non-hemorrhagic stroke latest

8/11/2019 Non-hemorrhagic Stroke Latest

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NON-HEMORRHAGICSTROKE

GUIDELINES FOR TREATMENT

(Stroke Society of the Philippines Handbook, 6thed)


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OBJECTIVE

To present the guidelines for treatment of Acute Stroke and TransienIschemic Attack (TIA)

To discuss briefly the guidelines for Antiplatelet Therapy inNoncardioembolic Stroke or Transient Ischemic Attack (TIA)


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Outline

Stroke Scales (Glasgow Coma Scale, NIHSS)

Classification of Acute Stroke Based on Clinical Severity

Guidelines for Management of TIA, Mild -, Moderate -, and Severe

Early Specific Treatment of Ischemic Stroke

Management of Increased Intracranial Pressure

Guidelines for Antiplatelet Therapy in Noncardioembolic Stroke orTransient Ischemic Attack (TIA)


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GLASGOW COMA SCALE


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National Institute of HealthStroke Scale


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CLASSIFICATION OFACUTE STROKE

BASED ONCLINICAL SEVERITY


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TRANSIENT ISCHEMIC ATTACK (T

a transientepisode of neurological dysfunction caused by focal brain

or retinal ischemia, withoutevidence of acute infarction in which clinical symtypically last less than an hour


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MILD STROKE

Alert patients with any (or combination) of the ff:

Mild pure motor weakness of one side of the body

Pure sensory deficit

Slurred but intelligible speech

Vertigo with incoordination

Visual field defects alone

or NIHSS score: 0-5


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MODERATE STROKE

Awake patient with significant motor and/or sensory and/or languagand/or visual deficit

or

Disoriented, drowsy or light stupor with purposeful response to painstimuli

or

NIHSS score: 6-21


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SEVERE STROKE

Deep stupor or comatose patient with non-purposeful response, decor decerebrate posturing to painful stimuli

or

Comatose patient with no response to painful stimulior

NIHSS score: >22


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Recommended Place of Treatment

(TIA)OPD

Occurred >2 wks prior (work-upshould be done within 24-48hrs)

ASU w/in 48hrs

Crescendo TIAs (multiple & incsymptoms)

With known high-risk cardiac soembolism

Known hypercoagulable state orsymptomatic ICA stenosis

ABCD2score >3

High Risk

AF (valvular or non-valvular) Rheumatic MS Prosthetic heart valves Recent MI LV/LA thrombus Atrial myxoma Infective endocarditis Dilated cardiomyopathy Marantic endocarditis


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a risk assessment tool designed toimprove the prediction of short-termstroke risk after a transient ischemicattack (TIA)

to predict the risk of stroke within 2

days after a TIA, but also predictsstroke risk within 90 days

Higher ABCD2 scores are associatedwith greater risk of stroke during the2, 7, 30, and 90 days after a TIA


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Mild Stroke

ASU/ regular room

Moderate Stroke

ASU/ ICU

Severe Stroke

ICU

Recommended Place of Treatmen


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GUIDELINES

Management Priorities

Emergent Diagnostics

Early Specific Treatment

Delayed Management and Secondary Prevention


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GUIDELINES FOR THEMANAGEMENT OF

TRANSIENT ISCHEMIC ATTAC(TIA)


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Transient Ischemic Attack

Management Priorities Ascertain clinical dx of TIA

Exclude common TIA mimics

ID comorbidities

ABCs of resuscitation

Monitor the ff:

NVS, pupil size, BP, MAP, RR, temp, SO2

Perform stroke scales (NIHSS, GCS) and riskstratification using ABCD2scale

Treat BP if MAP >130

Avoid precipitous drop (not >15% of baselin

24 hrs

Do not use rapid-acting SL agents; when need

titratable IV or short-acting oral antihyperten

Ensure appropriate hydration

0.9% NaCl


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Emergent Diagnostics CBC

CBG or RBS

PT, aPTT ECG

Cranial MRI-DWI is preferred; may doNCCT scan if MRI is not available/possible



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Early Specific Treatment

Cardioembolism NOT suspected

ASA 160-325 mg/day as early aspossible & continue for 14 days

ASA 80mg + Clopidogrel 75mgmay be considered for short-termtreatment

Ensure neuroprotection*

Cardioembolism Suspected

IV heparin or SQ LMWH forindividuals at high risk of earlrecurrence (AF with thrombuor MI) or ASA 160-325mg/d

anticoagulation is not possiblecontraindicated)

If IE is suspected, give antibiDO NOT anticoagulate


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Give antiplatelets (ASA,clopidogrel, cilostazol, triflusal,dipyridamole + ASA)

Control/treat risk factors Carotid UTZ (extracranialstenosis)

TCD studies or CTA/MRA(intracranialstenosis)


Echocardiography and/or rcardiologist

NOACs > dose-adjusted w

ASA 160-325mg/day ifanticoagulation is contraind

ASA + Clopidogrel is reaso


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Screening for hypercoagulable states and drug/toxicology tests may beconsidered for young patients with TIA/stroke especially when no vrisk factors exist and no underlying cause is identified.

If vasculitis is suspected, may do ESR, ANA and lupus anticoagulan

TEE to rule out PFO in cryptogenic strokes


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MILD STROKE


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Mild Stroke

Management Priorities Ascertain clinical dx of stroke

Exclude common stroke mimics

ID comorbidities

ABCs of resuscitation Monitor the ff:


Perform and monitor stroke scales(NIHSS, GCS)

Provide O2support to maintain SO



24 hrs




0.9% NaCl


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CBG or RBS

PT, aPTT

ECG

Cranial NCCT scan or MRI-DWI as soon aspossible

If ICH is evident, compute for the hematomavolume

Mild Stroke


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Mild Stroke

Early Specific Treatment(requires neuroimaging confirmation)

ISCHEMIC

ASA 160-325mg/day as early as possibleand continue for 14 days

ASA 80mg + Clopidogrel 75mg mayconsidered for short-term treatment


Consider IV heparin or SQ LMWindividuals at high risk of early r(AF with thrombus, VHD, or M160-325mg/day (if anticoagulati

possible or is contraindicated)


If IE is suspected, give antibiotiNOT anticoagulate

Cardioembolism SuspectedCardioembolism NOT suspected

(Thrombotic, Lacunar)


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Mild Stroke

Early Specific Treatment(requires neuroimaging confirmation)

HEMORRHAGIC Early neurology and/or neurosurgery consult for all ICH cases

Monitor and maintain target SBP 140mmHg during the first week


Early rehabilitation once stable within 72hrs

Give AEDs for clinical seizures and proven subclinical or electrographic seizures Prophylactic AEDs and steroids are generallynot recommended.

Monitor/ correct for metabolic parameters and coagulation/ bleeding abnormalities

Follow recommendations for neurosurgical intervention


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Mild Stroke

Delayed Management and Secondary PreventionISCHEMIC



Give antiplatelets (ASA, clopidogrel,cilostazol, triflusal, dipyridamole, ER-dipyridamole + ASA)

Control/treat risk factors

Carotid UTZ (extracranialstenosis)

TCD studies or CTA/MRA (intracranialstenosis)


Echocardiography and/or refer cardiologist

NOACs > dose-adjusted warfari

ASA 160-325mg/day if anticoagcontraindicated

ASA + Clopidogrel is reasonabl


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Mild Stroke

Delayed Management and Secondary PreventionHEMORRHAGIC

Long-term strict BP control and monitoring

Contrast CT scan, 4-vessel cerebral angiogram, MRA or CTA if the is:


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MODERATE STROKE


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Moderate Stroke



ID comorbidities

ABCs of resuscitation Monitor the ff:


Perform and monitor stroke scales (NIHSS,GCS)




24 hrs



Recognize and treat for early S/Sincreased ICP


0.9% NaCl


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CBG or RBS

PT, aPTT

Serum Na+ and K+

ECG


If ICH is evident, compute for the hematoma volume

Moderate Stroke


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Moderate StrokeEarly Specific Treatment

(requires neuroimaging confirmation)

ISCHEMIC


Refer to neurologist for evaluation anddecision

w/in 3-4.5hrs of stroke onset:

IV thrombolysis (rt-PA)

w/in 6hrs:

Intra-arterial thrombolysis (in specialized

centers)

ASA 160-325mg/day 24 hrs aftetreatment and continue for 14 da


Early rehabilitation once stable whrs


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ISCHEMIC





w/in 6hrs:


centers)

If px is ineligible for thrombolyticor 24hrs post-rt-PA treatment:

IV heparin or SQ LMWH for indhigh risk of early recurrence; or

ASA 160-325mg/day if anticoagnot possible or is contraindicated


if IE is suspected, give antibioticsNOT anticoagulate

Early rehabilitation once stable wi


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HEMORRHAGIC Early neurology and/or neurosurgery consult for all ICH cases

Monitor and maintain target SBP 140mmHg during the first week


Early rehabilitation once stable within 72hrs

Give AEDs for clinical seizures and proven subclinical or electrographic seizures

Prophylactic AEDs and steroids are generallynot recommended.

Monitor/ correct for metabolic parameters and coagulation/ bleeding abnormalities

Follow recommendations for neurosurgical intervention


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Moderate Stroke

Delayed Management and Secondary PreventionISCHEMIC





Carotid UTZ (extracranialstenosis)



NOACs > dose-adjusted warfari ASA 160-325mg/day if anticoag

contraindicated



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Moderate Stroke

Delayed Management and Secondary PreventionHEMORRHAGIC




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SEVERE STROKE


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Severe Stroke



ID comorbidities

ABCs of resuscitation

Monitor the ff:


Perform and monitor stroke scales (NIHSS,GCS)




24 hrs



Recognize and treat for early S/Sincreased ICP


0.9% NaCl


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CBG or RBS

PT, aPTT

Serum Na+ and K+ ECG


If ICH is evident, compute for the hematoma volume

Severe Stroke


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Severe StrokeEarly Specific Treatment


ISCHEMIC





w/in 6hrs:


centers)

ASA 160-325mg/day 24 hrs aftetreatment and continue for 14 da


Early rehabilitation once stable whrs


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ISCHEMIC


May give ASA 160-325mg/day


Refer to a neurologist for cases ofposterior circulation strokes within 12 hrsof onset for evaluation and decisionregarding thrombolytic therapy

For cases of cerebellar infarct, reneurosurgeon as soon as possibl

Early supportive rehabilitation


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HEMORRHAGIC

Supportive treatment: Mannitol 20% 0.5-1g/kg BW q 4-6h for 3-7days


Give AEDs for clinical seizures and proven subclinical or electrographic seizures

Prophylactic AEDs and steroids are generallynot recommended.


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HEMORRHAGIC Neurosurgical consult if:

Px is not herniated

Location of bleed is lobar, putamen, pallidum, or cerebellum

Pxsfamily is willing to accept consequences of irreversible coma or persistent vegetative state

ICP monitoring is contemplated and salvage surgery is considered

Early supportive rehabilitation

GOAL IS REDUCTION OF MORTALITY


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Severe StrokeDelayed Management and Secondary Prevention

ISCHEMIC







NOACs > dose-adjusted warfari ASA 160-325mg/day if anticoag

contraindicated



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Severe StrokeDelayed Management and Secondary Prevention

HEMORRHAGIC




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EARLY SPECIFIC TREATMENT OISCHEMIC STROKE


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ANTITHROMBOTIC THERAPYIN ACUTE STROKE

Aspirin (ASA)

[Clopidogrel + ASA] vs ASA alone

ClopidogrelASA vs ASA alone

Cilostazol vs ASA

LMWH


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NEUROPROTECTION

The Five H Principle:

AVOID

Hypotension, Hypoxemia, Hyperglycemia, Hypoglycemia andHypertherm

during acute stroke in an effort to salvage the ischemic penum


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Neuroprotective Interventions

1. Avoid HYPOTENSION and allow permissive hypertension dthe first (7) days.

Mean Arterial Pressure (MAP) = 2 (DBP) + SBP3

Cerebral Perfusion Pressure (CPP) = MAP - ICP


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Check if Px has any condition that may increase BP and address acc

Treat if SBP >220 mmHg or DBP >120 mmHg, or MAP >130.

Defer E BP therapy if MAP is within 110-130, or SBP = 185-220mor DBP = 105-120mmHg, UNLESS:

Px is a candidate for thrombolytic therapy

Presence of AMI, CHF, aortic dissection, acute pulmonary edema, ARF, andhypertensive encephalopathy

Neuroprotective InterventionsBP Management in Acute Ischemic Stro


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The use of IV Nicardepine is reasonable, readily available, easy to adand titrate, has short duration of action, and does not significantly af

Although rare in acute ischemic stroke, arterial hypotension (a baselineSBP


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In acute ischemic stroke, autoregulation is paralyzedin the affected tissues with

passively following MAP. Rapid BP lowering further decrease in perfus

penumbra.

Hypertension is typically present in acute stroke, with spontaneous decline in the 7days with attainment of neurological stability. SBP dropped by 28% du

first day whether or not medications were given.

SBP and DBP drops of >20mmHg were associated with early neurological

worsening, high rates of poor outcome or death, and larger volumes of inf

Rationale for Permissive Hypertension


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Treat if SBP > 180 mmHg

Acute lowering of SBP to 140mmHg within 7 days is safe and imp

outcome in patients with small-moderate size ICH not requiring surgintervention

If ICP monitor is available, keep CPP >70mmHg

Neuroprotective InterventionsBP Management in Acute Hypertensive I


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Treat hypertension with modest reductions in BP to minimize vasospand delayed cerebral ischemia

Preoperatively, for unsecured aneurysms, the use of IV Nicardepine target SBP


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1. Avoid HYPOTENSION and allow permissive hypertension during the first (7) days.

2. Avoid HYPOXEMIA

Routine O2is not warranted for all stroke patients unless theres evidence of h

or desaturation (target SO2>94%)

Monitor oxygenation via pulse oximeter and/or determine ABG Provide ventilator support if the upper airway is threatened, sensorium is imp

ICP is increased.



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2. Avoid HYPOXEMIA

3. Avoid HYPERGLYCEMIA or HYPOGLYCEMIA

Hyperglycemia causes lactic acidosis, increases free radical production, worsens cerebral weakens blood vessels

Hypoglycemia can mimic a stroke

Achieve glucose targets of 140-180mg/dl if the FBS is >140mg/dl or RBS isconsistently >180mg/dl



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2. Avoid HYPOXEMIA


Use an established and standardized IV insulin protocol for pxs who present extreme or persistent hyperglycemia, are critically ill, or who have received thr

therapy for at least the first 24-48hrs of hospitalization SQ basal long-actin+ rapid-acting insulin

For pxs who are feeding, add rapid-acting prandial (meal) insulin

Avoid D5 IV fluids



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2. Avoid HYPOXEMIA


4. Avoid HYPERTHERMIA

Associated withpoor outcome metabolic demand, free radical production, enh

neurotransmitter release RR of 1-year mortality by 3.4 times

Treat fever with antipyretics and cooling blankets. Investigate for source of feverinfection)



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Neuroprotective and Neurorestorative Dru

Cerebrolysin

Citicoline

NeuroAID

The use of drugs with neurorestorative andneuroprotective properties in acute stroke remains as a

matter of preference of the attending physician.


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ANTICOAGULATION INACUTE CARDIOEMBOLIC STRO

Sources of Cardioembolic Stroke

Low or Uncertain Risk High Risk

MVP Mitral annular calcification Patent Foramen Ovale (PFO) Atrial Septal Aneurysm

Calcific aortic stenosis Mitral valve strands

AF (valvular or non-valvular) Rheumatic MS Prosthetic heart valves Recent MI

LV/LA thrombus Atrial myxoma IE Dilated cardiomyopathy Marantic endocarditis


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Features Suggestive of Cardioembolic Stroke

Sudden onset of maximal deficit (


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Features Suggestive of Cardioembolic Stroke

Onset of symptoms after a Valsalva-provoking activity (e.g., coughing, bending)

Infratentorial ischemic stroke (cerebellar, PCA, and multi-level infarcts, top-of-thsyndrome)

Hemorrhagic transformation and early recanalization of occluded intracranial ves

Neuroimaging finding of acute infarcts involving multiple vascular territories in t(predominantly carotid and MCA territories), or multiple levels of the posterior c


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Indications and Contraindications for Anticoagulation in Patients with

Cardioembolic Stroke

Probably Indicated Contraindicated

Intracardiac thrombus Mechanical prosthetic valve

Recent MI CHF Bridging measure for long-term

coagulation

Bleeding diathesis Non-petechial intracranial

hemorrhage Recent major surgery or trauma Infective endocarditis


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How to anticoagulate

Heparin 600-800 units per hour TIV via infusion pump. Heparin bolus IS NOT rec

Perform aPTT as often as necessary, every 4-6hrs after dose adjustments, to keeplevels at 1.5-2.5x the control

Infusion may be discontinued once oral anticoagulation with warfarin has reached

therapeutic levels or once antiplatelet medication is initiated for secondary preven


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The benefits of reducing early stroke recurrence should be weighed against the rihemorrhagic transformation

higher in patients with large infarction, severe strokes or neurologic deficits, uncontrolled hypertension


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MANAGEMENT OF

INCREASED INTRACRANIALPRESSURE


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MANAGEMENT OF INCREASED

Signs and Symptoms of Increased ICP

Deteriorating level of sensorium

Cushings triad: hypertension, bradycardia, irregular respiration

Anisocoria


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General

Control agitation and pain with short-acting medications, such as NSAIDs an

Treat fever aggressively. Avoid hyperthermia.

Control seizures if present.

Phenytoin 18-20mg/kg LD slow IV, then maintained at 3-5 mg/kg; or

Levetiracetam 500mg IV q12

Strict blood glucose control between 140-180mg/dl


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General

Maintain normal fluid and electrolyte balance

Avoid excessive free water or any hypotonic fluids such as D5W

Maintain normal volume status

Encourage hyperosmolar state with hypertonic saline and/or induce free water clwith mannitol or diuretics

Use stool softeners to prevent straining


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Specific

Elevate the head at 30-45 degrees to assist venous drainage.

Do CSF drainage in the setting of hydrocephalus.

Administer osmotic therapy:

Give Mannitol 20% IV infusion: 0.5-1.5g/kg q 3-6h Hypertonic saline is an option

Always maintain serum osmolality at 300-320mosmol/kg


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Specific

Hyperventilate only in impending herniation by adjusting tidal volume (targetlevels of 30-35mmHg)

Carefully intubate patients with respiratory failure defined as:

SO2< 90% by pulse oximeter

By ABG: PaO2 < 60 mmHg, and/ or PaCO2> 55mmHg

Consider surgical evacuation or decompressive hemicraniectomy if indicated

ICP catheter insertion


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GUIDELINES FORANTIPLATELET THERAPY INNONCARDIOEMBOLIC

STROKE OR TRANSIENTISCHEMIC ATTACK


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GUIDELINES FOR ANTIPLATELET THERAPY IN


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GUIDELINES FOR ANTIPLATELET THERAPY INNONCARDIOEMBOLIC STROKE OR TRANSIENT ISCHE

ATTACK

Although often considered for patients who have an ischemic strokewhile already on ASA, there is insufficient evidence to show that swian alternative antiplatelet agents or the use of antiplatelet combinatioreduces the risk for subsequent events.

It is recommended that patients who develop recurrent stroke while

antithrombotic therapy be re-evaluated for pathophysiology and risk


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A good history and physical examination of patients could not beoveremphasized.

Identification of stroke mimickers should be facilitated to rule outpossible diagnoses.

Comorbid conditions should be addressed adequately.

In our setting, there should be a conscious effort in the judicious usediagnostic examinations to maximize our resources in the managemestroke patients.


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Care of critically ill patients is a TEAM EFFORT.

Guidelines are guidelines. Management of patients should be individdepending on the patients clinical profile.

Talk to your patients and their relatives.

We are not GOD but we can be ANGELS.


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