stroke

stroke

Department of Neurology, UK 2. LFAleš TomekDecember 2010

Evidence based therapy of stroke

ČNS ČLS JEP – Czech guidelineswww.cmp.cz

ESO Guidelines ischemic 2009, ICH 2006 www.eso-stroke.org

AHA-ASA Guidelines ischemic 2009, SAH 2009, ICH 2010

www.americanheart.org

Reading

Tomek et al. Neurointenzivní péče 2012

Školoudík et al. Neurosonologie 2003Uchino et al. Acute stroke care 2011Mohr, Choi, Grotta et al. Stroke 2008Caplan’s Stroke, 4th ed. 2009

Stroke typesSTROKE

Ischemic

TIA

RIND

Completed stroke

ICH

SAH

Venous thrombosis

3rd most frequent cause of death

11 640 200711 685 200812 192 200911 567 2010

32 deaths per day

(Deaths – total in 2010 - 106 844 persons)

Epidemiology in Czech Rep.

www.uzis.cz 9/2012

Hospitalisations I60-6957 484 (2010)853 078 days

Hospitalizations

www.uzis.cz

Hlavní příznaky - FAST (Face Arm Speech Test) 1x

Clinical signs – minor (2x)

Acute• Coma• Hemihypesthesia• Dysarthria• Hemianopia• Diplopia• Headache• Meningeal signs• Vertigo with nausea

Clinical examination and signs

FAST FaceArmSpeechTest

Internal Esp. cardio-

pulmonaryNeurological Consciousness Speech, mnestic

and cognitive, neglect

Cranial nerves Motoric and

sensory

Stroke scales

COMA GLASGOW COMA FOUR SCORE

ACUTE ISCHEMIC NIHSS

ICH ICH SCORE

SAH HUNT HESS WFNS (WORLD FEDERATION OF NEUROSURGEONS)

OUTCOME MODIFIED RANKIN SCALE

Prehospital care

ABCCorrect diagnosis or suspicion of

stroke (FAST)Do not lower blood pressure

(220/120) Immediate transportation to stroke

center

Situace u nás 2013

Tvorba sítě iktových center (Věstník 2 a 8/2010 MZd ČR), start 1.1.2011

KCC (komplexní cerebrovaskulární centrum) 10 center

IC (iktové centrum) 1. vlna - 23 center 2. vlna – 12 center

Soláň 13. - 14. 1. 2012

Ústecký kraj

I. MNUL

II. Chomutov

II. Děčín

II. Teplice Liberecký kraj

I. KN Liberec

II. Česká Lípa

Jihočeský kraj

I. Nemocnice Č. Budějovice

II. Nemocnice Písek

Královéhradecký kraj

I. FN Hradec Králové

II. Obl.nem.Trutnov

Jihomoravský kraj

I. FNUSA + FN Brno

II. Břeclav

II. Vyškov

Moravskoslezský kraj

I. FN Ostrava II. MN Ostrava

II. Vítkovická nemocnice

II. Krnov

II. Třinec

II. Karviná

Olomoucký kraj

I. FN Olomouc

Kraj Praha

I. Nemocnice Na Homolce

I. ÚVN

II. FN Motol II. VFN

II. FNKV + FTNsP

Plzeňský kraj

I. FN Plzeň

Karlovarský kraj

II. Nem. Sokolov

Zlínský kraj

II. Krajská nem.

T. Bati ZlínKraj Vysočina

II. Nemocnice Jihlava

Středočeský kraj

II. Kolín

II. Kladno

Pardubický kraj

II. Pardubice

II. Litomyšl

Komplexní cerebrovaskulár

ní a iktová centra

Soláň 13. - 14. 1. 2012

Ústecký kraj

Ústí n. Labem

Chomutov

Děčín

Teplice

Nem. Litoměřice

Liberecký kraj

KN Liberec

Česká Lípa

Jihočeský kraj

I. Nemocnice Č. Budějovice

II. Nemocnice Písek

Královéhradecký kraj

FN Hradec Králové

Obl.nem.Trutnov

Obl. Nem. Náchod

Jihomoravský kraj

FNUSA + FN Brno

Břeclav

Znojmo

Vyškov

Moravskoslezský kraj

FN Ostrava MN Ostrava

Vítkovická nemocnice

Krnov

Třinec

Karviná

Olomoucký kraj

IFN Olomouc

Prostějov

Hl. m. Praha

Nemocnice Na Homolce

ÚVN

FN Motol VFN

FNKV + FTNsP

Plzeňský kraj

I. FN Plzeň

Karlovarský kraj

Nem. Sokolov

Nem. Karlovy Vary

Zlínský kraj

Zlín (T. Bati)

Uh. Hradiště

Kraj Vysočina

JihlavaNové Město na Moravě

Středočeský kraj

Kolín

Kladno

Mladá Boleslav

Příbram

Pardubický kraj

Pardubice

Litomyšl

Komplexní cerebrovaskulár

ní a iktová centra

TIA x ischemic stroke

TIA x RIND x completed stroke 35% of TIA’s have DWI MR lesions Same mortality and morbidity as

minor stroke AHA-ASA 2009 new definition of TIA:= tissue definition

No signs of acute MR or CT lesion

Stroke imaging - CT

• Gold standard• ischemic / hemorhagic + availability, speed, senzitivity for

hemorhagy,... - negative first 3-6 hours, poor for

brainstem

ischemie

hemorhagie

Early CT diagnostics of stroke

Native CT – markers of early ischaemia:

Early hypodenzityLower difference between gray x white matter Lost gyrification (SA space)Dense artery sign (MCA)

MR diagnostics of stroke

More senzitive for smaller strokes and for brainstem

Early vs. Old ischemic stroke (DWI)Availability and duration of exam

ischemie

ischemie

akutní ischemie

Penumbra concept

Penumbra

Benign oligemia

Ischemic core

CBF < 10 ml/100g/min (< 20%)Cytotoxic oedema + neuronal cell deathCBV, CMRO2 decreased to zeroOEF 100%CBF 10-18 ml/100g/min

Cell death without reperfusionLoss of function of neuronsOEF 100% can not stop decline CMRO2

Normal tissue CBF 20-50 ml/100g/minSurvives without reperfusionElevated oxygen extraction fraction (OEF) Normal cerebral metabolic rate of oxygen (CMRO2)

CBF 50-60 ml/100g/minFunctional for CPP 60-130 mmH, changes CBV Warach S. Stroke 2001;32:2460-2461.

DWI PWI mismatch

24 hours later….

CT Perfusion

CT angiography

Ultrasound (TCD and carotid)

MR angiography

DSA – digital subtraction angiography

Strategy of ischemic stroke therapy

RecanalizationNeuroprotectionTherapy of complications (oedema,

epilepsy, infection…)Secondary prevention of recurrent

strokeRestoration of function

(physiotherapy, occupational therapy

The only causal therapy - recanalization

Katzan et al, Arch Neurol 2004Thomas et al, N Engl J Med 2006

Intravenous

thrombolysis

Intraarterial

thrombolysis

Mechanical recanalization

Sonothrombotripsy2 - 30% patients with stroke

IVT

“Time is brain”

NNT 2

NNT 7 (3,1)

NNT 14

Saver JL. Stroke 2006;37(1):263-6.Hacke W et al. NEJMN 2008;359:1317 29.

Every 1 minute: • 1 900 000 neurons• 14 000 000 000 synapsis• 12 km of myelinated fibers

90 minutes

180 minutes

270 minutes

rtPA (Actilyse)

r-TPA (Actilyse) 0,9mg/kg, max. 90 mg t½= 3-8min

IVT limitations

CT or MR without blood

Max. 4,5 hours after beginning

Min. 30 min of duration

Serious disability NIHSS 4 – 25 (relative)

Age 18-80 (relative)

Rescue therapy after IVT

Assessment of efficiency Examination in 60. minute Recanalized only in 40-50% cases, early

reocclusion, recanalisation does not mean clinical effect

Our goal: What happened during IVT? TCCS or NIHSS (40% points down) Ultimate DSA (after 30/60 minutes)

RESCUE = mechanical

Intraarterial thrombolysis – IATCombined IVT + IAT

Sonothrombotripsy

Mechanical recanalization MERCI

Experimental methods

PTA balloon angioplasty and stenting +/- IAT laser microcavitation: LaTIS, EPAR Ultrasound cavitatione: Ekos, ACS Thrombus aspiration: AngioJet, Oasis, Neurojet

Solitaire FR

Solitaire FR

Solitaire FR

Stroke diagnosisIschemic

85%Before 4,5 hours

IVT

4,5 – 8 h w. penumbra

4,5-6 IA

4,5-8 IA, mech,

TT

After 4,5 hrs. Wo. penumbra

ICH 12-15%SAK 1%Correction of hemostasis and oedema

Timetable of stroke th.

Secondary prevention

Antithrombotic Antiplatelet Anticoagulation (VKA)

ACEI or AT1 blocker, diuretic

Statine

TOAST subtypes

TOAST, Adams et al, Stroke 1993N = incidence for 100 000 persons, Kolominsky-Rabas et al, Stroke 2001

Small vessel disease

25.8/100 000

Large vessel disease

15.3/100 000

Cardiogenic

30.2/100 000

Other known

2,1/100 000

Cryptogenic

39,3/100 000

Cerebral veins (sinuses) thrombosis = CVT

Therapy of CVT

Anticoagulation (3, 6 months, chronic)

Lifestyle changes (smoking, hormonal, drinking)

Depends on etiology of thrombofilic state Inborn (Leiden, homocysteine…) Acquired (hormonal, posttraumatic, post

infection, surgery…etc)

Intracerebral hemorrhage (ICH)

Dynamics of ICH

**Kazui et al. Stroke. 1996;27:1783-1787.

*Brott et al. Stroke. 1997;28:1-5

First 24 hrs– 20*-36%**volume progression(majority first 3 hours)

Treatment options in ICHTherapy

Stabilisation of hemostasis

Blood pressure correction

Surgery – treatment of mass effect and

of source of bleeding

Antioedematous therapy,

decompression

EVD, shunts

DiagnosticsCT

AngiographyMRI + MRA

RHB

Bleedingprogression

24hrs

Brain oedema

3-5.day

Hydrocephalus

14 days

RHB

Hypertension

Goal – 140/90

Hypertonics Aim 120 MAP (160/100), maximum 180/105, no more than

than 20% Normotonisi – aim 110 MAP (150/90),

max.160/95 ABP monitoring , i.v. therapy (Urapidil,

Esmolol, Enalapril, Nitroprusid)

hemostasis

APTT, Quick, trombocytes Trombocytes

treat <75 000, substitution in caso of antiplatelet medication

Warfarine INR <8 FP 2-3 TU INR >8 FP 6 TU Better concentrated prothrombin complex (fa. II, VII,

IX, X) Prothromplex Total TIM4 rFVIIa – best ever- 10 minutes (10-40 μg/kg) Vitamin K - after 6-12 hoours

Heparine protamine sulphate (1mg/100 IU, max. 50mg/10 min)

Surgery

Craniectomy (mass + source)Stereotactic – event. + rtPAExternal ventricular drainage

– event. + rtPA

Surgery yes:

Cerebellar above 10ml (>3-4cm) + GCS =<13

Lobar superficial (temporal lobe) 10-40ml or with later clinical progression

Typical BG initialy 10-30ml with good clinical state and later worsening (first 24-48 hrs)

ICH score 3 and age under 50 years Ultimum refugium in case of cranio-

caudal deterioration

Secondary prevention of ICH

PRIMARY 80% Recurrence/ yearHypertensive microangiopathy 2%Amyloid angiopathy 10,5%AVM 18%Cavernous angioma 4,5%

SECONDARY 20%Tumors

Exclude the source of bleeding (if possible)HypertensionCorrection of bleeding disorders and exclusion of anticoagulantsLifestyle - smoking, alcohol

Subarachnoidal hemorrhage (SAH)

SAH diagnostics

Headache 97%Meningeal syndrome (after 6-24

hrs)Nausea, vomitting, loss of

conscioussness + neurological deficite

Grading by Hunta and Hess HH 1-5 or WFNS

Diagnostic problems with HH1 – CSF exam.

In the first 24 hours DSA – to find and treat source of bleeding

SAH: Coiling x Cliping

Specific complications of SAHRebleeding (7%)- Majority in the first two weeks (4% first

day, after that 1,5% daily for the first 2 weeks)

Hydrocephalus (20%)- Obstruction type acute (EVD),

hyporesorbtive type later (shunting)

Vasospasms (46%)- Max. 5. – 12. day- TCD daily