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STROKE MANAGEMENT
Adapted from source
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STROKE
Third commonest cause of all mortality
48000 new strokes annually
Direct cost 2 billion dollars annually Incidence increasing set to double by 2030
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STROKE
Sudden onset of neurological deficit
Clinical diagnosis
Imaging is supportive Emergency (brain attack)
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STROKE
Definitions:
± TIA
±
CVA ± Syncope
± Hypoxic ischaemic encephalopathy
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TYPES OF STROKE
ISCHAEMIC 85%
± Cardioembolic 17%
± Carotid atherosclerosis 4%
± Other 64%
HAEMORRHAGIC 15%
Aneurysmal SAH 4%
Hypertensive ICH 7%Other 4%
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STROKE
Initial assessment:
ABC
Level of consciousness
Maintain BP Blood panel
Hydrate
Identify pyrexia and hyperglycaemia
ECG Brain CT scan
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STROKE
Common causes of ischaemic stroke ± Thrombosis
± Lacunar
± Cardio-emboli
± Dehydration
± AF
± mechanical valves
± MS
±MI
± Bacterial endocarditis
± Intra-cardiac shunts
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STROKE
Left MCA ischaemic stroke
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STROKE
Right MCA ischaemic CVA
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STROKE
Thrombolysis
± NINDS rtPA Stroke Study 1995; used 0.9mg/kg produced insignificant4% reduction of mortality(21% to 17%) but produced 12% ARR(32%from 44%) in mortality and minimal disability. Bleeding risk was6.4%(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
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STROKE
THROMBOLYSIS
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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
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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
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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
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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
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STROKE
Anti-platelet agents:
1. Aspirin; most used,
± IST used 300mg within 48hrs of CVA produced insignificant reductionin 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 andrecurrence in first few weeks and 13 deaths and dependency in 6/12
± Asasantin
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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
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STROKE
Ace inhibitors:
PROGRESS 28% RR
HOPE 32% RR
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STROKE
Anti-coagulants:
Role unclear
±
TOAST demonstrated no extra benefit fromWarfarin vs. Aspirin
± IST showed on benefit but increased bleeding risk
± No data to support use in crescendo TIAS
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STROKE
Neuroprotection:
± Under study; useful in animal studies
± SAINT 1(Stroke-Acute Ischaemic NXY Treatment); 1800
patients showed improvement in reduction of disability at3/12 but no improvement in other outcome measures
± Magnesium
± Erthropioten
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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%
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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%
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Atrial Fibrillation
ACC/AHA/ESC 2006 Guidelines: Risk Factors for Stroke
Less Validated/Weaker Risk
Factors
Moderate Risk
Factors
High Risk Factors
Female gender Age 75 yrs Previous stroke, TIA, or
embolism
Age 65-74 yrs Hypertension Mitral stenosis
Coronary artery disease Heart failure
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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
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Atrial Fibrillation
ACC/AHA/ESC 2006 Guidelines: Recommended Therapies According toStroke 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)*
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CHADS 2
CCF
Hypertension
Age DM
Stroke
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STROKE
stroke prevention in asymptomatic CAS:
1. Anti-platelet agents
2. Statins: HPS 25% RRR, SPARCL 17%RRR
3. Risk factor modification
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STROKE
TIA
Neurological symptoms of <24 hrs
40% have real infarcts Risk of CVA 10% in first 3/12
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STROKE
TIA
Prevention
±
Treat risk factors ± Anti platelet agents
± Anti-coagulants
± Statins
± ACE inhibitors
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STROKE
Intracranial haemorrhage:
Causes:
Hypertension
TBI
Ischaemic transformationAneurysm
Metastasis
Coagulopathy
Drugs
Amyloid angiopathyAngioma
Telengectasia
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STROKE
Haemorrhagic CVA
SAH
± TBI is commonest cause
±
Aneurysm is second, prev 2%, 20% multiple, usuallyasymptomatic until rupture
± Presents with acute sudden symptoms
± 95% diagnosed on brain CT
± Mortality 45%, 50% of survivors have significant neurodeficit
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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)
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STROKE
Rehabilitation
Stroke units
Restraint therapy
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