Acute Ischemic Stroke & Transient Ischemic Attack (TIA) Sumet Preechawuttidej, M.D.

1. Acute Ischemic Stroke& Transient Ischemic Attack (TIA)Sumet Preechawuttidej, M.D.

2. โรคหลอดเลือดสมอง Cerebrovascular disease (CVD) CVA Stroke “Rapidly developed clinical signs of focal (global) disturbance of cerebral function lasting more than 24 hours or leading to death, with no apparent cause other than a vascular origin.”

3. เสียชีวิต ความผิดปกติ muscle weakness, ataxia, loss of sensation, etc Stroke ความพิการ Inability to walk, feed, etc เกิดโรคซ้ำ (สมองเสื่อมvascular dementia) ผลของโรคหลอดเลือดสมอง ปัจจัยเสี่ยง

4. อายุคาดเฉลี่ยคนไทย พ.ศ. 2546-2556

5. รายงานการสำรวจพฤติกรรมเสี่ยงโรคไม่ติดต่อและการบาดเจ็บรายงานการสำรวจพฤติกรรมเสี่ยงโรคไม่ติดต่อและการบาดเจ็บ

6. โรคที่เป็นสาเหตุของความสูญเสียปีสุขภาวะประชากรไทยโรคที่เป็นสาเหตุของความสูญเสียปีสุขภาวะประชากรไทย อัตราตายของประชากรไทย

7. Content Acute Ischemic Stroke & TIA • Etiology • Clinical manifestation • Diagnosis • Management • Prevention

8. Approach to Cerebrovascular disease Definition • conditions in which injury to the brain or spinal cord occurred from a vascular cause • 2 main types: ischemic and hemorrhagic stroke

10. Charcot-Bouchard aneurysm Parent artery

11. Acute Ischemic Stroke & TIA

12. Etiology Ischemic Stroke Subtypes (TOAST classification) • Large-artery atherosclerosis • Cardioembolism • Small-vessel occlusion (Lacunar infarction) • Stroke of other determined etiology • Hypercoagulable disorder • Venous sinus thrombosis • Vasculitis • Stroke of undetermined etiology

13. Risk Factors เปลี่ยนแปลงไม่ได้Non-modifiableAge, Gender, Race, Heredity เปลี่ยนแปลงได้Modifiable Behaviors • Cigarette smoking • Alcohol abuse • Physical inactivity • Medical Conditions • Hypertension • Cardiac disease • Atrial fibrillation • Dyslipidemia • Diabetes mellitus • Carotid stenosis • Prior TIA or stroke • Elevated homocysteine • Atherosclerosis of aorta Sacco RL, et al. Stroke 1997;28:1507-1517. Pancioli AM, et al. JAMA 1998;279:1288-1292.

14. Prevalence of Stroke by Age and Sex NHANES III: 1988-94 Risk Factors CDC/NCHS.

15. Risk Factors เปลี่ยนแปลงไม่ได้Non-modifiableAge, Gender, Race, Heredity เปลี่ยนแปลงได้Modifiable Behaviors • Cigarette smoking • Alcohol abuse • Physical inactivity • Medical Conditions • Hypertension • Cardiac disease • Atrial fibrillation • Dyslipidemia • Diabetes mellitus • Carotid stenosis • Prior TIA or stroke • Elevated homocysteine • Atherosclerosis of aorta Sacco RL, et al. Stroke 1997;28:1507-1517. Pancioli AM, et al. JAMA 1998;279:1288-1292.

16. Risk Factors

17. Clinical manifestation อาการของโรคหลอดเลือดสมอง • รวดเร็วหรือทันทีทันใด!! • อ่อนแรงของร่างกายครึ่งซีก • ชาครึ่งซีก • เวียนศีรษะ ร่วมกับเดินเซ • ตามัว หรือ มองเห็นภาพซ้อน • พูดไม่ชัด ลิ้นแข็ง • ปวดศีรษะ อาเจียน • ซึม ไม่รู้สึกตัว

18. Transient ischemic attacks (TIA) Duration is <24 hours, but most TIAs last <1-2 hours The risk of stroke after a TIA is ~10–15% in the first 3 months Most events occurring in the first 7 days ABCD2 score

20. MANAGEMENT

21. History and Physical examination History • Determining the exact time when symptoms began or the last time the patient was known to be well • Concomitant medical illnesses • Risk factors

22. History and Physical examination (cont.) Physical examination • Vital signs • Cardiovascular systems • General neurologic examination • The National Institutes of Health Stroke Scale (NIHSS)

23. NIHSS • 1. Level of consciousness • Level of consciousness • Question • Command • 2. Best gaze • 3. Visual field • 4. Facial palsy • 5. Motor arm • 6. Motor leg 7. Limb ataxia 8. Sensory 9. Best language 10. Dysarthria 11. Extinction and Inattention

24. STROKE Hemorrhagic Ischemic Stroke fast track Consult neuroSx STROKE 4.5-72 hr General Mx <4.5 hr Candidate for thrombolytic therapy? SUDDEN ONSET OF FOCAL NEUROLOGICAL DEFICITSUSPICIOUS STROKE Emergency lab+ CT brain NC Emergency lab+ CT brain NC Onset?

25. Initial investigation and Workup Blood test • FBS, CBC, Lipid profile, BUN/Cr, Electrolyte, PT, PTT, INR, UA Cardiac workup • EKG 12 lead, CXR • If suspect cardioembolism  TEE, Holter monitoring Pt. age <45 yr without evidence of cardioembolism/ atherosclerosis risk factor • ESR, ANA, Anti HIV, VDRL, LFT, Thrombophilia lab Vascular workup • Carotid duplex US, TCDUS MRA, CTA

26. Brain imaging • Early signs in CT (MCA infarction) • Loss of gray-white junction • Insular ribbon sign • Blurring of borders of basal ganglia • Dense artery sign CT brain non contrast • DDx Ischemic or Hemorrhagic MRI brain (further investigation)

28. Treatment IV thrombolytic treatment General management Antithrombotic treatment Stroke Unit and Rehabilitation

29. IV thrombolytic therapy Indication • Clinical diagnosis of stroke • Onset ≤ 4.5 hr • Age > 18 yr • CT brain  no hemorrhagic or edema of >1/3 of the MCA territory • Consent by patient or surrogate

30. IV thrombolytic therapy (cont.) Contraindication (onset within 3 hour) • Sustained BP ≥185/110 mmHg despite Tx • Platelet < 100,000; Hct < 25%; Glucose < 50mg% or > 400 mg% • Use heparin within 48 hr and prolonged PTT or elevated INR • Rapidly improving symptom  NIHSS ≤ 4 • Prior stroke or head injury within 3 months; prior intracranial hemorrhage • Major surgery in preceding 14 days • Minor stroke symptom • Gastrointestinal bleeding in preceding 21 days • Recent myocardial infarction • Coma or stupor

31. IV thrombolytic therapy (cont.) Additional contraindication in patient (onset within 3 – 4.5 hour) • History of warfarin use • Age > 80 year • Diabetic with prior ischemic stroke • NIHSS > 25

32. IV thrombolytic therapy (cont.) Administration of rt-PA (Recombinant tissue-plasminogen activator) • 0.9 mg/kg (maximum 90 mg) IV as 10% of total dose by bolus • The followed by remainder 90% over 1 hour • No other antithrombotic treatments for 24 hours • For decline in neurologic status/uncontrolled BP  stop infusion and give cryoprecipitate and reimage brain immediately • Avoid urethral catheterization

33. General management Keep SpO2 > 94% Antihypertensive drug • SBP ≤220 mmHg or DBP ≤120 mmHg with • CHF, Aortic dissection, Acute MI, Acute renal failure, Hypertensive encephalopathy • If SBP >220 mmHg or DBP >120 mmHg • Decrease blood pressure 10-15% • Nicardipine 5 mg/hr IV Keep BP <180/105 mmHg in Pt. received thrombolysis

34. General management (cont.) IV hydration • Isotonic solution (0.9%NaCl) NPO when • Unconsciousness • Suspected large infarction • Tendency to surgery • Infratentorial infarction

35. General management (cont.) Blood glucose controlled • Keep 140-180 mg% Avoid high body temperature If patient seizure  Antiepileptic drug (no need prophylaxis) Tx co-morbidity; MI, electrolyte imbalance Early mobilization for prevention DVT Swallowing evaluation

36. Medical treatment Antiplatelets • Aspirin 160 – 325 mg/day in first 24 – 48 hour • No Aspirin within 24 hours after thrombolytic therapy Anticoagulants Others; Immunosuppressive drug in vasculitis

37. Tx Increase intracranial pressure Intubation if deteriorated consciousness Semifowler position (20 – 30 degrees) Hyperventilation  16-20/min keep pCO2 30-35 mmHg Osmotherapy • 20% Mannitol 1g/kg IV in 20-30 min then 0.25-0.5g/kg IV in 10 min q 4-6 hour (max 2g/kg/day) for 24 – 48 hours • Keep Serum Osmo <320 mmol/L Consult neurosurgeon for decompressive craniectomy

38. Stroke Unit Rehabilitation Swallowing evaluation

39. Stroke Unit (cont.)

40. Stroke Unit (cont.)

42. Rehabilitation Contraindication Body temperature >38 degrees celcius HR >100 or <60/min BP >180/110 or <90/60mmHg Cardiac condition: MI, arrhythmia Dyspnea Deteriorated consciousness Seizure

44. Secondary prevention Atherosclerosis risk factor • BMI <23 kg/m2 • DM • HbA1C < 7% • HT • <140/90 mmHg in general patient • <130/80 mmHg in DM patient • Smoking  stop • Abnormal blood cholesterol (low HDL, high LDL) • Keep LDL < 100 mg/dL in general patient • Keep LDL < 70 mg/dL in DM/heart disease patient • Keep TG < 150 mg/dL, HDL >40 mg/dL (male), >50 mg/dL (female)

45. Secondary prevention (cont.) Antiplatelet agent • Non-cardioembolic stroke • ASA 50-325 mg/day • Clopidogrel 75 mg/day • ASA + dipyridamole 50/400 mg/day • Cilostazol 200 mg/day

46. Secondary prevention (cont.) Anticoagulant • Cardioembolic stroke • Warfarin  keep INR 2.0-3.0 in patient with • Persistent or paroxysmal AF • Acute MI and LV thrombus • Mechanical heart valve

47. Thank You For Your Attention