stroke, emphasing of early recognition of stroke, emphasing stroke is a medical emergency.stroke is a medical emergency.

Stroke patients should be given a high Stroke patients should be given a high priority by ambulance service.priority by ambulance service.

Ambulance services should be trained to Ambulance services should be trained to identify stroke by various tools and protocols.identify stroke by various tools and protocols.

Ambulance services should transfer Ambulance services should transfer suspected patients to hospital with stoke unit suspected patients to hospital with stoke unit care.care.

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EMS response to 108 call:EMS response to 108 call:WILL QUESTION:WILL QUESTION: Time of onset of stroke symptoms.Time of onset of stroke symptoms. Determine nature of neurological symptoms Determine nature of neurological symptoms

(F.A.S.T.).(F.A.S.T.). NIH Stroke Scale or Glasgow Coma Scale NIH Stroke Scale or Glasgow Coma Scale

(language/motor response/eye movement).(language/motor response/eye movement). Hx: recent illness, surgery or trauma.Hx: recent illness, surgery or trauma. Recent use of medication/illicit drugs.Recent use of medication/illicit drugs. Notify receiving hospital that patient Notify receiving hospital that patient

appears to be an acute stroke and gives appears to be an acute stroke and gives time window.time window.

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Guidelines for EMS management of Guidelines for EMS management of patients with suspected strokepatients with suspected stroke

RecommendedRecommended Manage ABCsManage ABCs Cardiac monitoringCardiac monitoring Intravenous accessIntravenous access O2(if spo2,92%)O2(if spo2,92%) Assess for Assess for

hypoglycemiahypoglycemia NBMNBM Alert receiving EDAlert receiving ED Rapid transfer to Rapid transfer to

closest stroke centreclosest stroke centre

Not recommendedNot recommended Dextrose containg Dextrose containg

fluid in non fluid in non hypoglycemic patientshypoglycemic patients

Hypotension/excessive Hypotension/excessive BP reductionBP reduction

Excess IV fluidsExcess IV fluids

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Stroke units: State of the Art

Admission to a unit that is dedicated to the care of stroke patients helps to reduce mortality and morbidity.

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Stroke: Differential Stroke: Differential DiagnosisDiagnosis

SyncopeSyncope Partial epileptic Partial epileptic

seizure with Todd’s seizure with Todd’s paresisparesis

Migraine attack Migraine attack (aura)(aura)

HypoglycaemiaHypoglycaemia HysteriaHysteria IntoxicationIntoxication

Subarachnoid Subarachnoid haemorrhagehaemorrhage

NeuroinfectionNeuroinfection NeoplasmNeoplasm Brain injuryBrain injury Multiple sclerosisMultiple sclerosis Peripheral vertigoPeripheral vertigo

Page 39: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

PHYSICAL EXAMPHYSICAL EXAM

GPE,ABCs, Pulse Oximetry,temp.GPE,ABCs, Pulse Oximetry,temp. Carotid Bruits, JVP, Irregular Carotid Bruits, JVP, Irregular

RhythmRhythm Head and Neck, Chest, AbdomenHead and Neck, Chest, Abdomen Skin –Jaundice, Purpura, PetechiaSkin –Jaundice, Purpura, Petechia

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Early diagnostic testsEarly diagnostic testsALL PATIENTSALL PATIENTS Non contrast brain CT Non contrast brain CT

or brain MRIor brain MRI Blood glucoseBlood glucose RFT,S. electrolytesRFT,S. electrolytes ECGECG Markers of cardiac Markers of cardiac

ischemiaischemia CBC, Plat count*CBC, Plat count* PT,INR,*APTT*PT,INR,*APTT* O2 SaturationO2 Saturation

SELECTEDSELECTED PATIENTSPATIENTS LFTLFT Toxicology screenToxicology screen Blood alcohol levelBlood alcohol level Pregnancy testPregnancy test ABGABG Chest radiographyChest radiography LP-if SAH is suspected LP-if SAH is suspected

and CT is negativeand CT is negative EEG –if seizures are EEG –if seizures are

suspected. suspected.

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EARLY DIAGNOSIS: EARLY DIAGNOSIS: NON CONTRAST CT SCAN OF BRAINNON CONTRAST CT SCAN OF BRAIN

Initial imaging modality in hyper ac strokeInitial imaging modality in hyper ac stroke Widely available, quick, easy to performWidely available, quick, easy to perform Accurately identifies ICH,SAHAccurately identifies ICH,SAH EARLY SIGNS OF CEREBRAL ISCHAEMIAEARLY SIGNS OF CEREBRAL ISCHAEMIA Hyper dense MCA artery signHyper dense MCA artery sign Hyper dense dot signHyper dense dot sign Hypo density of insular ribbonHypo density of insular ribbon Hypoensity of basal gangliaHypoensity of basal ganglia loss of grey white matter differentiation in cortical ribbonloss of grey white matter differentiation in cortical ribbon sulcal effacementsulcal effacement EARLY SIGNS ARE ASSOCIATED WITH POORER EARLY SIGNS ARE ASSOCIATED WITH POORER

OUTCOMESOUTCOMES

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Early HypodensityEarly Hypodensity

Hypodensity

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Hyperdense middle Hyperdense middle cerebral arterycerebral artery

Hyperdense middle cerebral artery

Page 46: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

BRAIN IMAGING (CONTD)BRAIN IMAGING (CONTD)MULTI MODEL CTMULTI MODEL CT (A) (A) Perfusion CT- more sensitive and specific to detect Perfusion CT- more sensitive and specific to detect

ischaemia.ischaemia. (b) CT Angio-for intra and extra cranial (b) CT Angio-for intra and extra cranial

vasculaturevasculatureMULTIMODEL MRIMULTIMODEL MRI T1,T2,PDT1,T2,PD DWI-Early visualization of ischaemic regions within DWI-Early visualization of ischaemic regions within

minutes of stroke.minutes of stroke. PWI,MRA,FLAIR,PWI,MRA,FLAIR,

MRI MORE SENSITIVE THAN CT(26%CT VS 83 %MRI) MRI MORE SENSITIVE THAN CT(26%CT VS 83 %MRI) FOR AC ISCHAEMIC STROKEFOR AC ISCHAEMIC STROKE

VASCULAR IMAGINGVASCULAR IMAGING TCD USG,CAROTID DUPLEX SONO,CATHETER ANGIO.TCD USG,CAROTID DUPLEX SONO,CATHETER ANGIO.

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Multimodal CT ImagingMultimodal CT Imaging

Tissue Status

Bioenergetic Compromise

Perfusion Status

Hemodynamic Compromise

Vessel Status

Occlusions or Stenoses

CT PCT CTA

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Acute Stroke: CT vs. MRIAcute Stroke: CT vs. MRI

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Multimodal Diffusion-Multimodal Diffusion-Perfusion MRIPerfusion MRI

Tissue Status

Bioenergetic Compromise

Perfusion Status

Hemodynamic Compromise

Vessel Status

Occlusions or Stenoses

DWI PWI MRA

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Arterial HypertensionArterial Hypertension Management of hypertension is Management of hypertension is

controversial.controversial.

Data are inconclusive,or conflicing.Data are inconclusive,or conflicing.

Elevations of Elevations of BP BP >160 mm of hg are >160 mm of hg are

detected in >60 % patients.detected in >60 % patients.

Many patients have spontaneous decline in Many patients have spontaneous decline in

BP during first 24 hours onset of stroke.BP during first 24 hours onset of stroke.

Both elevated and low bp are associated Both elevated and low bp are associated

with poor prognosis.with poor prognosis.

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A reasonable goal is to lower BP by 15% during A reasonable goal is to lower BP by 15% during first 24 hours after onset of stroke.first 24 hours after onset of stroke.

It is generally agreed that antihypertensive It is generally agreed that antihypertensive medicines can be restricted medicines can be restricted

24 hours after the stroke, in patients who have 24 hours after the stroke, in patients who have pre existing hypertension and are neurologically pre existing hypertension and are neurologically stable. stable.

DO NOT USE SUB LINGUAL NIFEDIPINE.IT DO NOT USE SUB LINGUAL NIFEDIPINE.IT MAY BE HAZARDOUS.MAY BE HAZARDOUS.

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Treatment of Arterial HypertensionTreatment of Arterial Hypertension((for patients who are not candidates for r TPA)for patients who are not candidates for r TPA)

The consensus is that antihypertensive The consensus is that antihypertensive agents should be withheld unless the agents should be withheld unless the diastolic blood pressure is >120 mm Hg diastolic blood pressure is >120 mm Hg or unless the systolic blood pressure is or unless the systolic blood pressure is >220 mm Hg (level V)>220 mm Hg (level V)

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ARTERIAL HYPOTENSIONARTERIAL HYPOTENSION

SBP<100 and DBP <70 is associated with SBP<100 and DBP <70 is associated with higher mobidity and mortality.higher mobidity and mortality.

Causes of hypotension should be sought. Causes of hypotension should be sought. Potential causes are aortic dissection, Potential causes are aortic dissection, volume depletion, blood loss, decreased volume depletion, blood loss, decreased cardiac output sec to MI or cardiac cardiac output sec to MI or cardiac arrhythmia.arrhythmia.

hypovolemia should be corrected with hypovolemia should be corrected with normal saline.normal saline.

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T-PA for Acute Ischemic T-PA for Acute Ischemic StrokeStroke

NEJM 95:333,1581-87NEJM 95:333,1581-87 624 patients randomized624 patients randomized 3 hour window3 hour window at three month. 30% less likely to have at three month. 30% less likely to have

minimal or no disabilityminimal or no disability 6.4% risk of hemorrhage6.4% risk of hemorrhage No change in mortality at 6 mosNo change in mortality at 6 mos

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Cerebral infarct <3hrsCerebral infarct <3hrs

Onset

Infarct

Ischaemic penumbra

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Cerebral infarct 6hrsCerebral infarct 6hrs

Infarct

Ischaemic penumbra

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Cerebral infarct 24hrsCerebral infarct 24hrs

Infarct

Ischaemic penumbra

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Intravenous thrombolysisIntravenous thrombolysis

The US FDA approved the use of r tpa in 1996 on the The US FDA approved the use of r tpa in 1996 on the basis of the results of the NINDS r TPA stroke Study.basis of the results of the NINDS r TPA stroke Study.

Patients treated with tpa were 30 % more likely to Patients treated with tpa were 30 % more likely to have minimal or no disability at 3 months compared have minimal or no disability at 3 months compared with placebo treated patients.with placebo treated patients.

Treatment with tpa resulted in 11 to 13 % absolute Treatment with tpa resulted in 11 to 13 % absolute increase in the number of patients with excellent increase in the number of patients with excellent outcomes.outcomes.

Mortality rate at 3 months was 17 % in tpa group and Mortality rate at 3 months was 17 % in tpa group and 21 % in placebo treated group.21 % in placebo treated group.

Symptomatic intracerebral haemorrhage occurred in Symptomatic intracerebral haemorrhage occurred in 6.4% of pts receiving tpa vs 0.6% of the palcebo group.6.4% of pts receiving tpa vs 0.6% of the palcebo group.

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CRITERIA FOR THROMBOLYSIS CRITERIA FOR THROMBOLYSIS WITH rTPAWITH rTPA

INCLUSION CRITERIAINCLUSION CRITERIA Clinical signs and symptoms consistent with ischaenic Clinical signs and symptoms consistent with ischaenic

stroke.stroke. MEASURABLE NEUROLOGIC DEFICITMEASURABLE NEUROLOGIC DEFICIT NEUROLOGICAL SIGNS SHOULD NOT BE CLEARING NEUROLOGICAL SIGNS SHOULD NOT BE CLEARING

SPONTANEOUSLY.SPONTANEOUSLY. Neurological signs should not be minor or isolated.Neurological signs should not be minor or isolated. Onset of symptoms <3 hour before beginning treatmentOnset of symptoms <3 hour before beginning treatment Caution should be exercised in treating a patient with a Caution should be exercised in treating a patient with a

major deficit.major deficit. Symptoms of stroke should not be s/o SAH.Symptoms of stroke should not be s/o SAH. No head trauma or prior stroke in previous 3 months.No head trauma or prior stroke in previous 3 months. No MI in previous 3 months.No MI in previous 3 months. No GI OR urinary tract haemorrhage in previous 21 days. No GI OR urinary tract haemorrhage in previous 21 days.

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Cont..Cont.. No major surgery in previous 14 days.No major surgery in previous 14 days. No arterial puncture at a noncompressible site in previous 7 No arterial puncture at a noncompressible site in previous 7

days.days. NO H/O previous intra cranial haemorrhage.NO H/O previous intra cranial haemorrhage. Systolic BP<185 and diastolic <110Systolic BP<185 and diastolic <110 No evidence of active bleeding or ac trauma on examnNo evidence of active bleeding or ac trauma on examn Not taking oral anticoagulant or if being taken INR <1.7Not taking oral anticoagulant or if being taken INR <1.7 If receiving HEPARIN in previous 48 hours A PTT must be If receiving HEPARIN in previous 48 hours A PTT must be

normal range.normal range. Platelet count <1 lac mm3Platelet count <1 lac mm3 Blood glucose >50 mg %Blood glucose >50 mg % No seizure with postictal residual neurol impairements.No seizure with postictal residual neurol impairements. CT does not show a multilobar infarction (hypodensity >1/3 CT does not show a multilobar infarction (hypodensity >1/3

cerebral hemisphere)cerebral hemisphere) The patient or family understands the potential risks and The patient or family understands the potential risks and

benefits of treatment.benefits of treatment.

Page 74: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

NINDS tPA Stroke TrialNINDS tPA Stroke Trial

0

10

20

30

0

10

20

30

tPA tPAPlacebo Placebo

31

20 9

8

20

1

NIHSS Excellent Recovery (%)

Total Death Rate (%)

Hemorrhagep < .05

New England Journal, 1995

Page 75: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012
Page 76: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

IV administration of tpa.IV administration of tpa.

Infuse 0.9mg/kg(max 90 mg ) over 60 mnts Infuse 0.9mg/kg(max 90 mg ) over 60 mnts with 10 % of the dose given as bolus over 1 with 10 % of the dose given as bolus over 1 mnt.mnt.

Admit pt in neuro ICU or stroke unit.Admit pt in neuro ICU or stroke unit. Perform neurological assessment every 15 Perform neurological assessment every 15

mnts during the infusion and every 30 mnts mnts during the infusion and every 30 mnts thereafter for next 6 hours then hourly until thereafter for next 6 hours then hourly until 24 hours after treatment.24 hours after treatment.

If pt develop severe head ache,ac HTN, If pt develop severe head ache,ac HTN, nausea,or vomitting discontinue infusion and nausea,or vomitting discontinue infusion and obtain emergency CT scan.obtain emergency CT scan.

Page 77: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012
Page 78: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Besides bleeding complications r tpa have potential Besides bleeding complications r tpa have potential

side effect of angioedema that may cause partial air side effect of angioedema that may cause partial air

way obstruction.way obstruction.

A patient with seizure at the time of onset of stroke A patient with seizure at the time of onset of stroke

may be eligible for tpa if physician is convinced that may be eligible for tpa if physician is convinced that

residual impairements are secondary to stroke not a residual impairements are secondary to stroke not a

postictal phenomenon.postictal phenomenon.

IV streptokinase is not recommended .IV streptokinase is not recommended .

IV ancrod, IV ancrod,

tenecteplase,reteplase,desmoteplase,urokinase outside tenecteplase,reteplase,desmoteplase,urokinase outside

the setting of clinical trial is not recommendedthe setting of clinical trial is not recommended

Page 79: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Time is BrainTime is Brain““The typical patient loses 1.9 million neurons The typical patient loses 1.9 million neurons

each minute in which stroke is untreated”each minute in which stroke is untreated”

Symptom-to-needle time in minutes

Odd

s R

atio

(c

orre

cted

; 95%

CI)

fa

vour

able

Out

com

e

60 90 120 150 180 210 240 270 300 330 360

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

NNT:3.5*

NNT:7*

(11)**

NNT:9*

(13)**

NNT:11*

(>30)**

Upper 95% CI

Mean

Lower 95% CI

* NNT at absolute point of time ** NNT for each 90 min interval

Symptom-to-needle time in minutes

Odd

s R

atio

(c

orre

cted

; 95%

CI)

fa

vour

able

Out

com

e

60 90 120 150 180 210 240 270 300 330 360

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

NNT:3.5*

NNT:7*

(11)**

NNT:9*

(13)**

NNT:11*

(>30)**

Upper 95% CI

Mean

Lower 95% CI

* NNT at absolute point of time ** NNT for each 90 min interval

Slide by Prof G Ford, presented at UKCRN 21.11.2007 based on Saver, Stroke 2006

Page 80: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Time is brain: benefit from rt-PA declines with increasing delay from onset to treatment time

Benefit

Harm

3 hours 6 hours

Upper and lower 95% confidence limits

Line of no effect

IST-3 protocol

Page 81: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Thrombolysis in EuropeThrombolysis in Europe

0

10

20

30

40

50

60

rt-P

A f

or

str

ok

e p

er

millio

n p

op

'n

Finland

Austria

SwedenNorway

Belgium

Spain

GermanyNetherlands

Denmark

Italy

UK

GreeceFrance

Portugal

Slide donated by P. Sandercock, IST-3 trialists meeting, Brussels 2006

Page 82: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Intra arterial ThrombolysisIntra arterial Thrombolysis PROACT IIPROACT II

Intra arterial ProurokinaseIntra arterial Prourokinase 6 Hour time window6 Hour time window Relative risk reduction of 15% in functional Relative risk reduction of 15% in functional

outcomeoutcome No difference in mortalityNo difference in mortality Procedural complication 9%Procedural complication 9% Early Intra cerebral haemorrhage 10%Early Intra cerebral haemorrhage 10% INTRA ARTERIAL THROMBOLYS IS REASONABLE INTRA ARTERIAL THROMBOLYS IS REASONABLE

IN PATIENTS WHO HAVE C/I TO USE OF IV TPA IN PATIENTS WHO HAVE C/I TO USE OF IV TPA LIKE RECENT SURGERY.LIKE RECENT SURGERY.

Page 83: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Guidelines for Guidelines for Anticoagulant TherapyAnticoagulant Therapy

Urgent administration of anticoagulants has not Urgent administration of anticoagulants has not yet been associated with lessening the risk of yet been associated with lessening the risk of early recurrent stroke or improving outcomes. early recurrent stroke or improving outcomes. Because it can increase the risk of brain Because it can increase the risk of brain hemorrhage, routine use cannot be hemorrhage, routine use cannot be recommended.recommended.

American Heart Association, 2003

Page 84: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Guidelines for Guidelines for Anticoagulant TherapyAnticoagulant Therapy

Anticoagulants are Anticoagulants are notnot recommended recommended for any subgroup of patients with acute for any subgroup of patients with acute stroke based on any presumed stroke based on any presumed mechanism or location (e.g., mechanism or location (e.g., cardioembolic, large vessel cardioembolic, large vessel atherosclerotic, vertebrobasilar, or atherosclerotic, vertebrobasilar, or “progressing” stroke) because data are “progressing” stroke) because data are insufficient.insufficient.American Academy of Neurology / AHA, 2003

Page 85: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Acute Treatment with Acute Treatment with Antiplatelet AgentsAntiplatelet Agents Aspirin (initial dose is 325 mg) should be given within 24 Aspirin (initial dose is 325 mg) should be given within 24

to 48 hours of stroke onset in most patients (Class 1, level to 48 hours of stroke onset in most patients (Class 1, level A). A).

The administration of aspirin as an adjunctive therapy, The administration of aspirin as an adjunctive therapy, within 24 hours of the use of thrombolytic agents, is not within 24 hours of the use of thrombolytic agents, is not recommended (Class 3,level A). recommended (Class 3,level A).

Aspirin should not be used as a substitute for other acute Aspirin should not be used as a substitute for other acute interventions, especially intravenous administration of interventions, especially intravenous administration of rtPA, for the treatment of acute ischemic stroke (Class rtPA, for the treatment of acute ischemic stroke (Class 3,level B).3,level B).

No recommendation can be made about the urgent No recommendation can be made about the urgent administration of other antiplatelet aggregating agents administration of other antiplatelet aggregating agents alone or in combination with aspirin (Class 3,level C).alone or in combination with aspirin (Class 3,level C).

Outside the setting of clinical trials IV administration of Outside the setting of clinical trials IV administration of antiplatelet agents that inhibit the glycoprotein 2b/3a ptor antiplatelet agents that inhibit the glycoprotein 2b/3a ptor is not recommended.(Class 3,level B).is not recommended.(Class 3,level B).

Page 86: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Benefit of Early Aspirin Treatment Benefit of Early Aspirin Treatment in Acute Ischemic Strokein Acute Ischemic Stroke

496636

205 168

12311327

16621843

0

500

1000

1500

2000

RecurrentIschemic Stroke

HemorrhagicStroke

Death Death or NonfatalStroke

Aspirin, n=20,207 Control, n=20,190

9 patients benefit per 1000 treated (p<0.001)

Combined Data from IST, CAST, MAST-I

Page 87: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Hemodilution,Vasodialators,anHemodilution,Vasodialators,and induced hypertensiond induced hypertension

Hemodilution with or without venesection Hemodilution with or without venesection and volume expansion is not and volume expansion is not recommended for treatment of ac recommended for treatment of ac ischaemic stroke.(Class 3,level A)ischaemic stroke.(Class 3,level A)

Vasodialators like pentoxifyline is not Vasodialators like pentoxifyline is not recommended for treatment of ac stroke.recommended for treatment of ac stroke.(Class 3 ,level A)(Class 3 ,level A)

Drug induced hypertension outside the Drug induced hypertension outside the setting of clinical trials is not setting of clinical trials is not recommended .)recommended .)

Page 88: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

MERCI TRIALMERCI TRIAL

Anterior circ strokes onlyAnterior circ strokes only Treatment <8 hoursTreatment <8 hours 151 patients entered151 patients entered

Page 89: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

MERCI RESULTSMERCI RESULTS

Recanalization in 46%Recanalization in 46% Historical 18%Historical 18%

Complication rate 7% (SAH, device Complication rate 7% (SAH, device fx, embolization)fx, embolization)

With recanalization, good outcome With recanalization, good outcome (46% vs. 10%) and mortality (46% vs. 10%) and mortality improved (32% vs. 54%)improved (32% vs. 54%)

ICH rate 7.8%ICH rate 7.8%

Page 90: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012
Page 91: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Thrombolysis AugmentationThrombolysis Augmentation

UltrasoundUltrasound With or without micro-bubblesWith or without micro-bubbles

Micro-bubbles containing TPAMicro-bubbles containing TPA

Combination with G2B3A inhibitorsCombination with G2B3A inhibitors

Page 92: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Neuroprotective agentsNeuroprotective agents

At present no neuroprotective agent At present no neuroprotective agent is found to be effective in improving is found to be effective in improving outcomes after stroke,and therefore outcomes after stroke,and therefore none currently can be none currently can be recommended(class 3,level A)recommended(class 3,level A)

Page 93: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

General Ac treatment after General Ac treatment after HospitalizationHospitalization 25 %of patients may have neurological 25 %of patients may have neurological

worsening during first 24-48 hours.worsening during first 24-48 hours. The use of stroke unit is recommended to The use of stroke unit is recommended to

improve general management.improve general management. Early mobilization of less severely affected Early mobilization of less severely affected

patients is recommended.patients is recommended. Assessment of swallowing before staring Assessment of swallowing before staring

eating or drinking is recommended.eating or drinking is recommended. Patients with suspected pneumonia,UTI should Patients with suspected pneumonia,UTI should

be treated with antibiotics.be treated with antibiotics.

Page 94: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Sub cut anticoagulants are recommended for Sub cut anticoagulants are recommended for treatment of immobilized patients to prevent treatment of immobilized patients to prevent DVT.Ideal timing for starting these medications DVT.Ideal timing for starting these medications is not known.is not known.

The use of intermittent external compression The use of intermittent external compression devices is recommended for treatment of devices is recommended for treatment of patients who can not receive antcoagulants.patients who can not receive antcoagulants.(Class 2a ,level B)(Class 2a ,level B)

Pulmonary embolism accounts for 10% of Pulmonary embolism accounts for 10% of deaths after stroke,and complicaton may be deaths after stroke,and complicaton may be detected in 1%of patients who have had a detected in 1%of patients who have had a stroke.stroke.

Page 95: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Patients who cannot take food and fluids Patients who cannot take food and fluids orally should receive orally should receive nasogastric,nasodudenal or PEG feedings to nasogastric,nasodudenal or PEG feedings to maintain hydration and nutrition.The timing maintain hydration and nutrition.The timing of PEG is uncertain.of PEG is uncertain.

Nutritional supplements are not needed.Nutritional supplements are not needed. Prophylactic administration antibiotic is not Prophylactic administration antibiotic is not

recommended.recommended. If possible the placement of indwelling If possible the placement of indwelling

bladder catheters should be avoided because bladder catheters should be avoided because of associated risk of UTI.(class3 ,level C)of associated risk of UTI.(class3 ,level C)

Page 96: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Treatment of ac neurological Treatment of ac neurological ComplicationsComplications

Brain EdemaBrain Edema

Development of brain edema is gradual and occurs most Development of brain edema is gradual and occurs most frequently 3- 5 days after stroke.frequently 3- 5 days after stroke.

Brain edema is most frequent neurological cause of death in Brain edema is most frequent neurological cause of death in patients with stroke.patients with stroke.

Early CTscan hypodensity,defined as <12 hours after Early CTscan hypodensity,defined as <12 hours after onset ,of >50 %of the MCA territory and presence of onset ,of >50 %of the MCA territory and presence of hyperdense MCA signs are independent predictors of hyperdense MCA signs are independent predictors of neurological deterioration.neurological deterioration.

Large hypodensity>2/3 of MCA terrority on CT and large Large hypodensity>2/3 of MCA terrority on CT and large hypoperfusion on CT perfusion maps predicted hypoperfusion on CT perfusion maps predicted development of malignant MCA infarct.development of malignant MCA infarct.

Page 97: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Modest fluid restrictionModest fluid restriction Avoidence of hypo osmolar fluids like Avoidence of hypo osmolar fluids like

GDW.GDW. Control of fever,hypoxia,hypercapnia.Control of fever,hypoxia,hypercapnia. Elevation of head end of bed by 30 Elevation of head end of bed by 30

degree.degree. Hyperventilation to a partial co2 Hyperventilation to a partial co2

pressure of 28-30 mm of hg.pressure of 28-30 mm of hg.

Management of brain edema and increased ICP

Page 98: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Administration of mannitol 0.25-Administration of mannitol 0.25-0.50gm /kg IV over 30 mnts every 6 0.50gm /kg IV over 30 mnts every 6 hours.hours.

Diuresis(furosemide 40 mg IV).Diuresis(furosemide 40 mg IV). Drainage of CSF.Drainage of CSF. Resection of infarcted Resection of infarcted

tissue./decompressive surgery.tissue./decompressive surgery. Antihypertensive agents particularly Antihypertensive agents particularly

those causing cerebral vasodilation those causing cerebral vasodilation should be avoided.should be avoided.

Page 99: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Contd……Contd…… Patients with ac hydrocephalus in ischaemic stroke most Patients with ac hydrocephalus in ischaemic stroke most

commonly affecting cerebellum can be treated with commonly affecting cerebellum can be treated with placement of a ventricular drain.(class 1 level B)placement of a ventricular drain.(class 1 level B)

Decompressive craniectomy is indicated for treatment of Decompressive craniectomy is indicated for treatment of large cerebellar infarcts in patients with clinical large cerebellar infarcts in patients with clinical deterioration and evidence of early brain stem deterioration and evidence of early brain stem compression or hydrocephalus.This is potentially life compression or hydrocephalus.This is potentially life saving measure and clinical recovery may be very good.saving measure and clinical recovery may be very good.(class 1 ,level B)(class 1 ,level B)

Decompressive surgery for malignant brain edema may Decompressive surgery for malignant brain edema may be life saving in selected patients with complete MCA be life saving in selected patients with complete MCA infarction who are significant risk for developing trans infarction who are significant risk for developing trans tentorial herniation.Timing of surgery is poorly tentorial herniation.Timing of surgery is poorly defined,with some opting for early surgery (in 24 hours)defined,with some opting for early surgery (in 24 hours)

Suboccipital craniotomy is the treatment to relieve both Suboccipital craniotomy is the treatment to relieve both hydrocephalus and brain stem compression caused by hydrocephalus and brain stem compression caused by large cerebellar infarctions.large cerebellar infarctions.

Page 100: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

No specific recommendation is made for No specific recommendation is made for treatment of patients with asymptomatic treatment of patients with asymptomatic haemorrhagic transformation after haemorrhagic transformation after ischaemic stroke.ischaemic stroke.

Corticosteroids are not recommended for Corticosteroids are not recommended for treatment of cerebral edema and treatment of cerebral edema and increased ICP(class 3,level A)increased ICP(class 3,level A)

Prophylactic administration of Prophylactic administration of anticonvulsants in patients of stroke who anticonvulsants in patients of stroke who have not had seizures is not have not had seizures is not recommended(class 3 ,level C)recommended(class 3 ,level C)

Page 101: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012
Page 102: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012
Page 103: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012
Page 104: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012
Page 105: Acute  management of Stroke By Dr Sanjay  jaiswal  Neurologist sept2012

Thank you ! ! !Thank you ! ! !