Management of stroke

This slide deals with the basic description of the types of stroke and further discuss about the management in short and precise manner

1. Management of STROKE Kalkidan Gulilat , Sujin Kim ( MMC 2 nd yr) 1

2. Outline Objective Introduction and prevalence of stroke Types and Risk factors of stroke Primary and secondary prevention Management and Rehabilitation Summary References 2

3. Objective know the different types of stroke Identify the signs and symptoms of stroke Describe the pathophysiology of both types of stroke Describe the primary and secondary prevention methods Identify the acute management of stroke 3

4. Introduction – Stroke apoplexy , cerebrovascular accident (CVA) is a sudden interruption of the blood supply to the brain . a medical emergency 4

5. The Global burden of stroke Source: http :// www.world-stroke.org/advocacy/world-stroke-campaign - 2016 Every 53 sec some one will have a stroke Every 3.3 min someone will die of stroke 5

6. Source: World Health Statistics 2007 Trends in Global Deaths 2002-30 6

7. Stroke in Ethiopia http://www.cdc.gov/globalhealth/countries/ethiopia /  2016 Data 7

8. Time lost is brain lost!! 8

9. Types of stroke 85% 15% 9

10. Embolic - cardiogenic sources such as atrial fibrillation Thrombotic - associated with atherosclerotic plaque Ischemic Stroke 10

11. Ischemic stroke symptoms 11

12. ‘‘mini-strokes’’ symptoms resolve completely (<24hr ) and the person returns to normal Transient Ischemic Attack (TIA) 12

13. Risk Factors for IS Oral contraceptives, HRT 13

14. Pathophysiology of IS 14

15. Hemorrhagic Stroke weakened regions of blood vessels rupture as a result of increased pressure HTN, cocaine,Amphetamine 15

16. Risk Factor of HS Brain Aneurism Arteriovenous malformation 16

17. Type of Hemmorhagic stroke 17

18. SSx of HS depressed level of consciousness, higher initial blood pressure, or worsening of symptoms after onset favor Hs “Worst headache of my life” 18

19. Remember determine cause of stroke before you start treatment emergency head CT scan No reliable clinical findings separate ischemia from hemorrhage 19

20. Management of a Stroke 20

21. General Picture of Tx 21

22. Primary and secondary prevention A- antiplatelet and anti coagulants B- blood pressure lowering medication C- cholesterol lowering, cessation of smoking D- diet E- exercise 22

23. Asprin Antiplatelet agent, irreversible COX inhibitor Prevent adhesion and aggregation of platelets dose of 81 mg enteric-coated aspirin is usually started 23

24. Platelet aggregation inhibitors Abiciximab Clopidogrel , Ticlopidine Dipyridamole 24

25. Warfarin Oral anticoagulant Slow onset Narrow therapeutic index, teratogenic Drug- drug interaction Inducers - phenytoin , rifampin , barbiturates Inhibitors – amiodarone,SSRI , cimetidine 25

26. Lipid lowering drugs ↓LDL Atorvastatin , Cholestyramine , Ezetimibe 26

27. Antihypertensive dugs Diuretics- thiazide ACE inhibitors – Enalapril CCB, beta blockers 27

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29. Acute management Harrison 19 th ed. 2015 pg. 2560 29

30. Treatment fall into 6 categories ( 1 ) Medical support (2 ) I ntravenous thrombolysis (3 ) E ndovascular techniques (4 ) A ntithrombotic treatment (5 ) N europrotection ( 6 ) Stroke centers and rehabilitation Acute management for IS 30

31. (1) M edical support ABC IV fluid Cardiac monitoring & treat arrhythmia Antipyretics 31

32. Should be normoglycemia (90-140 mg/dL) : Treat hypoglycemia(D50) & hyperglycemia(insuline) Candidates for IV fibrinolytic treatment Plus BP >185 /110 mmHg First, labetalol, nitroglycerin paste, or IV nicardipine 32

33. (2)Intravenous thrombolysis Restore blood flow to ischemic regions of the brain “ < 3H ” : prevent neurologic deficits tPA – the major tx of IS 33

34. Exclusion Criteria for tPA Use 34

35. (3) Endovascular techniques Occlusions of large arteries(MCA, ICA, BA) involve a large clot volume failure to open with IV tPA alone. thrombolytics via an intra-arterial route concentration of drug at the clot site systemic bleeding complications 35

36. (4 ) Antithrombotic treatment Asprin Only antiplatelet agent effective for the acute treatment of IS Use within 48 h of stroke onset : recurrence risk and mortality Rivaroxaban Selective inhibitor of factor Xa “bridging anticoagulation” Abiciximab, Ancrod (clinical trials) 36

37. (5 ) N europrotection NMDA receptor antagonist Dextrorphan GABA agonist Clomethiazole Free radical scavenger tirilazad Hypothermia, calcium channel blockers 37

38. Treatment of Hemorrhagic stroke Supportive therapy (no direct therapy) 38

39. Stablize vital signs Intubation and hyperventilation Stop any medication that could increase bleeding ( e.g. warfarin, aspirin). Evacuate the hematoma Measure and control the pressure within the brain 39

40. Cont… ICP osmotic diuretics – mannitol Loop diuretics – furosumide Anti hypertensive : Beta blocker Vitamin K, Fresh frozen plasma Acetaminophen : to reduce fever and headache Antiemetic agents : Promethazine Anti acids : for stress ulcers 40

41. Rehabilitation Mobility Activity of daily living Communication Swallowing Focuses on improving Shoulder pain Spasticity 41

42. Medical Interventions Skeletal muscle relaxants Botulinum Toxin – regional nerve block Diazepam, Baclofen , Dantrolene – systemic Anti depressant 42

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44. Tx of Stroke in Ethiopia Group 5- VAP VCs 44 ABC, non contrast and contrast CT then For IS: No rtPA (But it is on the Ethiopian Treatment Guideline) Asprin (80mg or 300 mg) Heparin (first loading dose 10,000 IU and then maintenance 5,000 IU) Warfarin For HS: Treat the HTN No surgery unless the hemorrhage is massive – blood enter in to the ventricles For SAH = Nimodipine injection 1 mg/5ml Source: Standard Treatment Guideline For General Hospitals, 2010 MCM physicians 44

45. Summary There are two types of stroke: Ischemic and Hemorragic . The most common cause of ischemic stroke (IS) is cerebral infraction caused by thrombi or emboli. hemorrhagic stroke (HS) is hypertension. The treatment goal is to restore cerebral perfusion (IS) and to decrease the hypertension (HS) The primary and secondary preventions aimed at decreasing the risk factors. 45

46. Reference Harrisons principles of internal medicine, 19th edition, 2015 Applied Therapeutics: The Clinical Use of Drugs, 9 th edition Standard Treatment Guideline For General Hospitals, 2010 Pharmacology : Examination & Board Review, 10 th edition Lippincott illustrative Review of pharmacology; 6 th ed., 2015 http://emedicine.medscape.com / http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2585721/1/ http:// www.medicaldaily.com/birthcontrolpillsincreaseriskischemicstrokeonlycertainwomenstudy353634 http://www.world-stroke.org/advocacy/world-stroke-campaign 46

47. THANK YOU! 47