Management of stroke

MANAGEMENT OF STROKE

DR W.D.A.Patirana

MBBS.MD

WHO definition

Clinical syndrome typified by rapidly

deveoloping signs of local or global

disturbance of cerebral functions, lasting

more than 24hrs or leading to death with

no apparent causes other than of vascular

origin

Introduction

• Stoke: sudden neurological deficit of presumed vascular origin

• It’s a syndrome rather than a single disease• Acute stroke is now a treatable condition that

deserves specialised attention• A senior clinician should review all pts with

presumed stroke (class B recommendation)• Drug Rx and specialised care both influence

survival and recovary

Assesing the patient

• Pts should be assessed at hospital immediately after stroke

• Hyperacute treatments such as thrombolysis must be administered within 3-6 hrs

• Stroke is a clinical diagnosis, but imaging is required to differentiate between ischemic and primary intracerebral h’age

• Following can be used to diagnose and predict prognosis– Eivdence of motor, sensory or cortical dysfunction– Hemianopia

Pathophysiology

• For practical purposes – 2 types of stroke (after excluding SAH)– Ischaemic: 85%– 1ry h’age: 15%

• H’ge causes direct neuronal injury and pressure effect causes adjacent ischemia

• 1ry ischaemia results from atheroembolic occlusion or embolism

• Usual sources of emboli are LA in pts with AF or LV in MI/LVF

Characteristics of subtypes of stroke

Lacunar PACI TACI Post

Signs Motor or sensory only

2 of the following: motor or sensory, cortical, hemianopia

All of: motor or sensorycortical, hemianopea

Hemianopia, brainstem, cerebellar

%dead at 1yr

10 20 60 20

%depend at 1 yr

25 30 35 20

Signs to be looked for

• Conscious level

• Neurological signs

• BP

• HR/rhythm

• Heart murmurs

• Peripheral pulses

• Systemic signs of infection or neoplasm

Death rate after stroke

30 days 1 year 5 years

Ischaemic stroke

10 23 52

ICH 52 62 70

SAH 45 48 52

Conditions that can mimick stroke

Diagnosis Diagnostic features

Decompression of previous stroke

Evidence of infection such as urinary or respiratory tract; metabolic dist.

Cerebral neoplasm (1ry or 2ry) Less abrupt; 1ry tumor or 2ry (lung or breast CA)

SAH Recent head injury

Epileptic seizures Possible previous fits

Traumatic brain injury H/O trauma

migraine Less abrupt onset; followed by headache; young pt

Multiple sclerosis Less abrupt onset, possible previous epi

Cerebral abscess Infection

Investigations of stroke

• All should have a CTwithin 48hrs to distiguish between ischaemic and h’gic stroke

• Imaging should be urgent in – Depressed conscious level, fluctuating symptoms,

papilloedema, neck stiffness, fever, severe headache, previous trauma, anticoagulant treatment or bleeding diathesis (B)

• MRI is superior, because it also assess blood flow and perfusion of the brain/detect wether lesion is old or new and identify carotid stenosis

• Imaging will also identify stroke mimicking conditions

• But a low grade glioma could still be difficult to be differentiated from cerebral infarction

Investigations of stroke

• All patients– CT/MRI– ECG– CXR– FBC– Clotting screen– SE/creatinine– Plasma glucose

Investigations of stroke

• Sub groups– Carotid duplex scanning

– ECHO– Thrombophilia screen– Immunology screen– Syphillis serology– Cerebral angiography (Rarely)

Justification for echo

• AF• HF• MI within 3/12• ECG abnormalities

– MI

– IHD

– BBB

• Heart murmur• Peripheral embolism• Clinical events in >2

territories– R & L hemisphere– Ant & post circulation

• >/= cotical events (in same territory) unless severe carotid disease

Investigations – to what extent

• Depends on several factors– Likely degree of recovary

– Presence of obvious risk factors– Age of the pt (younger pts likely to have

identifiable cause such as inflammatory or clotting dissorder)

• Ix better be restricted to tests that will help in the management

Stroke unit• Stroke unit should be centred in a hospital• Should be staffed by

– Multidisciplinary team with expertise in stroke care (A)– Team should work to agreed protocols for common problems (A)– Should provide educational programmes for staff, pts and carers

• Stroke unit trialist’s collobaration– Stroke units compared to alternatives showed reduction in odds

ration for death recorded at follow up (OR 0.86)– Odds ratio of death, instituitionalised care and death or

dependency were significantly less– Outcomes were independent of age, gender and stroke severity

and appeared to be better in stroke units based in a geographincally discrete ward

– No increase in hospital stay in stroke unit , mortality and institutionalisation rates at one year were lower in

patients who received care on the stroke ward– The benefits of stroke unit care have been shown to persist at 10

years after initial stroke

Emergency management

• Within the 1st hour after cerebral ischaemia, part of the brain is under threat of death

• The densly ischaemic area will inevitably die, but there is also tissue that could be salvaged

• At this stage oxygenation, haemodynamic and metabolic factors are crucial

Emergency management

• The emergency managemet of stroke requires– Medical stabilisation– Assesment of factors that may lead to complications

• Swallowing • hydration

– It is important to keep physiological variables such as hydration,– temperature, nutrition, and oxygenation within normal range– in the acute phase of stroke (C)– Thrombolysis may be considered–

Swallowing and feeding

• Dysphagia in ~35%– Unrecognised in mild stroke – But associated with poor outcome

• Aspiration• Pnuemonia• Poor nutrition

• They should be fed through NG or percutaneous endoscopic feeding tube

• Dysphagia Mx involves: – Initial swallow screen– Diet modification– Compensatory swallowing techniques

-reduces aspiration pneumonia

Communication and speech

• can affect in a variety of ways, including – impaired motor speech production (dysarthria)– impaired language skills (dysphasia) – Impaired planning and execution of motor speech (articulatory

dyspraxia)

• needs to be assessed by a speech and language therapist

Acute treatment of stroke

• Asprin: in most patients– 2 large trials (160-300mg/d by PO/NG/ Rectum) started within

48hrs of stroke, reduces subsequent death and disability– NNT- 77 (reducing risk by reducing reinfarction)– For 1000 pts –

• 12 avoid death and dependency• Risk of h’age minimal (1-2/1000)• Early asprin is beneficial

- if a diagnosis of haemorrhage is considered CT/MRI is essential before asprin

– But if CT is not availble and ischaemic stroke is highly suspected may give asprin

• IST(International Stroke Trial) and CAST (Chinese acute stroke trial) combined

– 40,000 pts– Significant decrease in death and

dependency at 6/12 if asprin is given immediately

– 13 more pts alive per 1000 Rxed– Increase in ICH – 2 per 1000

– Reduction in recurrence - 7 per 1000

• Anticoagulation has no net benefit

– Decreases recurrent ischaemic stroke (9 per 1000 Rxed) and pulmonary emboli (4 per 1000 Rxed)

– But 9 per 1000 increase in ICH– But it has definitive place in 2ry prevention– Immediate anticoagulation in AF is not

advised

– There is evidence for acute anticoagulation in the specific stroke syndrome of cerebral venous thrombosis

Acute treatment of stroke

• Thrombolysis– Standard acute Rx in USA, Australia and most

european countries– Type of drug and timing important– NINDS trial: Alteplase (tPA) within 3 hrs increases

the chances of near complete recovary (NNT-7)– 3-4x increase in ICH– 20% reduction in death and dependency– Rx after 6 hrs less effective (NNT-12)– Complications: intra or extracranial h’age

Acute treatment of stroke

– Contra indications to thrombolysis:• Seizure at onset• Pre Rx BP >185/110

• Major infarct on CT

• Previous ICH

• Recent MI• Recent or intended surgery• Use of anticoagulants

Acute treatment of stroke -- BP

• Withhold antihypertensives for 10 days• Indications for early Rx of high BP

– Evidence of pre existing HBP• Documented previous HT:clinic recors etc• Evidence of target organ damage

Hypertensive retinopathy, LVH on ECG

– Evidence of hypertensive emergancy• HT encephalopathy• LVF

– BP is very high• SBP >220-240• DBP >120

Complications of stroke

• Hyperglycaemia**• Hypertension**• Fever**• Infarct extension or

bleeding• Cerebral oedema• Herniation • coning

• Aspiration• Pneumonia• UTI• Cardiac dysrrhythmia• Recurrence

• DVT• PE

Rehabilitation

• Aims– Restore function– Reduce the effects of stroke on pt and theirs carers– Regain independence and maximise ability in all

activities of daily living• Should start early during recovery• Once pt is medically stable, should be

transferred to a stroke rehabilitation unit• Formal rehabilitation at a centre reduces death,

disability and hospital stay (NNT-12)

Summary of acute management of stroke

• Admit to stroke unit – improves survival & dependency

• Immediate CT• Leg stockings (CLOTS trial)• Asprin 300mg stat and 75mg thereafter• Avoid heparin• Thrombolysis (Randamise)• Relaxed about BP• Nursing, swallowing and nutrition

STROKE SECONDARY

PREVENTION

Secondary prevention

• Should start shortly after admission, except BP control

• All pts should be offered– Life style guidance– Stop smoking– Reduce saturated fat, alcohol and salt– Asprin for life

Risk of recurrence after stroke or TIA

• Stroke:– 8% per year

• TIA– 8% risk of stroke in the first month– 5% risk of stroke a year thereafter

– 5% risk of MI a year

Modifiable risk factors for stroke

• HBP• Smoking• DM• Diet: high salt & fat,

low K & vitamins• Excess alcohol

• Morbid obesity • Low physical exercise• Low temperature• Cholesterol

concentrations – atleast in pts with CAD

Management of risk factors

• Smoking:– Important correctable risk factors

– Risk returns to that of a non smoker within 3-5 yrs of cessation

Alcohol and risk of stroke

• Protective effect with light to moderate intake

• One drink a day – reduces stroke

• If more than one drink a day –risk increases

Management of risk factors

• Blood pressure– HT should be treated 1 or 2 weeks after the

stroke– Rx reduces

• Recurrence of fatal and non fatal stroke by 28%

– Pts at high risk of further stroke derive greatest benefit (eg: elederly)

– Target BP recommended by British Hypertension Society is <140/85

• PROGRESS study:– irrespective of baseline BP– Pts treated with Perindropril and

indapamide had a reduction in BP of 12/5– And reduced stroke risk of 43%–

• HOPE study– 32% relative risk reduction in 1ry and 2ry

stroke prevention in 9297 high risk pts with ramipril

– Base line BP was 139/79– Reduction in BP was only 3.8/2.8– Efficacy of ACEI may explained by anti-

inflammatory effect and plaque stabilization

Management of risk factors

• Role of cholesterol – contraversial

• But statins reduce risk of stroke in pts with CAD

• Use of statins after a athersclerotic stroke or TIA probably reduces recurrent events and IHD

Heart protection study

• Over 20,000 pts with high risk of vascular disease aged 40-80

• There were 1820 pts with history of non disabling stroke or TIA

• All were randomised to simvastatin 40mg/d or placebo for 5 years, independent of baseline cholesterol

• Simvastatin pts showed highly significant 25% reduction in incidence rate of 1st stroke

• The benefits were seen across all age ranges and base line cholesterol levels

Management of risk factors

• Diabetes:– Confers substantial dissadvantage for

• Survival

• Functioning outcome on pts with acute stroke

• Plasma glucose should be normalised early• BP targets for diabetics are lower

BP targets for non diabetic and diabetic stroke pts

No DM DM

Titrate to DBP </=85 </=80

Optimal BP <140/85 <130/80

Suboptimal BP >/=150/90 >/=140/85

Atrial fibrillation and stroke

• Over the age of 60 – 2-5% Have AF and associated with a stroke rate of 4-5%

• Meta-analysis of warfarin in Non rheumatic AF – 60-65% reduction in stroke (INR 2-3)

• With asprin 20% reduction

Atrial fibrillation and stroke – CHADS2 Scheme for risk assesment

• C – Congestive cardiac fairlure 1

• H – Hypertension 1

• A - Age >75 1

• D – Diabetes 1

• S – Past Stroke or TIA 2

Atrial fibrillation and stroke

• If patients aged 65-95 with AF– Score 0 – risk is 1.9– Score 6 –risk is 18.2

• Asprin is sufficient in patients with score 0• Warfarin is the choice if score 1 or more• Warfarin is under used, especially in

elderly (appropriate anticoagulation used in only 30-60%)

contraindications to long term warfarin

• GI bleeding

• Active peptic ulcer

• Frequent falls

• Alcohol misuse

• History of ICH

• Age by itself is not a contraindication

Anti platelet therapy

• Asprin

– should receive antiplatelet Rx as first line– Benefits of asprin conclusively proven– ASA – initial dose of 300mg & followed by 75mg/d

• Dipyridamol

– Dipyridamole MR 200mg BD has independent and additive effect to low dose asprin in preventing stroke, but not coronary events or overall mortality

– So routine addition of dipyridamol may be cost effective– Dipyridamol alone does not prevent cardiac events

Carotid endarterectomy for symptomatic

carotid stenosis in elderly patients

• Efficacy of CEA in symptomatic carotid stenosis >70% is well established

• Elderly – surgical risk is higher, but benefits even greated

• NASCET Trial– Absolute risk reduction is 28.9% in >75yrs– 15.1% for 65-74yrs– 9.7% for below 65yrs

THANK YOU