- SYMPOSIUM RECOMMENDATIONS FOR STROKE MANAGEMENT

1. - SYMPOSIUMRECOMMENDATIONS FOR STROKE MANAGEMENT European Federation of Neurological Societies EFNS Copenhagn 2000

2. Part 1: Organizing Modern Stroke Care Tom Skyhoj Olsen, Copenhagn (DEN) Part 2: Risk Factors and Primary Prevention Julien Bogousslavsky, Lausanne (SUI) Part 3: Acute Stroke Care - General Therapy Markku Kaste, Helsinki (FIN) Part 4: Acute Stroke Care - Specific Therapy Werner Hacke, Heidelberg (GER) Part 5: Rehabilitation and Secondary Prevention Jean-Marc Orgogozo, Bordeaux (FRA) RECOMMENDATIONS FOR STROKE MANAGEMENT

3. Part 1: Organizing Modern Stroke Care Tom Skyhoj Olsen, Copenhagn (DEN) RECOMMENDATIONS FOR STROKE MANAGEMENT

4. Part 2: Risk Factors and Primary Prevention Julien Bogousslavsky, Lausanne (SUI) RECOMMENDATIONS FOR STROKE MANAGEMENT

5. Part 3: Acute Stroke Care - General Therapy Markku Kaste, Helsinki (FIN) RECOMMENDATIONS FOR STROKE MANAGEMENT

6. Part 4: Acute Stroke Care - Specific Therapy Werner Hacke, Heidelberg (GER) RECOMMENDATIONS FOR STROKE MANAGEMENT

7. Part 5: Rehabilitation and Secondary Prevention Jean-Marc Orgogozo, Bordeaux (FRA) RECOMMENDATIONS FOR STROKE MANAGEMENT

8. Level I: Highest Level of Evidence Sources:a) Primary endpoint of double blind RCT with adequate sample size b) Meta-analysis of qualitatively outstanding RCTs Level II: Intermediate Level of Evidence Sources:a) Randomised not blinded trials b) Small randomised trials c) Predefined secondary endpoints of large RCTs Level III: Lower Level of Evidence Sources:a) Prospective case series with concurrent or historical control b) Post hoc analyses of large RCTs Level IV: Undetermined Level of Evidence Sources:a) Small uncontrolled case series b) General agreement despite lack of evidence Definitions of Levels of Evidencemodified from Adams et al. 1994

9. Differentiation between different types of stroke Ruling out other brain diseases Assessing the underlying cause of brain ischemia Providing a basis for physiological monitoring of the stroke patient Identifying concurrent diseases or complications associated with stroke Acute Stroke Care-Emergency Diagnostic Tests

10. Cranial computed tomography (CCT) distinguishes reliably between hemorrhagic and ischemic stroke early signs of ischemia detected as early as 2 h after stroke onset identifies hemorrhages almost immediately detects SAH in the majority of cases helps to identify other neurological diseases (e.g. neoplasms) Emergency Diagnostic Tests

11. Magnetic resonance imaging (MRI) only helpful in centres using modern MRI techniques diffusion- and perfusion-weighted MRI may help to differentiate between infarcted tissue and tissue at risk Emergency Diagnostic Tests

12. Electrocardiogram high incidence of heart involvement in stroke patients coincidence of stroke and myocardial infarction ischemic stroke may cause arrhythmias detection of atrial fibrillation as a possible cause of embolic stroke Emergency Diagnostic Tests

13. Ultrasound studies cw/pw- Doppler and/or duplex sonography of the extracranial cervical and the basal intracranial arteries identification of vessel stenosis, occlusion, state of collaterals, or recanalisation transesophageal echocardiography to screen for cardiogenic emboli (not in the ER but recommended within the first 24 h after stroke onset) Emergency Diagnostic Tests

14. Laboratory tests hematology clotting parameters electrolytes renal and hepatic chemistry cardiac enzymes basic parameters of infection Emergency Diagnostic Tests

15. EUSI Recommendations 1. CCT is the most important diagnostic tool in patients with suspected stroke (Level IV) 2.Early evaluation of physiological parameters, blood chemistry and hematology, and cardiac function (ECG, pulsoximetry, chest x-ray) is recommended in the management of acute stroke patients Emergency Diagnostic Tests

16. EUSI Recommendations 3. Cardiac and Neurological ultrasound should be readily available (Level IV) Emergency Diagnostic Tests

17. EUSI-recommendations include Pulmonary and airway care Blood pressure Body temperature Glucose metabolism Fluid and electrolyte management Acute Stroke Care-General Management

18. Monitoring of vital and neurological functions continuous monitoring: heart rate O2 saturation discontinuous monitoring Blood pressure (e.g. automatic inflatable sphygmomanometry) Clinical: Vigilance / GCS, pupils Neurological (e.g. NIH and Scandinavian stroke scale) General Management

19. Pulmonary function and airway protection Adequate oxygenation important for preservation of the penumbra Improved blood oxygenation by administration of > 2 l O2 (SO2 -guided) Risk for aspiration in patients with pseudobulbar/bulbar paralysis and reduced vigilance: side positioning, consider tracheotomia Consider hypoventilation by pathological respiration pattern Risk of airway obstruction (vomiting, oropharyngeal muscular hypotonia): mechanical airway protection General treatment

20. Blood pressure (BP) elevated in most of the patients with acute stroke Flow in the critical penumbra passively dependent on the mean arterial pressure Sufficient post-stenotic flow requires high blood pressure General treatment

21. Blood pressure There are no controlled, randomised studies guiding BP management Recommended target BP in patients with prior hypertension: 180 / 100-105 mmHg Recommended target BP in previously normotonic patients: 160-180 / 90-100 mmHg Avoid and treat hypotension or drastic reductions in BP General treatment

22. Blood pressure Indications for immediate antihypertensive therapy in acute stroke: Non-ischemic cause for stroke Cardiac insufficiency Aortic dissection Acute renal failure Hypertensive encephalopathy General treatment

23. Body temperature Facts Fever negatively influences neurological outcome after stroke Experimentally, fever increases infarct size Many patients with acute stroke develop a febrile infection after stroke Although no controlled trial supporting treatment of an elevated temperature, consider to treat fever when the body temperature reaches 37.5°C rectally General treatment

24. Glucose metabolism Facts Pre-existent diabetic metabolic derangement can be worsened High glucose levels in the acute phase of stroke may increase the size of the infarction and reduce functional outcome Hypoglycemia worsens outcome as well Hypoglycemia can mimic an acute ischemic infarction General treatment

25. Fluid and electrolyte management Serious electrolyte abnormalities are rare after ischemic stroke but frequent after ICH and SAH Balanced electrolyte and fluid status are important to avoid: plasma volume contraction raised hematocrit impaired rheologic properties General treatment

26. EUSI Recommendations 1. Neurological status and vital functions should be monitored 2. Glucose and body temperature should be monitored and corrected, if elevated (Level III) 3. Do not treat hypertension in patients with ischemic stroke, if they do not have critically elevated BP levels (Level III) General treatment

27. EUSI Recommendations 4. Secure airways and supply oxygen to patients with severe acute stroke (Level IV) 5. Monitoring and correction of electrolyte and fluid disturbances are advised (Level IV) General treatment

28. EUSI-recommendations include Acute anti-thrombotic therapy Thrombolytic therapy Defibrinogenating enzymes ASA Neuroprotection Treatment of elevated ICP and brain edema Medical treatment Surgical treatment Acute Stroke Care-Specific Treatment

29. IV-Thrombolysis (rtPA) Facts (NINDS Pt. 1 + 2, ECASS I + II, ATLANTIS) 3h time window approved in USA, CDN, MEX, I.V. 0.9mg/kg, max 90mg Not yet approved in Europe Efficacy signal beyond 3h (meta-analysis) IV-Thrombolysis (SK) Facts (MAST-I, MAST-E, AST) Although some efficacy signal in early time windwow, SK currently abandoned Thrombolytic Therapy

30. IA-Thrombolysis (rtPA, UK) Facts Only cases and some prospective uncontrolled case series IA-Thrombolysis (rPUK) Facts (PROACT I and II) Efficacy proven in small RCT, 6h window, Not approved, PROACT III? Thrombolytic Therapy

31. EUSI Recommendations (for centers offering thrombolysis) 1. I.V. rtPA (0.9mg/kg; max 90mg, 10% bolus, followed by 60 min infusion) is recommended within 3 hours after stroke onset (Level I) 2. The benefit from the use of I.V. rtPA beyond 3 hours is smaller, but present in selected patients (Level I) 3. I.V. rtPA is not recommended when time of onset is uncertain Thrombolytic Therapy

32. EUSI Recommendations (for centers offering thrombolysis) 4. I.V. SK outside of the setting of acontrolled clinical trial is dangerous and not indicated for the management of persons with ischemic stroke (Level I) 5. Intra-arterial treatment of acute M1 occlusion in a 6 h time window using rPUK results in a significantly improved outcome (Level II) 3. Acute BA-occlusion may be treted with I.A, therapy in selected centers (Level IV) Thrombolytic Therapy

33. ANCROD Treatment of acute ischemic stroke with I.V. Ancrod in a 3 h time window results in significantly improved outcome (primary endpoint only (STAT) Futility analysis of 6 h trial (ESTAT) led to premature termination of the trial Defibrinogenating Therapy

34. EUSI Recommendation 1. Ancrod given in a 3 h time window significantly improves outcome after acute ischemic stroke (Level II) Defibrinogenating Therapy

35. ASA only substance tested in acute (<48 h) stroke (IST, CAST) CT not required for randomisation small but significant reduction of mortality and recurrence of stroke in combined analysis of both trials Platelet Inhibitors

36. EUSI-recommendation 1. Aspirin 100-300 mg/day may be given to an unselected stroke population (Level II) Platelet Inhibitors

37. Unfractionated heparin no formal trial available testing standard I.V. heparin IST showed no benefit for sc heparin treated patients, increased risk of ICH Low molecular weight heparins Postive effect seen in small pilot trial (Kay 1995) was not found in subsequent trial (fisBIS) Heparinoid (Orgaran) TOAST trial negative Therapeutic Anticoagulation

38. EUSI-recommendation 1. There is no recommendation for the general use of heparin, low molecular weight heparines or heparinoids after ischemic stroke (Level I) 2. Full dose heparin may be used in selected indications such as AF, other cardiac sources with high risk of re-embolism, arterial dissection, or high grade arterial stenosis (Level IV) 3. Administration for DVT-prophylaxis see general treatment Therapeutic Antioagulation

39. Up to now, not a single neuroprotective substance has been shown to influence outcome after stroke. Currently there is no recommendation to treat patients with neuroprotective drugs after ischaemic stroke (Level I) Neuroprotection

40. Medical therapy Basic management Head positioning <30° Pain relief and sedation Normothermia Osmotic agents Glycerol Mannitol Hypertonic saline Barbiturates, hyperventilation and THAM-buffer Elevated Intracranial Pressure and Brain Edema Treatment

41. Surgical Therapy Ventricular drainage Posterior fossa space occupying infarction Thalamic infarction (rare) Decompressive surgery Posterior fossa space occupying infarctian Malignant MCA/hemispheric infarction Encouraging reduction of mortality with decent outcome i prospective case series RCT (HEADFIRST) starts recruiting Elevated Intracranial Pressure and Brain Edema Treatment

42. EUSI-recommendations 1. Osmotherapy is recommended for patients whose condition is deteriorating secondary to increased ICP, including those with herniation syndromes (Level III) 2. Surgical decompression of large cerebellar infarctions that compress the brainstem is justified (Level III) 3.Surgical decompression of large hemispheric infarction can be life-saving (Level III) Elevated Intracranial Pressure and Brain Edema Treatment

43. Definition: Hospital or part of a hospital that (nearly) exclusively takes care of stroke patients Specialised staff with multidisciplinary approach to treatment and care Core disciplines: medical treatment, nursing, physiotherapy, occupational therapy, speech and language therapy, social work Stroke Units

44. Facts (Stroke Unit Trialist´s Collaboration) Acute treatment in a stroke unit results in significant reduction in mortality, death, dependence, or need of institutional care in comparison to a general medical ward Stroke Units

45. Types of stroke units: 1. Acute stroke unit acute treatment < 1 week (2-3 days) 2. Combined acute and rehabilitation stroke unit acute phase + reha for several weeks / months 3. Rehabilitation stroke unit admission after 1to 2 weeks after stroke onset 4. Mobile stroke team offers stroke care and treatment on a variety of wards Stroke Units

46. EUSI Recommendations 1. Stroke patients should be treated in specialised stroke units (Level I) Stroke Units

47. Early rehabilitation 40% of stroke patients need active reha services active rehabilitation should start as soon as possible if the patient is unconscious, rehabilitation is passive to prevent contractions and other immobilisation-associated complications Rehabilitation

48. Rehabilitation programs - Assessment for the degree of disability (motor, cognitive, sensory, visual) - Assessment of the ability to respond to rehabilitation (financial burden, chances to return to social activities and work and to live alone, need of help) - adaptation of the intensity of the rehabilitation to status and the degree of disability Rehabilitation

49. Rehabilitation programs - daily documentation of the patients progress - teaching and involvement of the patient and his family members - home visitation as early as possible (smoothing the transit, increasing motivation) - planning the transfer to a specialised rehabilitation hospital if a longer reha period is expected Rehabilitation

50. ideal multidisciplinary stroke team for adequate rehabilitation - stroke physician and nurses experienced in stroke management - physiotherapist, speech therapist and occupational therapist trained in stroke rehabilitation - neuropsychologist and social worker accustomed to stroke rehabilitation Rehabilitation