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 insignificant
4% reduction of mortality(21% to 17%) but produced 12% ARR(32%
from 44%) in mortality and minimal disability. Bleeding risk was
6.4%(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 reduction
in 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 and
recurrence 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 from
Warfarin 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 at
3/12 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 Moderate Risk High Risk Factors

Factors 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 to
Stroke 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
• Carotid Artery Stenosis & CEA
• NASCET: Definite benefit 70-99% stenosis les robust for 50-
70% stenosis
• ECST showed harm in 30-50% stenosis
• ACAS showed benefit in > 60% stenosis treated with CEA and
Aspirin of 1.2 annual ARR
• Angioplasty and Stenting:
• Reserved for selected patients
 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 transformation
Aneurysm
Metastasis
Coagulopathy
Drugs
Amyloid angiopathy
Angioma
Telengectasia
 STROKE
• Haemorrhagic CVA
• SAH
– TBI is commonest cause
– Aneurysm is second, prev 2%, 20% multiple, usually
asymptomatic until rupture
– Presents with acute sudden symptoms
– 95% diagnosed on brain CT
– Mortality 45%, 50% of survivors have significant neuro
deficit
 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