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Medical Management of Stroke

Medical Management of Stroke. Stroke Code!. Rapid Assessment. (NIH Stroke Scale) Non-con CT CTA/CTP Call Duty Neurologist Is patient t-PA candidate? Or candidate for other acute therapies? See Neurology Sharepoint for Stroke Protocols Stroke registry Stroke review meetings.

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Medical Management of Stroke

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  1. Medical Management of Stroke

  2. Stroke Code! • Rapid Assessment. (NIH Stroke Scale) • Non-con CT • CTA/CTP • Call Duty Neurologist • Is patient t-PA candidate? • Or candidate for other acute therapies? • See Neurology Sharepoint for Stroke Protocols • Stroke registry • Stroke review meetings

  3. Stroke Definitions • Focal Neurologic • Negative Symptoms • Vascular Origin • Sudden Onset • Sudden Headache (SAH)

  4. Cerebral Blood Flow • Normal CBF 50 – 55 ml/100gm/min • About 18 - 20 ml/100gm/min – Failure of neuronal function • About 8 -10 ml/100gm/min – cellular death • Hypoperfused area = ischemic penumbra • Restore perfusion to ischemic penumbra • Protect neurons until perfusion restored • Rapid Diagnosis and intervention

  5. Transient Ischemic Attack • < 24 hours by definition • Most last 10 – 20 minutes • Warning sign of Stroke: like unstable angina and MI • Expedite work-up • Typically present with rapid-onset deficits maximal at onset. • Compare with “march” of Migraine or Seizure

  6. Signs of TIA • Anterior circulation • Aphasia, neglect, Amaurosis, isolated leg weakeness, abulia • Posterior circulation • Diplopia, ataxia, dysphagia,hiccups, vertigo, crossed signs • Either • Hemiplegia, visual field cuts, hemisensory loss, dysarthria

  7. TIA evaluation • Carotid imaging • Intracranial vessel imaging • Cardiac source eval

  8. TIA Rx • CEA for symptomatic Carotid Stenosis >70% • Stenting, if surgical contraindications • Cardiac source: Coumadin. ASA if not able to give coumadin. • Atherosclerosis: ASA, Statins, Clopidogrel. ASA + dipyridimole • Lacunar: ~ Same. Antihypertensive Rx.

  9. MATCH Trial • Management of Atherothrombosis with Clopidogrel in High-Risk Patients with Recent Transient Ischemic Attack (MATCH) study, • Clopidogrel + aspirin for secondary prevention of stroke • The efficacy of any antiplatelet therapy, including aspirin, is modest when it is used as monotherapy, and combination therapy with 2 antiplatelet agents has shown promise in reducing the risk for secondary stroke in patients who have had a previous transient ischemic attack (TIA) or ischemic stroke. • MATCH trial indicated that the reduction in risk achieved by adding aspirin to clopidogrel is not significantly greater than that achieved with clopidogrel alone. • Significant increase in life-threatening bleeding complications was associated with the combination of clopidogrel + aspirin. • Clopidogrel + aspirin cannot be recommended at this time for the secondary prevention of stroke in patients who have had a previous ischemic stroke or TIA. • (? 3 month short term Rx after ominous stroke) • From American Journal of Medicine

  10. ESPS-2 • Second European Stroke Prevention Study (ESPS-2) • Demonstrated a significant reduction in risk for secondary stroke with aspirin + extended-release dipyridamole versus aspirin alone

  11. PRoFESS Trial(Full results yet to be published) • Prevention Regimen for Effectively avoiding Second Strokes. • Plavix (clopidogrel) ~= Aggrenox (ASA + DP) • (Micardis not better than Placebo)

  12. CT scan of early stroke

  13. Types of Stroke • Ischemic • Arterial • Venous • Headache, lethargy, Seizure • Hemorrhagic • Intra-parenchymal • Sub-arachnoid

  14. Stroke etiologies

  15. Stroke risks

  16. Ischemic Stroke • Destructive cascade induced by ischemia • Decreased O2 and glucose • ATP insufficiency • Ca++ influx • Increase Glutamate • Membrane degradation • Free radical increase • Apotosis

  17. Large MCA Stroke

  18. Sources of stroke

  19. Stroke Syndromes • Carotid • ACA: Leg > Arm, Frontal lobe symptoms • MCA: Face, Arm > Leg; gaze preference, Aphasia, hemineglect etc • Vertebrobasilar • PCA: Hemianopsia, etc • Brain stem Stroke: Crossed signs, diplopia, vertigo, dysphagia, Horner’s Syndrome, etc

  20. Right PICA stroke

  21. Lacunar Syndromes • Pure Motor • Pure Sensory • Sensorimotor • Ataxia-hemiparesis • Dysarthria Clumsy Hand • Hemichorea

  22. Arteriopathies • Atherosclerosis • Non-Atherosclerotic • Inflamatory • Angiitis • GCA • Syphilis etc • Non-inflamatory • Dissection • FMD • Moya Moya • Homocysteinuria • CADASIL • cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy • Drugs etc

  23. Age Race Gender Family History Prior Stroke HTN DM Heart Disease Smoking Hyperlipidemia Carotid bruits Excessive EtOH BCP Obesity and inactivity Stroke Risk Factors

  24. Embolic Stroke • High Risk vs Low Risk Cardiac sources

  25. Hematological Diseases • Antiphospholipid Antibody Syndrome • Protein C deficiency • Protien S deficiency • Factor V Leiden • Other hypercoagulable states

  26. Venous Ischemic Stroke • Post partum • Hypercoagulable States • Infections • Dehydration • Tumors • Post-op

  27. Hemorrhagic Strokes • Hypertensive • Putamen • Thalamus • Cerebellar • Pontine • Aneurysmal • AVM • Amyloid Angiopathy

  28. Stroke Rx decision tree

  29. Ischemic Stroke Strategies • “Time is Brain” • Reperfusion • Ancillary Care • Systemic • Avoid Complications • Neuro-protection • Secondary Prevention • Anti-platelet agents • Statins • Hypertension Rx • Smoking cessation • Weight Control

  30. Initial Stabilization and Monitoring • Assess airway maintenance • Level of Arousal • Evaluation for MI • Dysrhythmia monitoring

  31. Diagnostic Eval for Stroke • Urgent, for all: CT or MRI, Electrolytes, glucose, BUN, Creatinine, CBC, PT/PTT, O2 Sat • Urgent, for some: Tox screen, Blood alcohol, LFTs, HCG, CXR, ABG, LP, EEG • Non-urgent, for etiologic eval: TEE or TTE, Carotid Doppler, MR angiogram, CT angiogram, Catheter angiogram, RPR, ESR, homocysteine, lipids. • Selected patient eval: Coag panel, TSH, MR imaging and MRA of intracranial vessels

  32. Stroke Rx • Anticoagulation ~doesn’t benefit • Consider anticoagulation • Known large vessel disease with fluctuating symptoms • Mechanical Heart valves • LV Thrombus • Prothrombotic states • Cerebral Venous Thrombosis • Prone to Hemorrhage: • Large infarcts • Extensive Occipital Lobe involvement • Early Petechial Conversion • Uncontolled hypertension, Hyperglycemia

  33. Stroke Rx • Induced hypertension might help salvage ischemic Penumbra • Double edge sword

  34. Fluid management • May need to be NPO • Avoid hypotonic solutions if risk of cerebral edema • Monitor electrolytes • Prevent hyperglycemia – leads to worse outcome

  35. Prevent Complications • DVT prophylaxis • Pneumatic compression stockings • SQ Low Molecular Weight Heparin • GI Prophylaxis • Feeding • Chest PT/positioning • Stool softeners • Prevent infection - UTI

  36. MRIs before and after t-PA

  37. Thrombolytic Therapy • Goal – preserve ischemic penumbra • 3 hour window for IV t-PA • 6% bleed. • Outcome: 12 % > placebo • Intra-arterial t-PA – not FDA approved – “investigational”, 6 hour window. • Abciximab – disappointing result • ASA acute Rx – some value • Hypothermia – shows promise, but technically difficult • “Merci” clot retriever – FDA approved

  38. Absolute contraindications to t-PA • Presenting symptoms and signs should not suggest acute subarachnoid hemorrhage • Head trauma or prior stroke within the previous 3 months • Myocardial infarction within the previous 3 months • Gastrointestinal or urinary tract hemorrhage within the previous 21 days • Major surgery within the previous 14 days • Arterial puncture at a noncompressible site within the previous 7 days • History of previous intracranial hemorrhage • Active bleeding or acute trauma (fracture) on examination • Platelet count <100,000 mm3 • Blood glucose <50 mg/dL • Seizure or postictal neurologic impairments

  39. Relative contraindications to t-PA • Oral anticoagulation (international normalized ratio must be ≤1.5) • Heparin within the previous 48 hours (activated partial thromboplastin time must be in the normal range)

  40. Stroke with hemorrhage s/p t-PA

  41. Protocol for thrombolytic therapy in patients with of acute ischemic stroke • 1. Determine if the patient is a candidate for thrombolytic therapy. • 2. Infuse alteplase (rt-PA) 0.9 mg/kg (maximum of 90 mg) over 60 minutes with 10% of the dose given as a bolus over 1 minute. • 3. Admit the patient to an intensive care unit or stroke unit for monitoring. • 4. Neurologic assessment to be performed every 15 minutes during the infusion of rt-PA and every 30 minutes for the first 2 hours for the next 6 hours, then every hour for 24 hours from the time of initial treatment. • 5. If the patient develops a severe headache, acute hypertension, nausea, or vomiting, discontinue the infusion and perform and emergency CT brain scan. • 6. Measure blood pressure every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and then every hour until 24 hours from the time of initial treatment. • 7. Increase the frequency of blood pressure measurements if a systolic blood pressure ≥180 mm Hg systolic or ≥105 mm Hg diastolic is recorded. Administer antihypertensive medications to maintain the blood pressure at or below these levels

  42. Antihypertensive Rx in acute stroke • Avoid Rx unless planned thombolysis and SBP > 185 or DBP >110 • Evidence of end organ damage • Excessively high BP: SBP > 220 ; DBP > 110 • Labetolol or Nicardipine Drip for BP Rx with thombolysis

  43. Antihypertensive Rx

  44. Vasopressor Rx

  45. Massive stoke with trans-falcine herniation

  46. Cerebral Edema Rx • First prevention • Higher risk • Large hemispheric stroke in younger person (little room to swell) • Cerebellar Stroke • H/o Hypertension

  47. Cerebral Edema Rx • HOB elevation, Fluid restriction, Treat fever • Hyperventilation – causes vasoconstriction: brief effect, may get rebound vasodilation, ?worsens ischemia • Osmotic agents – mannitol vs hypertonic saline vs furosemide • Barbiturates – decrease cerebral metabolic rate. Not really effective. • Steroids do not work for cytotoxic stroke edema • Hypothermic Rx? • Hemicranectomy/Surgical Decompression

  48. Large stroke s/p hemicraniectomy

  49. Hemorrhagic Stroke Strategies • Stop Bleeding • Ancillary Support • Neuro-protection

  50. Parenchymal Hemorrhage in Basal Ganglia

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