Management of stroke

An overview on the management of acute stroke with emphasis on the 2013 guidelines of the American stroke association/ American heart association .

1. MANAGEMENT OF STROKE DR MALLUM C.B. NEUROLOGY UNIT DEPT OF INTERNAL MEDICINE JUTH

2. OUTLINE DEFINITIONS TYPES OF STROKE EVALUATION OF STROKE INVESTIGATIONS POOR PROGNOSTIC FACTORS IN STROKE DEFINITION OF LEVELS OF EVIDENCE/RECOMMENDATIONS MEDICAL MANAGEMENT PREVENTION AND MANAGEMENT OF COMPLICATIONS SURGICAL MANAGEMENT

3. DEFINITION Stroke(CVA) is defined by the World Health Organization as a clinical syndrome consisting of ‘rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 h or leading to death with no apparent cause other than that of vascular origin’. CVD - parent term = also includes Cerebral arteriosclerosis; cerebral angioma ; Cerebral artero -venous malformation ; Subdural hematoma

4. TRANSIENT ISCHEMIC ATTACK(TIA) Transient ischemic attack is temporary focal neurological deficit of sudden onset caused by ischemia of the brain, retina lasting less than 24 hours followed by complete recovery . New definition: No objective evidence of acute infarction in the affected region of brain or retina; < I hour Therefore, CT/MRI necessary to increase diagnostic accuracy.

5. CLASSIFICATION OF STROKE Stroke Primary Hemorrhagic (20% of Strokes) Primary Ischemic (80% of Strokes) Thrombotic 50% Embolic 30% Intracerebral Hemorrhage 15% Subarachnoid Hemorrhage 5% 5

6. STROKE Which is an Ischaemic Stroke?

7. Causes Destruction of brain cells and tissue

8. Types of Stroke 85% Ischemic 15 % hemorrhagic

9. ISCHEMIC STROKE PATHOPHYSIOLOGY The First Few Hours Penumbra Core Clot in Artery “TIME IS BRAIN: SAVE THE PENUMBRA” Penumbra is zone of reversible ischemia around core of irreversible infarction—salvageable in first few hours after ischemic stroke onset Penumbra damaged by: Hypoperfusion Hyperglycemia Fever Seizure

10. Cerebral Arterial territory Anterior cerebral Middle cerebral Posterior cerebral Anterior choroidal

11. Cerebral BloodFlow

12. EVALUATION OF STROKE 1.    Determine if symptoms are due to stroke 2.    Localize site of brain lesion 3.    Establish the type of stroke 4.    Ascertain the likely cause The clinical assessment (history, general examination, and neurological examination) remains the cornerstone of the evaluation. The use of a stroke rating scale, preferably the NIHSS , is recommended (Class I; Level of Evidence B ). It has been recommended that patients with acute stroke <7 days or progressive stroke should be admitted

13. Stroke - questions Is it a stroke ? What type of stroke ? Why did it happen ? How does it affect the patient ? What is the prognosis ?

14. 14 The symptoms of a stroke are dependant on what portion of the brain is damage. http://www.pdrhealth.com/patient_education/images/BHG01NE13F01.GIF

15. 2/14/2014 15 Pathological: WHO Criteria C.I C.H L.O.C. -ve +ve Headache - ve +ve Vomiting - ve +ve T.I.A. +ve - ve Gradual onset +ve -ve Activity -ve + ve HBP mild /-ve mod/severe Bldy csf -ve + ve

16. EMERGENCY INVESTIGATIONS To establish the diagnosis of stroke to determine the underlying cause of the event.

17. Immediate Diagnostic Studies: Evaluation of a Patient With Suspected Acute Ischemic Stroke Stroke 2007;38;1655-1711;

18. INVESTIGATIONS full blood count, serum electrolytes, renal function tests, cardiac enzymes, and coagulation studies Blood sugar is mandatory to exclude hypoglycemia or diagnose diabetes mellitus Full blood count to detect Polycythaemia,ESR for endocarditis, clotting studies for Hypercoagulable States An electrocardiogram (ECG) : arrhythmias and myocardial infarction. Baseline ECG is recommended in all patients with stroke(AHA/ASA Guidelines) Echocardiography : valve disease and intra-cardiac clot

19. NEUROIMAGING Brain CT scan: CT is sensitive to the intracranial blood and is readily available. Normal early CT therefore rules out haemorrhagic stroke. CT Scan changes in ischemic stroke may take several days to develop. MRI: MRI is better at detecting posterior fossa lesions especially in posterior circulation stroke such as Pons or cerebellum It is also recommended that all patients with transient neurologic symptoms have a neuroimaging within 24 hours or as soon as possible.(Class 1,LOE B)

20. 3 types of stroke

21. POOR PROGNOSTIC FACTORS IN STROKE Accompanying fever Hypotension and severe hypertension Low oxygen saturation Hyperglycaemia and hypoglycemia Total anterior circulation stroke (55% dead) Pontine Haemorrhage Low GCS score heart failure severity of hemiparesis

22. Total Ant. Cir. Syndrome ALL OF THESE:- Higher Dysfunction Dysphasia Visuospatial Homonymous Hemianopia Motor / Sensory Deficit >2/3 Face / Arm / Leg

23. COMMON PITFALLS IN MANAGEMENT OF STROKE Aggressive early treatment of blood pressure in stroke. Misdiagnosis of haemorrhagic stroke as hypertensive encephalopathy . Failure of adequate hydration of patients Failure to diagnose and treat hypo/hyperglycemia Inability to effective diagnose and manage complications of stroke

24. Definition of Classes Used in AHA/ASA Recommendations Class I Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective. Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa The weight of evidence or opinion is in favor of the procedure or treatment. Class IIb Usefulness/efficacy is less well established by evidence or opinion. Class III Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful/effective and in some cases may be harmful.

25. Definition of L evels of Evidence Used in AHA/ASA Recommendations Therapeutic recommendations Level of Evidence A Data derived from multiple randomized clinical trials or meta-analyses Level of Evidence B Data derived from a single randomized trial or nonrandomized studies Level of Evidence C Consensus opinion of experts, case studies, or standard of care Diagnostic recommendations Level of Evidence A Data derived from multiple prospective cohort studies using a reference standard applied by a masked evaluator Level of Evidence B Data derived from a single grade A study or 1 or more case-control studies, or studies using a reference standard applied by an unmasked evaluator Level of Evidence C Consensus opinion of experts

26. Table 1 :PHASES OF CONTEMPORARY MANAGEMENT OF STROKE Phases Period from onset Activities Prefered location 1Acute (emergency) care : hyperacute / acute 1 st -7 th day a)Assessment b)Early supportive care Hospital 2 Early sub-acute(supportive) care 2 nd -4 th week a)prevention and treatment of complications Hospital 3 Late sub-acute( maintanance ) care 2 nd -6 th month a)Rehabilitation b)Psychological support c)Prevent recurrence Hospital/Community 4.Long-term (chronic) care 7 th month onwards a)Rehabilitation b)Psychological support c)Social support d)Prevent recurrence Community 2/13/2014 31

27. MEDICAL MANAGEMENT

28. PREVENTION AND MANAGEMENT OF COMPLICATIONS Management of complications improves both short-term and long-term prognosis. Complications of stroke can be divided into General medical and Neurological complications. They can also be divided into Acute(<7 days) or subacute (>7days) based on time of occurrence.

29. SURGICAL MANAGEMENT For Ischemic stroke: A) endovascular interventions: angioplasty and stenting, mechanical clot disruption,clot extraction B)carotid endartectomy C) EC/IC bypass surgery For ICH: Surgical evacuation of haematoma For Subarachnoid haemorrhage: Clipping and coiling of aneurysm Surgical decompression of cerebellar haematoma Decompressive craniectomy for cerebral oedema Ventricular drainage: pts with intra ventricular haemorrhage and acute hydrocephalus .

30. EARLY SUPPORTIVE CARE 25 %of patients may have neurological worsening during first 24-48 hours . The use of stroke unit is recommended to improve general management. Nurse in slight head-up tilt to improve venous drainage from the head region . continuous monitoring of neurological deficit for deterioration, including the level of consciousness, which may herald impending herniation .

31. EARLY SUPPORTIVE CARE Continuous cardiac monitoring, if indicated, particularly if risk factors for coronary heart disease are present. Do not feed orally if patient is unconscious or drowsy. Swallowing test should be done in conscious patients before oral feeding and feed in the semi-recumbent position (450) – ensure correct consistency of food . Early mobilization of less severely affected patients Early physiotherapy should be initiated

32. AIRWAY AND VENTILATION Airway – Foreign Bodies, dentures, tongue Patients who exhibit a decreasing level of consciousness or signs of brain stem dysfunction are candidates for elective intubation . Indications for intubation hypoxia (pO2 <60 mm Hg or PCO2 >50 mm Hg) - risk of aspiration with or without impairment of arterial oxygenation elective tracheostomy should be performed after 2 weeks for prolonged coma or pulmonary complications

33. SUPPLEMENTAL OXYGEN A dequate tissue oxygenation is important to prevent further brain injury Current American Stroke Association recommendations call for supplemental oxygen to be given as needed to maintain an oxygen saturation of more than 95% by pulse Oximetry .

34. VOLUME STATUS Hypovolaemia has been associated with worse outcome and increased mortality in acute ischemic stroke. Isotonic saline, i.e. "normal" or 0.9%, should be used for volume repletion and maintenance, typically 3 litres per day is given. Do not give hypotonic solution, eg 5% Dextrose in water, as it may worsen cerebral oedema .

35. TEMPERATURE FEVER in the setting of acute stroke is associated with poor outcome possibly due to 1. increased metabolic demands 2.enhanced release of neurotransmitters 3.increased free radical production Lowering acutely elevated body temperature might improve the prognosis in stroke pateints .Antipyretic agents like acetaminophen and coolIng devices might be used . Relevant antibiotics might also be used.

36. 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

37. THROMBOLYSIS Thrombolysis within 1st 4.5 hrs (3-15% pts ) rtPA , alteplase ; streptokinase. Door to needle < 1 hr . Patient - Normal CT scan - BP <180/100 mmHg. - No bleeding tendency Dose - 0.9mg /Kg. (max 90mg) - 10% bolus, Rest 60 min by infusion Risk - ICH in 6% of patients - Reduced morbidity by 30%

38. BLOOD PRESSURE MANAGEMENT Reduction of BP in acute stroke phase is controversial BP Should be kept within higher normal limits since low BP could precipitate perfusion failure When treatment is indicated, cautious lowering of blood pressure by approximately 15 percent during the first 24 hours after stroke onset is suggested Systolic blood pressure > 185 and diastolic > 110 is a contraindication for thrombolysis

39. BLOOD PRESSURE MANAGEMENT

40. BLOOD PRESSURE MANAGEMENT

41. BLOOD PRESSURE MANAGMENT Some authorities believe BP should not be actively lowered in the 1 st 10 days after stroke unless MAP > 145 (SBP > 220; DBP>120) Indications for lowering BP: -dissecting aortic aneurysm -Myocardial Ischemia or acute myocardial infarction -Acute pulmonary o edema . -Rapid decline in renal function . Aim: MAP = 130; DBP = 105; (185/105)

42. BLOOD PRESSURE MANAGEMENT In patients with markedly elevated blood pressure who do not receive fibrinolysis, a reasonable goal is to lower blood pressure by 15% during the first 24 hours after onset of stroke. The level of blood pressure that would mandate such treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is >220 mm Hg or the diastolic blood pressure is >120 mm Hg (Class I; Level of Evidence C).

43. BLOOD PRESSURE MANAGMENT Evidence from one clinical trial indicates that initiation of antihypertensive therapy within 24 hours of stroke is relatively safe. Restarting antihypertensive medications is reasonable after the first 24 hours for patients who have preexisting hypertension and are neurologically stable unless a specific contraindication to restarting treatment is known (Class IIa ; Level of Evidence B).

44. BLOOD PRESSURE MANAGEMENT No data are available to guide selection of medications for the lowering of blood pressure in the setting of acute ischemic stroke If systolic BP >180–230 mm Hg or diastolic BP >105–120 mm Hg: -Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; or - Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 minutes , maximum 15 mg/h If BP not controlled or diastolic BP >140 mm Hg, consider IV sodium nitroprusside use oral agents (captopril, calcium channel blockers)

45. BLOOD PRESSURE MANAGEMENT • Systolic > 220  OR Diastolic 121 to 140:  treat with goal of  a 10% to 15% reduction in blood pressure using: 1.    Labetalol 10 to 20 mg intravenously over 1 to 2 minutes (may repeat or double every 10 minutes; max dose is 300 mg)  or 2.    Nicardipine infusion, 5mg/hour, titrate up by 0.25 mg/hour at 5- to 15-minute intervals, maximum dose 15 mg/hour. When desired blood pressure is attained, reduce to 3 mg/hour 

46. GUIDELINES FOR BP MGT IN HAEMORRHAGIC STROKE 1. Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence. Current suggested recommendations for target BP in various situations are available and may be considered (Class IIb ; Level of Evidence: C). (Unchanged from the previous guideline ) 2 .    In patients presenting with a systolic BP of 150 to 220 mm Hg, acute lowering of systolic BP to 140 mm Hg is probably safe (Class IIa ; Level of Evidence: B).

47. GLYCAEMIC CONTROL Hyperglycemia may augment brain injury by several mechanisms including increased tissue acidosis from anaerobic metabolism free radical generation increased blood brain barrier permeability . Aggressive Glycaemic control utilizing a continuous insulin, potassium, and glucose infusion(GKI) is feasible . For patients with blood glucose >200 mg/dl, 6 units of insulin hrly can be given until blood sugar is <120 mg/ dl. GKI infusion may need to be continued in comatose patients or those unable to swallow

48. GLYCAEMIC CONTROL HYPOGLYCEMIA - Hypoglycemia can cause focal neurologic deficits mimicking stroke, and severe hypoglycemia alone can cause neuronal injury Check the blood sugar and rapidly correct low serum glucose Hypoglycemia (blood glucose <60 mg/ dL ) should be treated in patients with acute ischemic stroke ( Class I ; Level of Evidence C). The goal is to achieve normoglycemia .

49. GLYCAEMIC CONTROL Evidence indicates that persistent in-hospital hyperglycemia during the first 24 hours after stroke is associated with worse outcomes than normoglycemia , and thus, it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/ dL and to closely monitor to prevent hypoglycemia in patients with acute ischemic stroke (Class IIa ; Level of Evidence C ).

50. ANTI COAGULANTS Anticoagulation in acute ischemic stroke is not recommended for treatment of stroke. If hemiplegia is dense, commence subcutaneous Heparin 5,000 units 12 hourly(or 8hrly) low dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of DVT in patients with intracerebral haemorrhage after 4 days from onset (latest AHA/ASA guidelines)

51. ANTIPLATELET AGENTS Aspirin –within 48hrs – reduce risk of mortality/ disability in ischemic stroke Other antiplatelets : Abciximab - II B / III A inhibitor, Cilostazol - phosphodieterase (PDE ) type 3 inhibitor, Dipyridamole , Antiplatelets contraindicated in haemorrhagic stroke

52. ANTIPLATELETS

53. Volume Expansion, Vasodilators, and Induced Hypertension The administration of high-dose albumin, Hemodilution by volume expansion, and administration of vasodilatory agents , is not recommended for treatment of ischemic stroke.

54. NEUROPROTECTIVE AGENTS Protect Neurones from adverse milleu created by the biochemical changes triggered by ischaemia : attenuate neuronal injury Examples are free radical scavengers – Vit C ; E encephabol ( piritinol ) At present, no pharmacological agents with putative neuroprotective actions have demonstrated efficacy in improving outcomes after ischemic stroke, and therefore, other neuroprotective agents are not recommended (Class III; Level of Evidence A).

55. NEUROPROTECTIVE AGENTS In addition to their low-density lipoprotein cholesterol–lowering effects , statins, or HMG-CoA reductase inhibitors, exert acute neuroprotective properties, including beneficial effects on endothelial function, cerebral blood flow, and inflammation. Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable (Class IIa;Level of Evidence B).

56. MEDICAL COMPLICATIONS OF STROKE Medical complications of stroke have been reported to occur in as high as 85% of patients with stroke (Langhorne et al, 2000 ). Medical complications account for at least 50% of mortality after the first week of stroke. The most commonly encountered complications are those related to immobility and infection . However, the most important causes of mortality in the early period following a stroke are cardiac (arrhythmias, myocardial infarction), infections (pneumonia, urosepsis ), and venous thrombo -embolism (pulmonary embolus)

57. Medical Complications in Hospitalized Patients With Stroke Complications of Immobilit y Deep vein thrombosis/pulmonary embolism Falls Pressure sores or ulceration Infections Chest infection- aspiration pneumonia Urinary tract infection Other infections Malnutrition Dysphagia Dehydration

58. Medical Complications in Hospitalized Patients With Stroke Pain Shoulder pain (subluxation in the paretic limb) Miscellaneous pain (headache, musculoskeletal ) Central post-stroke pain Neuropsychiatric Disturbance s Depression, anxiety ,Emotional incontinence Acute confusional states (delirium) Miscellaneous Cardiac complications (arrhythmia, myocardial ischemia) Gastrointestinal bleed Constipation Arthritis Sleep apnea Nutritional deficiencies

59. Deep Venous Thrombosis and Pulmonary Embolism The highest incidence occurs between the second and seventh day poststroke .(continuum) Estimates of early deaths attributable to PE range from 13% to 25 % and occur most frequently between the second and fourth week. Measures to prevent DVT should be routine for all patients with ischemic stroke admitted to the hospital.

60. DVT PROPHYLAXIS Tight fitting knee-high or thigh-high antiembolic stockings reduce venous stasis in the leg. Pneumatic compression devices can be applied to the lower extremities of nonambulatory patients. The use of low-intensity anticoagulation for DVT prophylaxis is recommended for all immobilized patients with stroke. ( Adams et al, 2007 ). In patients with primary intracerebral hemorrhage, initiation of anticoagulation for DVT prophylaxis is often delayed for 3 to 4 days.

61. DVT PROPHYLAXIS Early mobilization Mechanical compressive devices Antiembolic stockings Sequential pneumatic compression devices Subcutaneous unfractionated heparin Low-molecular-weight heparins patients with embolic infarction should not be treated with heparin or with any form of anticoagulant in the first 30 days.

62. 2013 AHA/ASA GUIDELINES ON DVT PROPHYLAXIS The PREVAIL showed superiority of LMWH (Low Molecular weight Heparin)over UFH (Unfractionated Heparin) Early administration of Heparin for the prevention of early recurrent stroke,for improving outcome after ischemic stroke, in patients with severe stenosis of internal carotid artery is not recommended

63. Malnutrition and aspiration Malnutrition and aspiration : - A preserved gag reflex may not indicate safety with swallowing. -Swallowing evaluation should be performed in all patients with dysarthria, aphasia, or facial, buccal , or lingual weakness. -Inability to swallow safely should precipitate early placement of a naso -gastric tube in order to assure gastrointestinal access for nutrition and medications.

64. INFECTIONS Urinary tract infection: this is common as a result of catheterization. Frequent urine culture and antibiotic treatment is required. To avoid pseudomonas infection, acidify urine by giving patient 2.4 g of vitamin C daily. Some specialists favour the use of parenteral Vitamin C for this purpose If possible the placement of indwelling bladder catheters should be avoided because of associated risk of UTI

65. 2/13/2014 70 TABLE 2: ACUTE AND SUB-ACUTE COMPLICATIONS OF STROKE Neurological Systemic ACUTE (<7 days) 1.Cerebral oedema 2.Increased ICP 3.Hydrocephalous 4.Haemorrhagic transformation 5.Seizures 6.Transtentorial herniation 1.Hypoxia 2.Hypertension 3.Hyperglycemia 4.Aspiration 5.Cardiac arrythmias 6.Inappropriate ADH secretion SUB-ACUTE (>7 DAYS) 1.Seizures 2. Depression 1.D.V.T & Pulmonary embolism 2.Bronchopneumonia 3.Urinary tract infections 4.Septicaemia 5.Decubitus ulcers 6.Joint stiffness

66. ACUTE NEUROLOGIC COMPLICATIONS OF STROKE This is the most common cause of deterioration in neurologic status in patients hospitalized for stroke. The most common neurologic complications Cerebral edema -Mass effect and herniation - Hemorrhagic transformation - Seizures -Progressing ischemia (33%) - Recurrent stroke(11%) (Weimar et al, 2002).

67. TREATMENT OF RAISED ICP AND CEREBRAL OEDEMA Usually occurs between 3-5 days of stroke Clinical features include deteriorating levels of consciousness, ipsilateral pupillary enlargement,worsening neurological status Patients may also have evidence of cushing’s reflex – elevated BP with bradycardia . Patients with intracerebral haemorrhage and large hemispheric infarcts are prone to raised intracranial pressure. Brain CT scan may show features of oedema or hydrocephalus(dilatation of ventricles)

68. TREATMENT OF RAISED ICP AND CEREBRAL OEDEMA Elevation of head of the bed to 30 degrees Pain relief and sedation Normothermia Hyperventilation Administration of osmotic agents like mannitol , hypertonic saline, glycerol, Use of barbiturates Surgical treatment like decompressive craniectomy and placement of a ventricular drain in cases of hydrocephalus

69. TREATMENT OF RAISED ICP AND CEREBRAL OEDEMA

70. Hemorrhagic transformation occurs in about 40%. Occurs in first 2 weeks. 10% of patients worsen. Increased risk with antithrombotics , anticoagulants, and thrombolytic therapy. Size (>1/3rd) of the vascular territory and elderly are more prone for hemorrhagic transformation. Managed conservatively with short-term discontinuation of antithrombotic agents and careful control of arterial blood pressure.

71. 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

72. SURGICAL TREATMENT Surgical removal of hemorrhage with cerebellar decompression should be performed for patients with cerebellar hemorrhages greater than 3 cm in diameter who are deteriorating, or who have brainstem compression and/or hydrocephalus due to ventricular obstruction For patients with supratentorial ICH , current guidelines suggest consideration of standard craniotomy only for those who have lobar clots >30 mL within 1 cm of the surface. Mortality at 30 days in general compared with conservative management is not different.

73. MANAGEMENT OF SAH Bed rest Analgesic Blood pressure control TRIPLE – H therapy(hypervolemia , induced hypertension, hemodilution ) Oral nimodipine 60mg q6hx21 days Angiography for localization of bleeding If aneurysm Immediate surgical clipping for Grade 1-3 patient without contraindication Grade 4-5 with intracerebral clot and deterioratio

74. Secondary prevention of stroke Management of hypertension (goal <140/85 mm Hg ) Diabetes control (goal<126 mg/ dL ) Lipid management: Statins (goal cholesterol<200 mg/ dL , LDL<100 mg/ dL ) Anticoagulants: Warfarin (target INR 2 to 3); esp. recommended in patients with cardioembolic stroke Appropriate life style modification (cessation of smoking, exercise, diet etc ) Antiplatelet agents:Antiplatelet agents such as aspirin(300mg) reduce the risk of recurence of all ischaemic stroke & for patients with TIAs. Aspirin is not useful for preventing a first stroke in persons at low risk (Class III; Level of Evidence A).