Management of acute ischemic stroke

This talk covers the most important aspects of treatment of acute ischemic stroke, such as thrombolysis, use of antiplatelets, BP and sugar control and general supportive care.

1. MANAGEMENT OF ACUTE STROKE DR SUDHIR KUMAR MD DM SENIOR CONSULTANT NEUROLOGIST APOLLO HOSPITALS, HYDERABAD

2. AIMS OF ACUTE STROKE TREATEMNT Screen patients rapidly, identify those eligible for thrombolysis, as thrombolysis is time-bound Thrombolysis is the only approved treatment for acute ischemic stroke, Prevent infarct progression or recurrence, Optimum control of b lood pressure and sugars, Prevent aspiration pneumonia and DVT, Start physiotherapy early

3. INTRAVENOUS THROMBOLYSIS IV thrombolysis can be done for eligible patients within the first four and half hours after onset, Agent used: tissue plasminogen activator (tPA) Dose: 0.9 mg per kg body weight (maximum 90 mg) 10% of total dose given as IV bolus over 1 minute, remaining 90% given as infusion over 60 minutes Monitoring of BP, pulse and neurological status should be done for 24 hours in stroke unit/ICU

4. INCLUSION CRITERIA for IV tPA Duration less than 4.5 hours from symptom onset, Absence of bleed on CT/MRI brain scan, Symptoms are due to stroke (stroke mimics have been ruled out)

5. EXCLUSION CRITERIA FOR IV tPA Time of onset uncertain, or duration more than 4.5 hours after onset of symptoms, Presence of blood on brain scan, Symptoms have completely resolved (TIA) Very minor symptoms such as tingling or mild facial weakness (NIHSS score <4) Severe stroke (NIHSS score>24) Infarct occupying more than ½ of hemisphere or dense MCA sign SBP>180 mmHg or DBP>105 mmHg, despite treatment

6. WHO CAN THROMBOLYSE? Neurologist, Internal Medicine specialist or ER physicians can thrombolyse, In a recent study, door-to-needle time reduced from 54 minutes to 28 minutes, when ER physicians were permitted to thrombolyse (as compared to Neurologist/Internists) . Thrombolysis improves functional outcome and reduces morbidity at 3 and 6 months, Even though IV thrombolysis is effective within 4 and half hours, every effort should be made to administer it at the earliest.

7. STROKE TREATMENT TIMELINES Evaluation by ER doctor- 10 min, Stroke team Neurologist contacted- 15 min, Brain scan done- 25 min, Interpretation of scan/labs ready- 45 min, Start of treatment- 60 minutes from arrival (door-to-needle time)

8. ENDOVASCULAR INTERVENTIONS Patients eligible for IV tPA should receive IV tPA, even if endovascular treatments are being considered (Class 1, Level of evidence A) Patients should receive endovascular treatment with a stent retriever, if all the following criteria are met: Pre-stroke mRS score 0 or 1, Acute ischemic stroke receiving IV tPA within 4.5 hours as per the guidelines, Causative occlusion of ICA or proximal MCA (M1)

9. ENDOVASCULAR INTERVENTIONS (2) 4. Age 18 years or more, 5. NIHSS score 6 or more, 6. ASPECTS of 6 or more, 7. Treatment can be initiated within 6 hours of onset ( groin puncture)

10. ENDOVASCULAR INTERVENTIONS (3) Procedures should be done as early as possible to ensure maximum benefit, and definitely before 6 hours of stroke onset (Class 1, Level of evidence B) Benefits of endovascular therapy beyond six hours of stroke onset is uncertain In selected patients with anterior circulation occlusion, who have contraindications for IV tPA; endovascular therapy with stent retrievers within 6 hours of stroke onset is a reasonable alternative. (Class IIa , Level of evidence C)

11. ENDOVASCULAR INTERVENTIONS (4) Endovascular therapy with stent retrievers may be reasonable in patients with occlusion of MCA (M2 or M3 portions, ACA, vertebral, basilar or PCAs), if procedure can be started within 6 hours. ( IIb , Evidence C), May be reasonable in children below 18, in selected cases, Technical goal should be a TICI grade 2b/3 angiographic result to maximize benefits.

12. ANTIPLATELETS AND ANTICOAGULANTS All patients with ischemic stroke should receive aspirin or clopidogrel within 24-48 hours, Those who received tPA, should receive aspirin/clopidogrel after 24 hours, Urgent anticoagulation is not recommended with the aim of preventing recurrence or halting stroke progression or for improving outcomes. Anticoagulation can not be used as a substitute for thrombolysis in eligible patients. Vasodilators such as pentoxifylline are not recommended in acute stroke.

13. PIRACETAM IN ACUTE ISCHEMIC STROKE Piracetam at a dose of 4.8 grams/day for a period of 12 weeks was found to be effective in reducing post-stroke aphasia. (Clinical Neuropharmacology, 1994) Piracetam 2400 mg twice daily improves the cerebral blood flow in left transverse temporal gyrus, left triangular part of inferior frontal gyrus and left posterior superior temporal gyrus, based on a PET-based study. (Stroke, 2000) Piracetam was found to be useful in post-ischemic palatal myoclonus. (J Int Med Res, 1999)

14. CITICOLINE IN ACUTE ISCHEMIC STROKE Oral citicoline at a dose of 500-2000 mg per day, started within 24 hours, increases the probability of complete recovery at three months. (Stroke, 2002) 2000 mg per day was found to be the most effective dose. Citicoline provides maximum benefit to patients with less severe strokes (NIHSS<14), older people (>70 years) and those who have not been thrombolysed with rt-PA. (J Stroke Cerebrovasc Dis, 2014)

15. SUPPORTIVE CARE OF ACUTE STROKE PATIENTS Cardiac monitoring, Maintaining adequate oxygenation, Protection of airway, Treatment of hypertension, Treatment of fever, Treatment of hyperglycemia

16. CARDIAC MONITORING Cardiac monitoring should be done for 24 hours after acute stroke, Aim is to pick up atrial fibrillation and other cardiac arrhythmia Class I, Level of evidence B

17. BLOOD PRESSURE CONTROL Target BP in those thrombolysed (for first 24 hours) Target systolic BP<180 mmHg Target diastolic BP<105 mmHg Target BP in those who are not thrombolysed Systolic BP<220 mmHg Diastolic BP<120 mmHg

18. AIRWAY AND OXYGENATION Airway support and ventilatory assistance are required for those with decreased consciousness and those who have bulbar dysfunction, Supplemental oxygenation should be provided to maintain oxygen saturation >94% Class I, Level of evidence C

19. Hyperglycemia and Acute Stroke (1) Among patients admitted with stroke, 40-50% have diabetes mellitus ( Stroke, 2009 ) Additional 20% have hyperglycemia without any history of diabetes, termed as stress hyperglycemia, So, a total 0f 60-70% of patients with acute stroke have hyperglycemia at admission. Admission plasma glucose>110 mg% and HbA1C> 6.2% are good predictors of (undiagnosed) diabetes mellitus in patients with acute stroke, ( Age Ageing, 2004 )

20. Hyperglycemia and Acute Stroke (2) Patients with hyperglycemia and acute stroke have prolonged hospital stay and incur higher hospitalization costs ( Neurology 2002 ) Hyperglycemia at admission in patients with stroke results in poor functional outcome at 3 months ( Neurology,1999 ) Hyperglycemia independently increases the risk of death at 90 days, 1 year and 6 years after stroke (all p<0.01) ( Neurology 2002 )

21. American Stroke Association Guideline Maintain plasma glucose levels within 140 to 180 mg% in the first 24 hours, Close monitoring should be done to detect hypoglycemia, For patients being considered for IV thrombolysis, blood sugar should be within 50-500 mg% range. ( Stroke,2013 )

22. CARE IN STROKE UNIT/ICU (1) Stroke team, and stroke unit with rehabilitation is recommended, Early mobilization of less severely affected patients is recommended, Swallowing should be assessed before starting eating or drinking, Patients with suspected pneumonia or UTI should be treated with antibiotics,

23. CARE IN STROKE UNIT/ICU (2) Immobilized patients should be started on LMW heparin to prevent DVT, Intermittent compression devices should be used in those who cannot receive heparin, Concomitant medical illnesses should be treated, Temperature should be kept normal, and hyperthermia above 38 o should be treated with antipyretics.

24. MANAGEMENT OF ACUTE NEUROLOGICAL COMPLICATIONS (1) Raised ICP (due to large infarcts, hemorrhagic transformation)- mannitol, mechanical ventilation, decompressive surgery Malignant MCA infarction- decompressive hemicraniectomy Large cerebellar infarcts- posterior fossa decompression Acute hydrocephalus- external ventricular drain Better to have neurosurgical facilities while managing acute stroke

25. MANAGEMENT OF ACUTE NEUROLOGICAL COMPLICATIONS (2) Seizures- Seizures can occur in 2-33% of acute stroke patients Prophylactic anti-epileptic medications are not needed in all, Those who get seizures can be treated in a manner similar to other seizure patients (non-stroke setting)

26. SUMMARY IV thrombolysis is the only approved treatment for acute stroke, Aspirin should be administered as early as possible (24-48 hours ) Piracetam/Citicoline are effective and safe agents in several cases of acute stroke, Appropriate control of BP and sugars is needed Maintain adequate airway, oxygenation and temperature Prevent aspiration pneumonia and DVT Recognize and treat acute neurological complications

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