Eusi Stroke


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Eusi Stroke

  1. 1. - SYMPOSIUM RECOMMENDATIONS FOR STROKE MANAGEMENT European Federation of Neurological Societies EFNS Copenhagn 2000
  2. 2. RECOMMENDATIONS FOR STROKE MANAGEMENT <ul><li>Part 1: Organizing Modern Stroke Care Tom Skyhoj Olsen, Copenhagn (DEN) </li></ul><ul><li>Part 2: Risk Factors and Primary Prevention Julien Bogousslavsky, Lausanne (SUI) </li></ul><ul><li>Part 3: Acute Stroke Care - General Therapy Markku Kaste, Helsinki (FIN) </li></ul><ul><li>Part 4: Acute Stroke Care - Specific Therapy Werner Hacke, Heidelberg (GER) </li></ul><ul><li>Part 5: Rehabilitation and Secondary Prevention Jean-Marc Orgogozo, Bordeaux (FRA) </li></ul>
  3. 3. RECOMMENDATIONS FOR STROKE MANAGEMENT <ul><li>Part 1: Organizing Modern Stroke Care Tom Skyhoj Olsen, Copenhagn (DEN) </li></ul>
  4. 4. RECOMMENDATIONS FOR STROKE MANAGEMENT <ul><li>Part 2: Risk Factors and Primary Prevention Julien Bogousslavsky, Lausanne (SUI) </li></ul>
  5. 5. RECOMMENDATIONS FOR STROKE MANAGEMENT <ul><li>Part 3: Acute Stroke Care - General Therapy Markku Kaste, Helsinki (FIN) </li></ul>
  6. 6. RECOMMENDATIONS FOR STROKE MANAGEMENT <ul><li>Part 4: Acute Stroke Care - Specific Therapy Werner Hacke, Heidelberg (GER) </li></ul>
  7. 7. RECOMMENDATIONS FOR STROKE MANAGEMENT <ul><li>Part 5: Rehabilitation and Secondary Prevention Jean-Marc Orgogozo, Bordeaux (FRA) </li></ul>
  8. 8. Definitions of Levels of Evidence modified from Adams et al. 1994 <ul><li>Level I: Highest Level of Evidence </li></ul><ul><ul><li>Sources: a) Primary endpoint of double blind RCT with adequate sample size </li></ul></ul><ul><ul><li>b) Meta-analysis of qualitatively outstanding RCTs </li></ul></ul><ul><li>Level II: Intermediate Level of Evidence </li></ul><ul><ul><li>Sources: a) Randomised not blinded trials </li></ul></ul><ul><ul><li>b) Small randomised trials </li></ul></ul><ul><ul><li>c) Predefined secondary endpoints of large RCTs </li></ul></ul><ul><li>Level III: Lower Level of Evidence </li></ul><ul><ul><li>Sources: a) Prospective case series with concurrent or historical control </li></ul></ul><ul><ul><li>b) Post hoc analyses of large RCTs </li></ul></ul><ul><li>Level IV: Undetermined Level of Evidence </li></ul><ul><ul><li>Sources: a) Small uncontrolled case series </li></ul></ul><ul><ul><li>b) General agreement despite lack of evidence </li></ul></ul>
  9. 9. Acute Stroke Care- Emergency Diagnostic Tests <ul><li>Differentiation between different types of stroke </li></ul><ul><li>Ruling out other brain diseases </li></ul><ul><li>Assessing the underlying cause of brain ischemia </li></ul><ul><li>Providing a basis for physiological monitoring of the stroke patient </li></ul><ul><li>Identifying concurrent diseases or complications associated with stroke </li></ul>
  10. 10. Emergency Diagnostic Tests <ul><li>Cranial computed tomography (CCT) </li></ul><ul><ul><li>distinguishes reliably between hemorrhagic and ischemic stroke </li></ul></ul><ul><ul><li>early signs of ischemia detected as early as 2 h after stroke onset </li></ul></ul><ul><ul><li>identifies hemorrhages almost immediately </li></ul></ul><ul><ul><li>detects SAH in the majority of cases </li></ul></ul><ul><ul><li>helps to identify other neurological diseases (e.g. neoplasms) </li></ul></ul>
  11. 11. Emergency Diagnostic Tests <ul><li>Magnetic resonance imaging (MRI) </li></ul><ul><ul><li>only helpful in centres using modern MRI techniques </li></ul></ul><ul><ul><li>diffusion- and perfusion-weighted MRI may help to differentiate between infarcted tissue and tissue at risk </li></ul></ul>
  12. 12. Emergency Diagnostic Tests <ul><li>Electrocardiogram </li></ul><ul><ul><li>high incidence of heart involvement in stroke patients </li></ul></ul><ul><ul><li>coincidence of stroke and myocardial infarction </li></ul></ul><ul><ul><li>ischemic stroke may cause arrhythmias </li></ul></ul><ul><ul><li>detection of atrial fibrillation as a possible cause of embolic stroke </li></ul></ul>
  13. 13. Emergency Diagnostic Tests <ul><li>Ultrasound studies </li></ul><ul><ul><li>cw/pw- Doppler and/or duplex sonography of the extracranial cervical and the basal intracranial arteries </li></ul></ul><ul><ul><ul><li>identification of vessel stenosis, occlusion, state of collaterals, or recanalisation </li></ul></ul></ul><ul><ul><li>transesophageal echocardiography to screen for cardiogenic emboli (not in the ER but recommended within the first 24 h after stroke onset) </li></ul></ul>
  14. 14. Emergency Diagnostic Tests <ul><li>Laboratory tests </li></ul><ul><ul><li>hematology </li></ul></ul><ul><ul><li>clotting parameters </li></ul></ul><ul><ul><li>electrolytes </li></ul></ul><ul><ul><li>renal and hepatic chemistry </li></ul></ul><ul><ul><li>cardiac enzymes </li></ul></ul><ul><ul><li>basic parameters of infection </li></ul></ul>
  15. 15. Emergency Diagnostic Tests <ul><li>EUSI Recommendations </li></ul><ul><ul><li>1. CCT is the most important diagnostic tool in patients with suspected stroke (Level IV) </li></ul></ul><ul><ul><li>2.Early evaluation of physiological parameters, blood chemistry and hematology, and cardiac function (ECG, pulsoximetry, chest x-ray) is recommended in the management of acute stroke patients </li></ul></ul>
  16. 16. Emergency Diagnostic Tests <ul><li>EUSI Recommendations </li></ul><ul><ul><li>3. Cardiac and Neurological ultrasound should be readily available (Level IV) </li></ul></ul>
  17. 17. Acute Stroke Care- General Management <ul><li>EUSI-recommendations include </li></ul><ul><ul><li>Pulmonary and airway care </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><li>Body temperature </li></ul></ul><ul><ul><li>Glucose metabolism </li></ul></ul><ul><ul><li>Fluid and electrolyte management </li></ul></ul>
  18. 18. General Management <ul><li>Monitoring of vital and neurological functions </li></ul><ul><ul><li>continuous monitoring: </li></ul></ul><ul><ul><ul><li>heart rate </li></ul></ul></ul><ul><ul><ul><li>O 2 saturation </li></ul></ul></ul><ul><ul><li>discontinuous monitoring </li></ul></ul><ul><ul><ul><li>Blood pressure (e.g. automatic inflatable sphygmomanometry) </li></ul></ul></ul><ul><ul><ul><li>Clinical: Vigilance / GCS, pupils </li></ul></ul></ul><ul><ul><ul><li>Neurological (e.g. NIH and Scandinavian stroke scale) </li></ul></ul></ul>
  19. 19. General treatment <ul><li>Pulmonary function and airway protection </li></ul><ul><ul><li>Adequate oxygenation important for preservation of the penumbra </li></ul></ul><ul><ul><li>Improved blood oxygenation by administration of > 2 l O 2 (S O 2 -guided) </li></ul></ul><ul><ul><li>Risk for aspiration in patients with pseudobulbar/bulbar paralysis and reduced vigilance: side positioning, consider tracheotomia </li></ul></ul><ul><ul><li>Consider hypoventilation by pathological respiration pattern </li></ul></ul><ul><ul><li>Risk of airway obstruction (vomiting, oropharyngeal muscular hypotonia): mechanical airway protection </li></ul></ul>
  20. 20. General treatment <ul><li>Blood pressure (BP) </li></ul><ul><ul><li>elevated in most of the patients with acute stroke </li></ul></ul><ul><ul><li>Flow in the critical penumbra passively dependent on the mean arterial pressure </li></ul></ul><ul><ul><li>Sufficient post-stenotic flow requires high blood pressure </li></ul></ul>
  21. 21. General treatment <ul><li>Blood pressure </li></ul><ul><ul><li>There are no controlled, randomised studies guiding BP management </li></ul></ul><ul><ul><ul><li>Recommended target BP in patients with prior hypertension: 180 / 100-105 mmHg </li></ul></ul></ul><ul><ul><ul><li>Recommended target BP in previously normotonic patients: 160-180 / 90-100 mmHg </li></ul></ul></ul><ul><ul><ul><li>Avoid and treat hypotension or drastic reductions in BP </li></ul></ul></ul>
  22. 22. General treatment <ul><li>Blood pressure </li></ul><ul><ul><li>Indications for immediate antihypertensive therapy in acute stroke: </li></ul></ul><ul><ul><ul><li>Non-ischemic cause for stroke </li></ul></ul></ul><ul><ul><ul><li>Cardiac insufficiency </li></ul></ul></ul><ul><ul><ul><li>Aortic dissection </li></ul></ul></ul><ul><ul><ul><li>Acute renal failure </li></ul></ul></ul><ul><ul><ul><li>Hypertensive encephalopathy </li></ul></ul></ul>
  23. 23. General treatment <ul><li>Body temperature </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>Fever negatively influences neurological outcome after stroke </li></ul></ul></ul><ul><ul><ul><li>Experimentally, fever increases infarct size </li></ul></ul></ul><ul><ul><ul><li>Many patients with acute stroke develop a febrile infection after stroke </li></ul></ul></ul><ul><ul><li>Although no controlled trial supporting treatment of an elevated temperature, consider to treat fever when the body temperature reaches 37.5°C rectally </li></ul></ul>
  24. 24. General treatment <ul><li>Glucose metabolism </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>Pre-existent diabetic metabolic derangement can be worsened </li></ul></ul></ul><ul><ul><ul><li>High glucose levels in the acute phase of stroke may increase the size of the infarction and reduce functional outcome </li></ul></ul></ul><ul><ul><ul><li>Hypoglycemia worsens outcome as well </li></ul></ul></ul><ul><ul><ul><li>Hypoglycemia can mimic an acute ischemic infarction </li></ul></ul></ul>
  25. 25. General treatment <ul><li>Fluid and electrolyte management </li></ul><ul><ul><li>Serious electrolyte abnormalities are rare after ischemic stroke but frequent after ICH and SAH </li></ul></ul><ul><ul><li>Balanced electrolyte and fluid status are important to avoid: </li></ul></ul><ul><ul><ul><li>plasma volume contraction </li></ul></ul></ul><ul><ul><ul><li>raised hematocrit </li></ul></ul></ul><ul><ul><ul><li>impaired rheologic properties </li></ul></ul></ul>
  26. 26. General treatment <ul><li>EUSI Recommendations </li></ul><ul><ul><li>1. Neurological status and vital functions should be monitored </li></ul></ul><ul><ul><li>2. Glucose and body temperature should be monitored and corrected, if elevated (Level III) </li></ul></ul><ul><ul><li>3. Do not treat hypertension in patients with ischemic stroke, if they do not have critically elevated BP levels (Level III) </li></ul></ul>
  27. 27. General treatment <ul><li>EUSI Recommendations </li></ul><ul><ul><li>4. Secure airways and supply oxygen to patients with severe acute stroke (Level IV) </li></ul></ul><ul><ul><li>5. Monitoring and correction of electrolyte and fluid disturbances are advised (Level IV) </li></ul></ul>
  28. 28. Acute Stroke Care- Specific Treatment <ul><li>EUSI-recommendations include </li></ul><ul><ul><li>Acute anti-thrombotic therapy </li></ul></ul><ul><ul><ul><li>Thrombolytic therapy </li></ul></ul></ul><ul><ul><ul><li>Defibrinogenating enzymes </li></ul></ul></ul><ul><ul><ul><li>ASA </li></ul></ul></ul><ul><ul><li>Neuroprotection </li></ul></ul><ul><ul><li>Treatment of elevated ICP and brain edema </li></ul></ul><ul><ul><ul><li>Medical treatment </li></ul></ul></ul><ul><ul><ul><li>Surgical treatment </li></ul></ul></ul>
  29. 29. Thrombolytic Therapy <ul><li>IV-Thrombolysis (rtPA) </li></ul><ul><ul><li>Facts (NINDS Pt. 1 + 2, ECASS I + II, ATLANTIS) </li></ul></ul><ul><ul><ul><li>3h time window approved in USA, CDN, MEX, I.V. 0.9mg/kg, max 90mg </li></ul></ul></ul><ul><ul><ul><li>Not yet approved in Europe </li></ul></ul></ul><ul><ul><ul><li>Efficacy signal beyond 3h (meta-analysis) </li></ul></ul></ul><ul><li>IV-Thrombolysis (SK) </li></ul><ul><ul><li>Facts (MAST-I, MAST-E, AST) </li></ul></ul><ul><ul><ul><li>Although some efficacy signal in early time windwow, SK currently abandoned </li></ul></ul></ul>
  30. 30. Thrombolytic Therapy <ul><li>IA-Thrombolysis (rtPA, UK) </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>Only cases and some prospective uncontrolled case series </li></ul></ul></ul><ul><li>IA-Thrombolysis (rPUK) </li></ul><ul><ul><li>Facts (PROACT I and II) </li></ul></ul><ul><ul><ul><li>Efficacy proven in small RCT, 6h window, </li></ul></ul></ul><ul><ul><ul><li>Not approved, PROACT III? </li></ul></ul></ul>
  31. 31. Thrombolytic Therapy <ul><li>EUSI Recommendations (for centers offering thrombolysis) </li></ul><ul><ul><li>1. I.V. rtPA (0.9mg/kg; max 90mg, 10% bolus, followed by 60 min infusion) is recommended within 3 hours after stroke onset (Level I) </li></ul></ul><ul><ul><li>2. The benefit from the use of I.V. rtPA beyond 3 hours is smaller, but present in selected patients (Level I) </li></ul></ul><ul><ul><li>3. I.V. rtPA is not recommended when time of onset is uncertain </li></ul></ul>
  32. 32. Thrombolytic Therapy <ul><li>EUSI Recommendations (for centers offering thrombolysis) </li></ul><ul><ul><li>4. I.V. SK outside of the setting of acontrolled clinical trial is dangerous and not indicated for the management of persons with ischemic stroke (Level I) </li></ul></ul><ul><ul><li>5. Intra-arterial treatment of acute M1 occlusion in a 6 h time window using rPUK results in a significantly improved outcome (Level II) </li></ul></ul><ul><ul><li>3. Acute BA-occlusion may be treted with I.A, therapy in selected centers (Level IV) </li></ul></ul>
  33. 33. Defibrinogenating Therapy <ul><li>ANCROD </li></ul><ul><ul><li>Treatment of acute ischemic stroke with I.V. Ancrod in a 3 h time window results in significantly improved outcome (primary endpoint only (STAT) </li></ul></ul><ul><ul><li>Futility analysis of 6 h trial (ESTAT) led to premature termination of the trial </li></ul></ul>
  34. 34. Defibrinogenating Therapy <ul><li>EUSI Recommendation </li></ul><ul><li>1. Ancrod given in a 3 h time window significantly improves outcome after acute ischemic stroke (Level II) </li></ul>
  35. 35. Platelet Inhibitors <ul><li>ASA </li></ul><ul><ul><li>only substance tested in acute (<48 h) stroke (IST, CAST) </li></ul></ul><ul><ul><li>CT not required for randomisation </li></ul></ul><ul><ul><li>small but significant reduction of mortality and recurrence of stroke in combined analysis of both trials </li></ul></ul>
  36. 36. Platelet Inhibitors <ul><li>EUSI-recommendation </li></ul><ul><ul><li>1. Aspirin 100-300 mg/day may be given to an unselected stroke population (Level II) </li></ul></ul>
  37. 37. Therapeutic Anticoagulation <ul><li>Unfractionated heparin </li></ul><ul><ul><li>no formal trial available testing standard I.V. heparin </li></ul></ul><ul><ul><li>IST showed no benefit for sc heparin treated patients, increased risk of ICH </li></ul></ul><ul><li>Low molecular weight heparins </li></ul><ul><ul><li>Postive effect seen in small pilot trial (Kay 1995) was not found in subsequent trial (fisBIS) </li></ul></ul><ul><li>Heparinoid (Orgaran) </li></ul><ul><ul><li>TOAST trial negative </li></ul></ul>
  38. 38. Therapeutic Antioagulation <ul><li>EUSI-recommendation </li></ul><ul><ul><li>1. There is no recommendation for the general use of heparin, low molecular weight heparines or heparinoids after ischemic stroke (Level I) </li></ul></ul><ul><ul><li>2. Full dose heparin may be used in selected indications such as AF, other cardiac sources with high risk of re-embolism, arterial dissection, or high grade arterial stenosis (Level IV) </li></ul></ul><ul><ul><li>3. Administration for DVT-prophylaxis see general treatment </li></ul></ul>
  39. 39. Neuroprotection <ul><li>Up to now, not a single neuroprotective substance has been shown to influence outcome after stroke. </li></ul><ul><li>Currently there is no recommendation to treat patients with neuroprotective drugs after ischaemic stroke (Level I) </li></ul>
  40. 40. Elevated Intracranial Pressure and Brain Edema Treatment <ul><li>Medical therapy </li></ul><ul><ul><li>Basic management </li></ul></ul><ul><ul><ul><li>Head positioning <30° </li></ul></ul></ul><ul><ul><ul><li>Pain relief and sedation </li></ul></ul></ul><ul><ul><ul><li>Normothermia </li></ul></ul></ul><ul><ul><ul><li>Osmotic agents </li></ul></ul></ul><ul><ul><ul><ul><li>Glycerol </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mannitol </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypertonic saline </li></ul></ul></ul></ul><ul><ul><ul><li>Barbiturates, hyperventilation and THAM-buffer </li></ul></ul></ul>
  41. 41. Elevated Intracranial Pressure and Brain Edema Treatment <ul><li>Surgical Therapy </li></ul><ul><ul><li>Ventricular drainage </li></ul></ul><ul><ul><ul><li>Posterior fossa space occupying infarction </li></ul></ul></ul><ul><ul><ul><li>Thalamic infarction (rare) </li></ul></ul></ul><ul><ul><li>Decompressive surgery </li></ul></ul><ul><ul><ul><li>Posterior fossa space occupying infarctian </li></ul></ul></ul><ul><ul><ul><li>Malignant MCA/hemispheric infarction </li></ul></ul></ul><ul><ul><ul><ul><li>Encouraging reduction of mortality with decent outcome i prospective case series </li></ul></ul></ul></ul><ul><ul><ul><ul><li>RCT (HEADFIRST) starts recruiting </li></ul></ul></ul></ul>
  42. 42. Elevated Intracranial Pressure and Brain Edema Treatment <ul><li>EUSI-recommendations </li></ul><ul><ul><li>1. Osmotherapy is recommended for patients whose condition is deteriorating secondary to increased ICP, including those with herniation syndromes (Level III) </li></ul></ul><ul><ul><li>2. Surgical decompression of large cerebellar infarctions that compress the brainstem is justified (Level III) </li></ul></ul><ul><ul><li>3.Surgical decompression of large hemispheric infarction can be life-saving (Level III) </li></ul></ul>
  43. 43. Stroke Units <ul><li>Definition: </li></ul><ul><ul><li>Hospital or part of a hospital that (nearly) exclusively takes care of stroke patients </li></ul></ul><ul><ul><li>Specialised staff with multidisciplinary approach to treatment and care </li></ul></ul><ul><ul><li>Core disciplines: medical treatment, nursing, physiotherapy, occupational therapy, speech and language therapy, social work </li></ul></ul>
  44. 44. Stroke Units <ul><li>Facts (Stroke Unit Trialist´s Collaboration) </li></ul><ul><ul><li>Acute treatment in a stroke unit results in significant reduction in mortality, death, dependence, or need of institutional care in comparison to a general medical ward </li></ul></ul>
  45. 45. Stroke Units <ul><li>Types of stroke units: </li></ul><ul><ul><li>1. Acute stroke unit </li></ul></ul><ul><ul><ul><li>acute treatment < 1 week (2-3 days) </li></ul></ul></ul><ul><ul><li>2. Combined acute and rehabilitation stroke unit </li></ul></ul><ul><ul><ul><li>acute phase + reha for several weeks / months </li></ul></ul></ul><ul><ul><li>3. Rehabilitation stroke unit </li></ul></ul><ul><ul><ul><li>admission after 1to 2 weeks after stroke onset </li></ul></ul></ul><ul><ul><li>4. Mobile stroke team </li></ul></ul><ul><ul><ul><li>offers stroke care and treatment on a variety of wards </li></ul></ul></ul>
  46. 46. Stroke Units <ul><li>EUSI Recommendations </li></ul><ul><ul><li>1. Stroke patients should be treated in specialised stroke units (Level I) </li></ul></ul>
  47. 47. Rehabilitation <ul><li>Early rehabilitation </li></ul><ul><ul><li>40% of stroke patients need active reha services </li></ul></ul><ul><ul><li>active rehabilitation should start as soon as possible </li></ul></ul><ul><ul><li>if the patient is unconscious, rehabilitation is passive to prevent contractions and other immobilisation-associated complications </li></ul></ul>
  48. 48. Rehabilitation <ul><li>Rehabilitation programs </li></ul><ul><ul><li>- Assessment for the degree of disability (motor, cognitive, sensory, visual) </li></ul></ul><ul><ul><li>- Assessment of the ability to respond to rehabilitation (financial burden, chances to return to social activities and work and to live alone, need of help) </li></ul></ul><ul><ul><li>- adaptation of the intensity of the rehabilitation to status and the degree of disability </li></ul></ul>
  49. 49. Rehabilitation <ul><li>Rehabilitation programs </li></ul><ul><ul><li>- daily documentation of the patients progress </li></ul></ul><ul><ul><li>- teaching and involvement of the patient and his family members </li></ul></ul><ul><ul><li>- home visitation as early as possible (smoothing the transit, increasing motivation) </li></ul></ul><ul><ul><li>- planning the transfer to a specialised rehabilitation hospital if a longer reha period is expected </li></ul></ul>
  50. 50. Rehabilitation <ul><li>ideal multidisciplinary stroke team for adequate rehabilitation </li></ul><ul><ul><li>- stroke physician and nurses experienced in stroke management </li></ul></ul><ul><ul><li>- physiotherapist, speech therapist and occupational therapist trained in stroke rehabilitation </li></ul></ul><ul><ul><li>- neuropsychologist and social worker accustomed to stroke rehabilitation </li></ul></ul>
  51. 51. Rehabilitation <ul><li>EUSI Recommendations </li></ul><ul><ul><li>1. Rehabilitation should be initiated early after stroke (Level I) </li></ul></ul><ul><ul><li>2. Every patient should have access to evaluation for rehabilitation (Level III) </li></ul></ul><ul><ul><li>3. Rehabilitation services should be provided by a multidisciplinary team (Level III) </li></ul></ul>
  52. 52. Primary Prevention <ul><li>Conditions and lifestyle factors identified as a risk for stroke: </li></ul><ul><ul><li>arterial hypertension </li></ul></ul><ul><ul><li>myocardial infarction </li></ul></ul><ul><ul><li>atrial fibrillation </li></ul></ul><ul><ul><li>diabetes mellitus </li></ul></ul><ul><ul><li>elevated cholesterol levels </li></ul></ul><ul><ul><li>carotid artery disease </li></ul></ul><ul><ul><li>smoking </li></ul></ul><ul><ul><li>alcohol use </li></ul></ul><ul><ul><li>physical activity </li></ul></ul>
  53. 53. Primary Prevention <ul><li>Hypertension </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>most prevalent and modifiable risk factor for stroke </li></ul></ul></ul><ul><ul><ul><li>significant reduction of stroke incidence with a decrease of 5 mmHg in diastolic BP or teatment of isolated systolic BP elevation </li></ul></ul></ul>
  54. 54. Primary Prevention <ul><li>Diabetes mellitus </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>independent risk factor for ischemic stroke </li></ul></ul></ul><ul><ul><ul><li>strict control of blood glucose not established for stroke prevention </li></ul></ul></ul><ul><ul><ul><li>elevated blood glucose at stroke onset worsens mortality and functional outcome </li></ul></ul></ul>
  55. 55. Primary Prevention <ul><li>Hypercholesterolemia </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>no strong association between serum cholesterol levels and stroke </li></ul></ul></ul><ul><ul><ul><li>reduction in the relative risk of stroke with pravastatin therapy </li></ul></ul></ul><ul><ul><ul><li>reduction of stroke mortality by statin therapy: controversial </li></ul></ul></ul>
  56. 56. Primary Prevention <ul><li>Cigarette smoking </li></ul><ul><ul><li>Facts (Cohort studies) </li></ul></ul><ul><ul><ul><li>independent risk factor for ischemic stroke in men and women </li></ul></ul></ul><ul><ul><ul><li>6-fold risk compared to non-smokers </li></ul></ul></ul><ul><ul><ul><li>50% risk reduction by stop of smoking </li></ul></ul></ul>
  57. 57. Primary Prevention <ul><li>Alcohol consumption </li></ul><ul><ul><li>decreased risk by moderate consumption (men: 20-30 mg/die) </li></ul></ul><ul><ul><li>increased risk for both ischemic and hemorrhagic stroke by heavy alcohol consumption </li></ul></ul>
  58. 58. Primary Prevention <ul><li>Physical activity </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>vigorous exercise is associated with a decreased risk of stroke </li></ul></ul></ul><ul><ul><li>this effect may be mediated by reduction in body weight, BP, cholesterol and increased glucose tolerance </li></ul></ul>
  59. 59. Primary Prevention <ul><li>Antithrombotic drugs </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>trend to higher incidence of disabling strokes (hemorrhagic) by aspirin ingestion (325-500 mg/die) in males </li></ul></ul></ul><ul><ul><ul><li>no risk alteration in women </li></ul></ul></ul><ul><ul><ul><li>risk reduction in MI for both men and women </li></ul></ul></ul>
  60. 60. Primary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>1. BP measurement should be an essential component of regular health care visits; BP should be lowered to normal (140/85 mmHg) values by means of life-style and/or pharmacological treatment (Level I) </li></ul></ul><ul><ul><li>2. Although strict control of glucose or high cholesterol levels has not been proven to be associated with a decreased risk of stroke, it should be encouraged because of benefits in terms of other diseases (Level III) </li></ul></ul>
  61. 61. Primary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>3. In coronary patients, treatment with simvastatin or pravastatin clearly reduces the risk of stroke (Level II). Statins should be prescribed in patients with CHD and high or moderate cholesterol levels; the benefits of statins probably extend to patients with stroke and high cholesterol levels. </li></ul></ul><ul><ul><li>4. Cigarette smoking should be discouraged (Level II) </li></ul></ul>
  62. 62. Primary Prevention <ul><li>EUSI-recommendations </li></ul><ul><li> 5. Heavy use of alcohol should be avoided, while moderate consumption may be permitted (Level II) </li></ul><ul><ul><li>6. Regular physical activity is recommended (Level II) </li></ul></ul><ul><ul><li>7. There is no scientific support for prescribing aspirin to reduce the risk of stroke in asymptomatic patients (Level I); however, aspirin may reduce the risk of MI (Level I) </li></ul></ul>
  63. 63. Primary Prevention <ul><li>Atrial fibrillation (AF) </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>average stroke rate of 5% per year </li></ul></ul></ul><ul><ul><ul><li>warfarin reduces the rate of ischemic strokes by 25 % </li></ul></ul></ul><ul><ul><ul><li>anticoagulation with an INR of 2.0 to 3.0 reduces the rate of ischemic and hemorrhagic events by 80% when compared to below 2.0, where non-significant reduction in thromboembolic events is seen </li></ul></ul></ul><ul><ul><ul><li>unacceptable risk for bleeding complications with an INR > 5.0 </li></ul></ul></ul>
  64. 64. Primary Prevention <ul><li>Atrial fibrillation </li></ul><ul><ul><li>Facts </li></ul></ul><ul><ul><ul><li>aspirin (300 mg) achieves a pooled risk reduction of 21 % </li></ul></ul></ul><ul><ul><ul><li>aspirin is less efficacious than warfarin </li></ul></ul></ul><ul><ul><ul><li>patients less than 65 years of age with “lone AF” are at low risk, whereas patients older than 65 years are at moderate risk for embolic stroke </li></ul></ul></ul>
  65. 65. Primary Prevention <ul><li>Atrial fibrillation: EUSI-recommendations </li></ul><ul><ul><li>1. Long-term oral anticoagulation therapy (target INR 2.5; range 2.0 - 3.0) should be considered for all AF patients who are at high risk for stroke (Level I) </li></ul></ul><ul><ul><li>2. Patients aged less than 65 years with no cardiovascular disease or patients who are unable to receive anticoagulants should be offered 300 mg aspirin per day (Level I) </li></ul></ul>
  66. 66. Primary Prevention <ul><li>Atrial fibrillation: EUSI-recommendations </li></ul><ul><ul><li>3. Although not yet established by randomised studies, patients over 65 years of age without risk factors could be offered both AC and aspirin 300 mg/ day (Level III) </li></ul></ul><ul><ul><li>4. Although not yet established by randomised studies, patients over 75 years of age, warfarin may be used with a lower INR (target INR of 2.0; range 1.6. - 2.5) to decrease the risk of hemorrhage (Level III) </li></ul></ul>
  67. 67. Primary Prevention <ul><li>Asymptomatic carotid artery stenosis </li></ul><ul><ul><li>CEA is still a matter of controversy </li></ul></ul><ul><ul><li>5-year relative risk reduction by CEA for carotid artery stenosis >65% of 50% (absolute reduction about 6%) </li></ul></ul><ul><ul><li>absolute risk reduction by medical treatment of 11%/ 5 years </li></ul></ul>
  68. 68. Secondary Prevention <ul><li>Antithrombotic drugs </li></ul><ul><ul><li>Aspirin: Facts </li></ul></ul><ul><ul><ul><li>25% risk reduction </li></ul></ul></ul><ul><ul><ul><li>optimal dose still matter of debate </li></ul></ul></ul><ul><ul><ul><li>no proven advantage by low (< 160 mg) versus medium (160 - 325) or high (500 - 1500 mg) doses </li></ul></ul></ul>
  69. 69. Secondary Prevention <ul><li>Antithrombotic drugs </li></ul><ul><ul><li>Dipyridamole + aspirin: </li></ul></ul><ul><ul><ul><li>ESPS II: risk reduction of stroke with a combination is significantly higher (37%) than with aspirin alone </li></ul></ul></ul>
  70. 70. Secondary Prevention <ul><li>Antithrombotic drugs </li></ul><ul><ul><li>Clopidogrel </li></ul></ul><ul><ul><ul><li>CAPRIE: Clopidogrel is slightly but significantly more effective than medium-dose aspirin </li></ul></ul></ul>
  71. 71. Secondary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>1. Low- or medium-dose ASA (50-325 mg) should be given as first-choice agent to reduce stroke recurrence (Level I) . </li></ul></ul><ul><ul><li>2. Alternatively, where available, the combination of ASA (25 mg) and dipyridamole (200 mg) twice daily may be given as first choice (Level I) </li></ul></ul>
  72. 72. Secondary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>3. Clopidogrel is slightly more effective than aspirin (Level I) . It may be prescribed as first-choice or when aspirin is not tolerated or efficacious, and in special indications, such as in high-risk patients (Level III) </li></ul></ul>
  73. 73. Secondary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>4. Patients starting treatment with thienopyridine derivatives should receive clopidogrel instead of ticlopidine since it has fewer side-effects (Level I); </li></ul></ul><ul><ul><li>patients who have already been treated with ticlopidine for a long time should be maintained on this regimen because the most severe side-effects (neutropenia and rash) appear at the beginning of treatment </li></ul></ul>
  74. 74. Secondary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>5. Patients who do not tolerate both ASA or clopidogrel may be treated with dipyridamol ret 2x200 mg daily (Level I) </li></ul></ul>
  75. 75. Secondary Prevention <ul><li>Anticoagulation after thromboembolic stroke </li></ul><ul><ul><li>Facts (EAFT) </li></ul></ul><ul><ul><ul><li>oral anticoagulation with an INR of 2 - 3 reduces the risk of recurrent stroke in patients with AF </li></ul></ul></ul><ul><ul><li>Oral anticoagulation is well established for other causes of embolism such as mechanical prosthetic valve replacement, rheumatic valvular heart disease, ventricular aneurysm, cardiomyopathy, or PFO </li></ul></ul>
  76. 76. Secondary Prevention <ul><li>EUSI-recommendation </li></ul><ul><li> 1. Oral anticoagulation (INR 2.0 - 3.0) is indicated after stroke associated with AF (Level I) </li></ul><ul><ul><li>2. Patients with mechanical prosthetic valves should receive long-term anticoagulation therapy with a target INR between 3.0 and 4.0 (Level III) </li></ul></ul>
  77. 77. Secondary Prevention <ul><li>EUSI-recommendation </li></ul><ul><ul><li>3. Patients with proven cardioembolic stroke should be anticoagulated if the risk of recurrence is high, with a target INR between 2.0 and 3.0 (Level III) </li></ul></ul>
  78. 78. Secondary Prevention <ul><li>Carotid Endarterectomy (CEA) </li></ul><ul><ul><li>Facts (NASCET, ECST) </li></ul></ul><ul><ul><ul><li>surgery is efficacious for symptomatic patients with ipsilateral carotid stenosis > 70% </li></ul></ul></ul><ul><ul><ul><li>if perioperative complications exceed 2.5 %, the benefit of CEA will diminish; if it approaches 10%, the benefit will vanish entirely </li></ul></ul></ul><ul><ul><ul><li>there is also some risk reduction in male patients with 50 - 69% stenosis of the ipsilateral carotid artery </li></ul></ul></ul>
  79. 79. Secondary Prevention <ul><li>Percutaneous Transluminal Angioplasty (PTA) </li></ul><ul><ul><li>Advantages </li></ul></ul><ul><ul><ul><li>short hospital stay </li></ul></ul></ul><ul><ul><ul><li>avoidance of general anesthesia and surgical incision </li></ul></ul></ul><ul><ul><ul><li>ability to treat surgically inaccessible sites </li></ul></ul></ul><ul><ul><li>PTA and stenting as most effective means of treating restenosis after CEA </li></ul></ul><ul><ul><li>preliminary results of controlled trials:comparable procedural risks compared to CEA </li></ul></ul>
  80. 80. Secondary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>1. CEA is indicated in symptomatic patients with stenosis of 70 - 90%. This is valid only for centres with a perioperative complication rate (all strokes and death) < 6% (Level I) </li></ul></ul>
  81. 81. Secondary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>2. CEA may be indicated in some patients with stenosis of 50 - 59% without a severe neurologic deficit. This is valid only for centres with a perioperative complication rate of < 6%. Males with recent hemispheric symptoms are the subgroup of patients most likely to benefit from surgery (Level I) </li></ul></ul>
  82. 82. Secondary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>3. CEA is not recommended for symptomatic patients with stenosis < 50% (Level I) </li></ul></ul><ul><ul><li>4. CEA should not be performed in centres not exhibiting equally low complication rates like NASCET or ECST. </li></ul></ul>
  83. 83. Secondary Prevention <ul><li>EUSI-recommendations </li></ul><ul><ul><li>5. CEA may be indicated for some patients with stenosis between 60 and 99%. Only patients with a low surgical risk (<3%) and a life expectancy of at least 5 years are likely to benefit from surgery (Level II) </li></ul></ul>
  84. 84. Primary Prevention <ul><li>EUSI-recommendations </li></ul><ul><li>6. Surgery for asymptomatic carotid stenosis is not generally recommended (Level II). </li></ul><ul><li> 7. It may be recommended in individual patients if the surgical risk is low </li></ul>
  85. 85. Secondary Prevention <ul><li>EUSI-recommendations </li></ul><ul><li>8. Carotid PTA with or without stenting may be performed in patients with contra-indications to CEA (Level IV) </li></ul><ul><ul><li>9. Carotid PTA with or without stenting may be indicated in patients with stenosis at surgically inaccessible sites (Level IV) </li></ul></ul><ul><ul><li>10. Carotid PTA and stenting may be indicated in patients with re-stenosis after initial CEA (Level IV) </li></ul></ul>