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Management of acute ischaemic stroke: new guidelines from the American Stroke Association and European Stroke Initiative  ...
Background   <ul><li>0·2% of the population each year </li></ul><ul><li>Important cause of death and Dependency  </li></ul...
Background <ul><li>1/2 survivors are permanently disabled Despite best efforts to rehabilitate them and To prevent complic...
Recent developments Guidelines   <ul><li>Stroke Council of the American Stroke Association (ASA; Adams and co-Workers, Str...
Recent developments Guidelines <ul><li>Remarkably similar, even regarding Controversial issues  </li></ul><ul><li>Evidence...
Recent developments Guidelines <ul><li>ASA : Early diagnosis and management  </li></ul><ul><li>Of patients in the first 24...
Diagnosis  <ul><li>Clinical history and examination  </li></ul><ul><li>CT brain scan: most important to Exclude non-vascul...
Diagnosis <ul><li>MRI :Contraindicated in metal implants,  </li></ul><ul><li>Cardiac pacemakers, or  </li></ul><ul><li>Cla...
Diagnosis <ul><li>Further research : Diffusion and Perfusion MRI, magnetic resonance Spectroscopy, may be of additional he...
Stroke-care delivery : Site   <ul><li>Stroke unit rather than a general Medical ward (level I)  </li></ul><ul><li>Reduces ...
Stroke-care delivery : Process  <ul><li>Specialised, organised, and Multidisciplinary(medical, nursing, Physiotherapy, occ...
General supportive care to maintain physiological homoeostasis  <ul><li>Despite the absence of reliable evidence For the e...
General supportive care to maintain physiological homoeostasis <ul><li>Target O 2  saturation: EUSI ≥92%; ASA ≥95%  </li><...
General supportive care to maintain physiological homoeostasis <ul><li>Low blood glucose :rapidly corrected With intraveno...
General supportive care to maintain physiological homoeostasis <ul><li>Management of high BP is Highly controversial </li>...
General supportive care to maintain physiological homoeostasis <ul><li>ASA : nicardipine  </li></ul><ul><li>ASA : 10–15% r...
General supportive care to maintain physiological homoeostasis <ul><li>EUSI : 180/100–105 mm Hg (previous  HTN), and 160–1...
Reperfusion of ischaemic brain   <ul><li>IV alteplase (0·9 mg/kg, at most 90 mg), With 10% as a bolus followed by an Infus...
Reperfusion of ischaemic brain <ul><li>people whose strokes are recognised on waking ?  </li></ul><ul><li>Either streptoki...
Reperfusion of ischaemic brain <ul><li>EUSI :intra-arterial treatment of acute Middle cerebral artery occlusion with Prour...
Reperfusion of ischaemic brain <ul><li>Both :intra-arterial thrombolysis of Acute basilar artery occlusion is limited  </l...
Protection of ischaemic brain cells   <ul><li>Currently, no agent with putative Neuroprotective effects (level I)  </li></ul>
Augmentation of cerebral blood flow   <ul><li>Isovolaemic haemodilution  </li></ul><ul><li>Increasing cerebral perfusion p...
Prevention of early recurrent ischaemic stroke  : Aspirin  <ul><li>Within 48 h unless thrombolytic therapy Is planned (wit...
Prevention of early recurrent ischaemic stroke  : Heparins  <ul><li>Do not recommend routine, urgent use Of heparin, low-m...
Prevention of early recurrent ischaemic stroke  : Heparins <ul><li>ASA :more conservative, does not Recommend urgent antic...
Revascularisation procedures  <ul><li>ASA :no definitive data about carotid Endarterectomy, extracranial–Intracranial arte...
Prevention of complications : Medical complications  <ul><li>Not proven by randomised controlled Trials : but suggested by...
Prevention of complications : Medical complications <ul><li>Infections : appropriate antibiotics ; EUSI : NG tube feeding ...
Prevention of complications : Medical complications <ul><li>ASA : Subcutaneous anticoagulants to Prevent venous thromboemb...
Prevention of complications : Neurological complications( Brain oedema and high intracranial pressure )  <ul><li>Corticost...
Prevention of complications : Neurological complications( Brain oedema and high intracranial pressure ) <ul><li>External v...
Prevention of complications : Neurological complications( Brain oedema and high intracranial pressure )  <ul><li>Surgical ...
Prevention of complications : Neurological complications( Seizures ) <ul><li>Prophylactic use is not recommended (level IV...
Conclusion  <ul><li>Evidence-based, comprehensive, up-to-Date, and consistent overall  </li></ul><ul><li>Accurate diagnosi...
Conclusion <ul><li>Minor disagreements and Inconsistencies between the ASA and EUSI :1.acute treatment of particular Patie...
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Stroke 2003

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Management of acute ischaemic stroke: new guidelines from the American Stroke Association and European Stroke Initiative

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  1. 1. Management of acute ischaemic stroke: new guidelines from the American Stroke Association and European Stroke Initiative The Lancet Neurology Volume 2 • Number 11 • November 2003
  2. 2. Background <ul><li>0·2% of the population each year </li></ul><ul><li>Important cause of death and Dependency </li></ul><ul><li>1/6 patients die in the first month </li></ul>
  3. 3. Background <ul><li>1/2 survivors are permanently disabled Despite best efforts to rehabilitate them and To prevent complications, recurrent stroke, And other serious vascular events </li></ul><ul><li>Early, and ongoing, management : Reduction of both case fatality and Long-term disability </li></ul>
  4. 4. Recent developments Guidelines <ul><li>Stroke Council of the American Stroke Association (ASA; Adams and co-Workers, Stroke 2003; 34: 1056–83) </li></ul><ul><li>European Stroke Initiative (EUSI; European Stroke Initiative Executive Committee and Writing Committee, Cerebrovasc Dis 2003; 16: 311–38) </li></ul>
  5. 5. Recent developments Guidelines <ul><li>Remarkably similar, even regarding Controversial issues </li></ul><ul><li>Evidence-based medicine and a major Step </li></ul>
  6. 6. Recent developments Guidelines <ul><li>ASA : Early diagnosis and management </li></ul><ul><li>Of patients in the first 24–48 h of </li></ul><ul><li>Ischaemic stroke </li></ul><ul><li>EUSI :Primary and secondary stroke </li></ul><ul><li>Prevention, rehabilitation, </li></ul><ul><li>Improvement of public awareness of </li></ul><ul><li>The symptoms of stroke, and the need </li></ul><ul><li>For urgent medical attention after a </li></ul><ul><li>Stroke </li></ul>
  7. 7. Diagnosis <ul><li>Clinical history and examination </li></ul><ul><li>CT brain scan: most important to Exclude non-vascular, structural, Intracranial lesions , brain ischaemia And haemorrhage </li></ul>
  8. 8. Diagnosis <ul><li>MRI :Contraindicated in metal implants, </li></ul><ul><li>Cardiac pacemakers, or </li></ul><ul><li>Claustrophobia ; and less widely </li></ul><ul><li>Available, more costly, And less </li></ul><ul><li>Reliable in identifying acute ICH </li></ul><ul><li>MRI :Sensitive in the detection of brain </li></ul><ul><li>Infarction </li></ul>
  9. 9. Diagnosis <ul><li>Further research : Diffusion and Perfusion MRI, magnetic resonance Spectroscopy, may be of additional help For the assessment of the risk to Benefit ratio for early reperfusion Therapy </li></ul><ul><li>Vascular imaging (ultrasound, CT Angiography, and magnetic resonance Angiography) </li></ul>
  10. 10. Stroke-care delivery : Site <ul><li>Stroke unit rather than a general Medical ward (level I) </li></ul><ul><li>Reduces the odds of death or Dependency : 22% (95% CI 11–32) </li></ul><ul><li>Monitoring in an intensive care setting Is not necessary </li></ul>
  11. 11. Stroke-care delivery : Process <ul><li>Specialised, organised, and Multidisciplinary(medical, nursing, Physiotherapy, occupational therapy, Speech therapy, and social work staff) </li></ul>
  12. 12. General supportive care to maintain physiological homoeostasis <ul><li>Despite the absence of reliable evidence For the effectiveness of interventions Aimed at the maintenance of Physiological homoeostasis </li></ul><ul><li>Airway support and ventilatory Assistance:reduced consciousness or a Compromised airway </li></ul>
  13. 13. General supportive care to maintain physiological homoeostasis <ul><li>Target O 2 saturation: EUSI ≥92%; ASA ≥95% </li></ul><ul><li>Antipyretic agents : if the body Temperature is high (high temperature Defined as: EUSI ≥37·5°C; ASA no Temperature threshold stated) </li></ul><ul><li>Gradual lowering of high glucose concentrations : (target glucose : EUSI about 10 mmol/L; ASA <16·63 mmol/L) with normal Saline and insulin titration </li></ul>
  14. 14. General supportive care to maintain physiological homoeostasis <ul><li>Low blood glucose :rapidly corrected With intravenous dextrose bolus or Infusion of 10–20% glucose </li></ul><ul><li>Hypotonic solutions (NaCl 0·45% or Glucose 5%) should be avoided </li></ul>
  15. 15. General supportive care to maintain physiological homoeostasis <ul><li>Management of high BP is Highly controversial </li></ul><ul><li>Lowering of BP unless : >200–220 mm Hg systolic or >120 mm Hg diastolic in Ischaemic stroke ; >180/105 mm Hg in a patient with haemorrhagic stroke </li></ul><ul><li>Labetalol and sodium nitroprusside </li></ul><ul><li>Avoidance of drugs such as sublingual Nfedipine </li></ul>
  16. 16. General supportive care to maintain physiological homoeostasis <ul><li>ASA : nicardipine </li></ul><ul><li>ASA : 10–15% reduction </li></ul><ul><li>EUSI : intravenous urapidil, Nitroglycerin, and oral captopril </li></ul>
  17. 17. General supportive care to maintain physiological homoeostasis <ul><li>EUSI : 180/100–105 mm Hg (previous HTN), and 160–180/90–100 mm Hg in Patients (without previous HTN) </li></ul><ul><li>Both : <180/110 mm Hg before Thrombolysis is potentially indicated </li></ul>
  18. 18. Reperfusion of ischaemic brain <ul><li>IV alteplase (0·9 mg/kg, at most 90 mg), With 10% as a bolus followed by an Infusion Lasting 60 min: selected Patients within 3h of Onset of ischaemic Stroke </li></ul><ul><li>Reduces the odds of death or Dependency at Final follow-up by 44% </li></ul><ul><li>110 people (50–170) from death or Dependency for every 1000 treated </li></ul>
  19. 19. Reperfusion of ischaemic brain <ul><li>people whose strokes are recognised on waking ? </li></ul><ul><li>Either streptokinase or ancrod (a defibrinating enzyme) >>> (x) </li></ul><ul><li>3 times, both the risk of symptomatic ICH (10% with alteplase vs 3% with placebo; absolute excess 62 per 1000 patients treated) and of fatal ICH within 7–10 days (4% vs 1%;25 per 1000 patients treated; level 1) </li></ul>
  20. 20. Reperfusion of ischaemic brain <ul><li>EUSI :intra-arterial treatment of acute Middle cerebral artery occlusion with Prourokinase in a 6 h time window : Improved outcome (level II) </li></ul><ul><li>ASA :more conservative,selected Patients,not approved by the FDA(no at Least two double-blind, placebo-Controlled, randomised trials ) </li></ul>
  21. 21. Reperfusion of ischaemic brain <ul><li>Both :intra-arterial thrombolysis of Acute basilar artery occlusion is limited </li></ul>
  22. 22. Protection of ischaemic brain cells <ul><li>Currently, no agent with putative Neuroprotective effects (level I) </li></ul>
  23. 23. Augmentation of cerebral blood flow <ul><li>Isovolaemic haemodilution </li></ul><ul><li>Increasing cerebral perfusion pressure (eg, hypervolaemic haemodilution) </li></ul><ul><li>Both :not been established as useful </li></ul><ul><li>ASA :risk of serious neurological and Cardiovascular complications </li></ul>
  24. 24. Prevention of early recurrent ischaemic stroke : Aspirin <ul><li>Within 48 h unless thrombolytic therapy Is planned (withheld for 24 h ) </li></ul><ul><li>160–300 mg/day reduced the odds of Recurrent stroke during the treatment Period by 13% and of death or Dependency at the end of follow-up by 5% </li></ul><ul><li>ASA : no recommendation of other Antiplatelet drugs in acute ischaemic stroke </li></ul>
  25. 25. Prevention of early recurrent ischaemic stroke : Heparins <ul><li>Do not recommend routine, urgent use Of heparin, low-molecular weight Heparin, or heparinoids after ischaemic Stroke </li></ul><ul><li>Risk of haemorrhagic transformation </li></ul><ul><li>EUSI :cardiac sources with a high risk Of re-embolism, arterial dissection, or High grade arterial stenosis before Surgery (level IV) </li></ul>
  26. 26. Prevention of early recurrent ischaemic stroke : Heparins <ul><li>ASA :more conservative, does not Recommend urgent anticoagulation for Patients with moderate-to-severe stroke Because of a high risk of serious Intracranial bleeding complications </li></ul>
  27. 27. Revascularisation procedures <ul><li>ASA :no definitive data about carotid Endarterectomy, extracranial–Intracranial arterial bypass, or Endovascular treatments (eg, stent, Angioplasty, clot removal, suction Thrombectomy, and thrombolysis Assisted by laser and power Doppler) Within the first few hours to days of Acute ischaemic stroke </li></ul><ul><li>EUSI :does not discuss these </li></ul>
  28. 28. Prevention of complications : Medical complications <ul><li>Not proven by randomised controlled Trials : but suggested by both that early Mobilisation is favoured to prevent Complications including aspiration Pneumonia, venous thromboembolism, Decubital ulcers (pressure sores), and Contractures </li></ul>
  29. 29. Prevention of complications : Medical complications <ul><li>Infections : appropriate antibiotics ; EUSI : NG tube feeding can’t prevent Aspiration pneumonia (level IV) </li></ul><ul><li>Venous thromboembolism : early rehydration And mobilisation, and graded external Compression stockings (level IV), and that Low dose subcutaneous heparin or low Molecular weight heparins should only be Used in patients at high risk of venous Thromboembolism (level II) by EUSI </li></ul>
  30. 30. Prevention of complications : Medical complications <ul><li>ASA : Subcutaneous anticoagulants to Prevent venous thromboembolism for All immobilised patients, or the use of Intermittent external graduated Compression stockings or aspirin for Patients who cannot receive Anticoagulants </li></ul>
  31. 31. Prevention of complications : Neurological complications( Brain oedema and high intracranial pressure ) <ul><li>Corticosteroids have no place in Cerebral oedema and may cause IICP (level 1) </li></ul><ul><li>Osmotherapy and hyperventilation : Condition is deteriorating secondary to High intracranial pressure, including Herniation syndromes (level IV) </li></ul>
  32. 32. Prevention of complications : Neurological complications( Brain oedema and high intracranial pressure ) <ul><li>External ventricular drainage or Ventriculostomy : treat IICP due to Hydrocephalus (level III) </li></ul><ul><li>Surgical decompression and evacuation Of large cerebellar infarctions that Compress the brainstem and cause Hydrocephalus is justified (level III) </li></ul>
  33. 33. Prevention of complications : Neurological complications( Brain oedema and high intracranial pressure ) <ul><li>Surgical decompression with evacuation Of a large hemispheric infarction can be A life-Saving measure but needs further Investigation </li></ul><ul><li>ASA :most survivors have severe Residual Neurological deficits (level III) </li></ul><ul><li>EUSI :survivors may have residual Neurological deficit that allows an Independent life (level III) </li></ul>
  34. 34. Prevention of complications : Neurological complications( Seizures ) <ul><li>Prophylactic use is not recommended (level IV) </li></ul><ul><li>Recurrent seizures should be treated </li></ul>
  35. 35. Conclusion <ul><li>Evidence-based, comprehensive, up-to-Date, and consistent overall </li></ul><ul><li>Accurate diagnosis, early reperfusion, Implementation of effective therapies to Minimise recurrent stroke and Complications, and maximised Rehabilitation : improve patient Outcome </li></ul>
  36. 36. Conclusion <ul><li>Minor disagreements and Inconsistencies between the ASA and EUSI :1.acute treatment of particular Patients with intra-arterial thrombolysis, Heparin, and craniectomy </li></ul><ul><li>2.Secondary prevention with clopidogrel as a Substitute for ticlopidine; and heparin Prophylaxis of venous thromboembolism Reflect different interpretations of unreliable (level III and level IV) evidence </li></ul>
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