Management of Ischemic Stroke

Deals with common issues like management of hypertension and diabetes during stroke, as well as the role of surgical procedures.

1. Acute Ischemic Stroke Rahul Kumar Consultant Interventional Neurologist

2. Why do we need guidelines ? 2.4 per 1000 people per year 10,00,000 strokes per year in India 3000 strokes a day 2% of all admissions Crude prevalence rate is 220/100,000.

3. Estimated Pace of Neural Circuitry Loss in a typical, large, S upratentorial Ischemic S troke Neurons Lost Synapses Lost Myelinated Fibers Lost Accelrated Ageing Per Stroke 1.2 Billion 8.3 trillion 7140 Km 36 years Per Hour 120 million 830 billion 714 Km 3.6 years Per Minute 1.9 million 14 billion 12 Km 3.1 weeks Per Second 32,000 230 million 200 meters 8.7 hours Jeffery L Slaver, Stroke, 2006; 37, 263-66

4. Which Guidelines to follow ? AHA AAN RCOP Australian SA ESA IAN

5. Which Guidelines to follow ? AHA AAN RCOP Australian SA ESA IAN Guidelines are Guidelines Individualize Deviations Not applicable across the board Help us in optimizing outcomes Preventing therapeutic misadventures

6. The Continuum of Stroke Care

7. How do we approach a patient with suspected stroke ? Assesment Phase History, Clinical Evaluation Imaging Other Supportive Tests Treatment Phase Supportive Treatment Specific Treatment Treatment of Complications

8. How do we approach a patient with suspected stroke ? Assesment Phase History, Clinical Evaluation Sudden Onset Time of Onset Grading of Severity - Clinical

9. Stroke Scales Severity NIH stroke scale 0-42, 0 = normal valid, reproducible, assists in patient selection, facilitates communication Functional Scales m-Rankin 0-5, 0 = normal Barthel index 100, 100 = normal Glasgow outcome 0-5, 5= normal in NINDS t-PA stroke trial, 0 = normal

10. Stroke Scales NIH stroke scale 0-42 0-5 mild/minor in most patients 5-15 moderate 15-20 moderately severe > 20 very severe underestimates volume of infarct in non-dominant (R) hemispheric strokes

11. How do we approach a patient with suspected stroke ? Assesment Phase History, Clinical Evaluation Imaging

12. Non-contrast CT of the Head Initial imaging study of choice Readily available Very sensitive for blood in the acute phase blood - 50-85 Hounsfield Units bone- 120 (70-200) Hounsfield Units Not sensitive for acute ischemic stroke nearly 100% sensitive by 7 days Posterior fossa structures - bone artifact

13. Other Imaging Modalities MRI standard DWI/PWI Xenon CT Perfusion CT CT Angiography

14. How do we approach a patient with suspected stroke ? Assesment Phase History, Clinical Evaluation Imaging Other Supportive Tests

15. Diagnostic Testing Laboratory studies CBC, differential, platelets electrolyte profile, glucose (finger stick) INR, aPTT Troponin ECG CXR

16. Stroke Mimics – Exclusion Establishes Stroke Hypoglycemia Seizure Migraine with aura Hypertensive encephalopathy Wernicke ’ s encephalopathy CNS tumor Drug toxicity CNS abscess Psychogenic

17. Stroke – General Assessment Airway – Foreign Bodies, dentures, tongue Breathing and oxygenation – ABG, Pulse Ox Circulation- BP, Urine Output, Peripheral Circulation Glucose > 60 Temperature - Normothermia

18. How do we approach a patient with suspected stroke ? Assesment Phase History, Clinical Evaluation Imaging Other Supportive Tests Treatment Phase Supportive Treatment

19. Vascular Access Two peripheral IVs Use .9NS or .45 NS unless hypotensive Use .9NS if hypotensive Replace blood products as indicated

20. Treatment of Hypertension

21. Autoregulation The ability of the vasculature in the brain to maintain a constant blood flow across a wide range of blood pressures

22. Autoregulation of Cerebral Blood Flow

23. Hypertension Ischemic Stroke Treat judiciously if at all Treatment guidelines - not receiving rt -PA AHA: MAP > 130 or Sys BP > 220 NSA: 220/115

24. Hypertension - Ischemic Stroke Drugs - short acting, titrate Labetalol IV: 10-20 mg increments, double dose Q 20 min, max cumulative dose 300mg Enalapril Oral: 2.5 - 5.0 mg/day, max 40mg/day IV : 0.625-1.25 mg IV Q 6hrs, max 5.0 Q 6 hrs

25. For how long to allow Hypertension to Continue ? 1 Hr 3 Hr 6 Hr average slow fast

26. Hypertension: rt-PA Candidate Exclude for persistent BP > 185/110 Check BP q 15 min May not aggressively lower BP to meet entry criteria Use Labetolol or Nitropaste

27. Hypertension -Ischemic Stroke Nitroglycerine Paste: 1-2 inches to skin IV Drip: 5mcg/min, increase in increments of 5-10mcg every 3-5 min Nitroprusside IV Drip: 0.3 - 10 mcg/min/kg Continuos BP monitoring AVOID NIFEDIPINE

28. Hypotension More detrimental than hypertension Seek cause and treat aggressively CVP monitoring may be necessary Use .9 NS first to ensure adequate preload Then add vasopressors if needed

29. Treatment of Hyperglycemia

30. Glucose Worse outcome after stroke: diabetics acute hyperglycemia at time of infarct Mechanism uncertain increase in lactate in area of ischemia gene induction, increased number of spreading depolarizations Insulin is a neuroprotective

31. Target Values Intensive – 80 to 110 Desirable – 140 to 180 Not above 200 How to Achieve Oral agents Insulins

32. Sliding scale insulin Abandoned! Retroactive not proactive Variation in disease state Dangers of hypoglycemia

33. Initiating insulin: New to Insulin For most patients with type 2 diabetes (or being initiated to insulin therapy), total daily insulin dose can be estimated at 0.3 to 0.6 units/kg/day The dosing range represents varying degrees of insulin resistance: dose kg 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 50 5 10 15 20 25 30 35 40 45 50 60 6 12 18 24 30 36 42 48 54 60 70 7 14 21 25 35 42 43 56 63 70 80 8 16 24 32 40 48 56 64 72 80 90 9 18 27 36 45 54 63 72 81 90 100 10 20 30 40 50 60 70 80 90 100

34. Insulin drip Advantages Tightest control Good absorption Rapid adjustments Easy standardized Disadvantages Frequent monitoring (ICU/IMCU needed?) Nursing time! Catheter complications Problems when switching to SQ regimen Rapid Glucose shifts?

35. Temperature Fever worsens outcome: for every 1°C rise in temp, risk of poor outcome doubles (Reith, Lancet 1996) Greatest effect in the first 24 hours Brain temp is generally higher than core Treat aggressively with acetaminophen, ibuprofen, or both Search for underlying cause Hypothermia currently under investigation

36. How do we approach a patient with suspected stroke ? Assesment Phase History, Clinical Evaluation Imaging Other Supportive Tests Treatment Phase Supportive Treatment Specific Treatment

37. 37 Recanalization , anti Ischemic Treatment Recanalization IV rt -PA IA r- proUK (FDA?) Neuroprotective treatment Aspirin in first 48 hours Anticoagulant Hemodilution Therapeutic hypothermia Stroke unit Craniectomy

38. Aspirin (mg) Role of Clopidogrel , Dypiridamole Place for Combination therapy 38 EUSI ASA RCOP (London) Acute treatment 100-300 325 300 2 nd prevention 50-325 150-325 50-300

39. Empirical Aspirin !!!

40. PRE AND POST Interventional Therapy Pre Procedure, NIHSS - 18 Post Procedure, NIHSS - 0

41. How do we approach a patient with suspected stroke ? Assesment Phase History, Clinical Evaluation Imaging Other Supportive Tests Treatment Phase Supportive Treatment Specific Treatment Treatment of Complications

42. 43 Treatment of neurological complication Seizures Cerebral edema and increased intracranial pressure, Hemorrhagic transformation

43. Seizures Occur in 5% of acute strokes Usually generalized tonic- clonic Possible causes: severe strokes cortical involvement unstable tissue at risk spreading depolarizations hx of seizure disorder

44. Seizures Protect patient from injury during ictus Maintain airway Benzodiazepines: lorazepam (1-2 mg IV) diazepam (5-10 mg IV) Phenytoin : 15 mg/kg loading dose, at 25-50 mg/min infusion with cardiac monitor No need for prophylaxis

45. Cerebral edema and increased intracranial pressure Applicable only in large artery strokes and in some cerebellar strokes Elevated head of the bed 20- 30 degrees Avoid “ Jugular vein ” compression Avoid hypotonic solution Avoid hypoxia, consider intubation Hyperventilation keep pCO 2 30-35 mmHg

46. 47 Cerebral edema and increased intracranial pressure Consider osmotherapy 20% Mannitol 0.25-0.5 g / Kg IV in 20 mins 4-6 times / day or 10% Glycerol 250 ml IV in 30-60mins 4 time / day or 50% Glycerol 50 ml oral 4 time / day and / or Furosemide 1 mg / kg IV Avoid steroid Consider decompressive surgery

47. Hemicraniectomy not Performed

48. Hemicraniectomy performed within 4 hours of onset

49. Hemicraniectomy performed within 24 hours of onset

50. Conclusions Acute stroke is an emergency condition, is the same level as MI, serious trauma Emergency management is need rt -PA & Interventional therapies, are the major advances Appropriate general care are also need To improve the quality of care : Multidisciplinary/ network approach

51. Take Home Message… Manitain ABC, low threshold for intubation Hypertension better than Hypotension Normoglycemia No Role of Empirical Antiplatelets Use of Statins recommended Try to administer reperfusion if within window More widespread use of surgical and interventional procedures Treatment of Complications

52. Thank You.