El Ictus

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  • The European Stroke Initiative
    Recommendations for Stroke Management
    Update 2003
    European Stroke Initiative (1, 2)
    (1)For the European Stroke Initiative Executive Committee
    (Werner Hacke, Heidelberg, Germany; Markku Kaste, Helsinki, Finland, Julien Bogousslavsky, Lausanne, Switzerland; Michael Brainin, Maria Gugging, Austria; Angel Chamorro, Barcelona, Spain; Kennedy Lees, Glasgow, United Kingdom; Didier Leys, Lille, France; Hubert Kwiecinski, Warsaw, Poland; Danilo Toni, Rome, Italy)
    and the EUSI Writing Committee
    (Tom Skyhoj Olsen, Copenhagen, Denmark; Peter Langhorne, Glasgow, United Kingdom; Hans Christoph Diener, Essen, Germany; Michael Hennerici, Mannheim, Germany; Jose Ferro, Lisbon, Portugal; Johani Sivenius, Kuopiu, Finland; Nils Gunnar Wahlgren, Stockholm, Sweden; Philip Bath, Nottingham, United Kingdom)
    (2) On behalf of the European Stroke Council (ESC), The European Neurological Society (ENS) and the European Federation of Neurological Societies (EFNS)
    Reprint adress:
    WERNER HACKE MD PhD
    Department of Neurology, University of Heidelberg
    INF 400
    D 69120 HEIDELBERG GER
    phone: +49 6221 568210 fax: +49 6221 565348
    e-mail:werner_hacke@med.uni-heidelberg.de
  • 1ª parte: Un nuevo modelo de atención al ictus
    Educación sanitaria , sensibilizar población, opinión pública, reestructuración de los servicios de urgencias, optimización de neuroimagen y neurodiagnóstico, unidades de neurovascular , rehabilitación.
    2ªparte a: factores de riesgo y prevención primaria.
    Factores de riesgo modificables y no modificable, estilo de vida, prevención primaria médica,quirúrgica o intervencionista.
    2ªparte b: prevención secundaria. Médica, antitrombótica, quirúrgica, intervencionista.
    3ªparte: Manejo de la fase aguda
    tratamiento general( hipertensión y otras patologías no neurológicas)
    tratamiento específico ( trombolisis, anticoagulación) , ICP?
  • 1ª parte: un nuevo modelo de atención al paciente neurovascular
  • Introduction
    The European Stroke Initiative Recommendations for Stroke Management were first published in this Journal in 2000. The first publication was well received and was followed by a lengthier supplement to Cerebrovascular Diseases. After 3 years, the EUSI Executive Committee felt that there were enough new data to justify a complete revision of the recommendations. The EUSI Executive Committee also decided, that the consensus for the recommendations should have a broader base and therefore invited several European stroke neurologists from different countries to join the writing group. The members of both, Writing Group and Executive Committee met for 3 days in December 2002 in Heidelberg and prepared the new recommendations. The recommendations from the European Stroke Initiative (EUSI) published in 2000 (European Stroke Initiative 2000) have now been completely revised and updated. In accordance with the European Neurological Society (ENS), the European Federation of Neurological Society (EFNS) and the European Stroke Council (ESC), which also represents the European Stroke Conference, they provide an overview of established or widely used therapeutic strategies as well as an evaluation of evolving, but not yet proven strategies. These are discussed in detail as well as classified according to their scientific levels of evidence. On the basis of such evidence, specific recommendations are made. Experts’ opinions on several issues on stroke prevention and treatment can be assessed at the EUSI website free of charge at www.eusi-stroke.com. These lectures represent an extension of many issues discussed in these recommendations but have not passed the consensus process of the EUSI documents and therefore only reflect the opinion of the lecturing experts.
    The levels of evidence in this article are defined by the same criteria as in the previous recommendations. They correspond to those published by the EFNS (Hughes et al. 2001) and are listed in this slide.
  • The aims of public education initiatives are to enable and encourage the general population to recognise immediately the symptoms of stroke, to realise that urgent medical attention is needed, and to use the emergency transportation services and immediately go to an adequately equipped hospital. Primary contact with general practitioners may cause delays and prevent early start of adequate therapy (Evenson et al. 2000). Educational efforts should be directed to patients at risk for stroke, their families, caregivers or co-workers and to large employers (Wein et al 2000). Teaching the public about symptoms and signs of stroke is one of the highest priorities of public medical education.
    Inaccurate initial diagnosis by professional groups represents a major problem. Ambulance dispatchers may have false positive assessment rate of up to 50%, and even in trained paramedics, this rate is about 25% (Kothari et al. 1997). However, this result can be improved by adequate training (Kothari et al. 1997).
    Physicians also need to be trained in the recognition of symptoms and signs of acute stroke and the necessity of immediate transportation to an adequately equipped unit. The medical personnel should be trained in recognising the acute presentations of ischaemic stroke and should be able to cope with the early complications after stroke. Training should include the ability to conduct a medical examination that focuses on the level of consciousness, presence of focal weakness, presence of seizure activity and recognition of aphasia and other major cognitive disturbances. The concept of “Time is Brain” should be understood by all involved in the “Stroke Chain of Survival”. No waste of time should be allowed when the patient has arrived to hospital and written standards for in-hospital delays should be available in hospitals receiving patients with acute stroke. Although such pathways have not been shown to be effective by themselves (Kwan and Sandercock 2003) they can be considered effective in preventing in-hospital delays. One example is that set by the National Institute of Neurological Disorders and Stroke in 1997 (National Institute of Neurological Disorders and Stroke 1997).
  • Stroke is a medical and occasionally also a surgical emergency. Successful care of the acute stroke victim begins with the recognition both by the public and the health professional that stroke is an emergency, like acute myocardial infarction and trauma. The majority of stroke patients do not receive adequate therapy because they do not reach the hospital soon enough (Barber et al. 2001). Successful care of the acute stroke victim as an emergency depends on a 4-step chain:
    1.Rapid recognition of and reaction to stroke warning signs,
    2.Immediate use of emergency medical system (EMS) services
    3.Priority transport with notification of the receiving hospital and
    4.Rapid and accurate diagnosis and treatment at the hospital.
    Failure to recognise stroke symptoms and consulting a primary physician delay the interval between stroke onset and hospital arrival (Ferro et al. 1994; Derex et al. 2002; Harraf et al. 2002).
    Once stroke symptoms are suspected, patients or their proxies should call the emergency medical system. Ambulance transportation decreases the delay onset of stroke hospital arrival (level III). Helicopter transport is playing an increasing role in transfer of patients with stroke between hospitals and should be activated earlier (Thomas et al. 2002). The EMS system should have an electronic validated algorithm of questions to diagnose stroke during the phone interview with the patient/proxy (Porteus et al. 1999; Camerlingo et al. 2001). Patients with onset of stroke symptoms within less than 3 hours should be given priority in evaluation/transportation by EMS. The EMS ambulance dispatchers should be able to recognise stroke symptoms and signs (Kothari et al. 1997) and identify and provide appropriate help for patients who need emergent care because of impaired consciousness, seizures, vomiting, haemodynamic instability or other early complication or co-morbidity of stroke.
    If a general practicioner or other doctor receives a call or consults a patient with suspected stroke, he/she should recommend/arrange emergent transportation, preferably through the EMS system, to the nearest emergency room of a hospital providing organized acute stroke care or stroke unit if available. The EMS ambulance dispatchers should inform the stroke unit personnel that they are going to refer a stroke patient and describe the clinical status.
    The initial evaluation of stroke patients can be made by emergency room doctors. In fact, emergency room doctors can correctly make the diagnosis of stroke in about 90% of cases (Ferro et al. 1998).
    Patients with subarachnoid haemorrhage should be referred urgently to a hospital where neurosurgical treatment, neuroradiological interventions and intensive care are available.
  • Stroke care should take place in a stroke unit. A meta-analysis by the Stroke Unit Trialist's collaboration (Stroke Unit Trialists' Collaboration 2002) showed a 18% relative reduction in mortality, a reduction in death or dependence and a reduction in death or need of institutional care when treated in a stroke unit in comparison to a general medical ward (level I). The absolute changes indicated a 3% reduction in all cause mortality (NNT 33), a 3% reduction in the need for nursing home care, and a 6% increase in the number of independent survivors (NNT 16). All types of patients with stroke benefit from treatment and rehabilitation in stroke units: males and females, young and elderly stroke patients and patients with mild, moderate and severe strokes.
    A stroke unit consists of a hospital unit or part of a hospital unit that exclusively or nearly exclusively takes care of stroke patients. A survey across Europe showed that various forms of stroke unit care exist (Brainin et al.2000). Most of such stroke units provide a co-ordinated multidisciplinary approach to treatment and care. The core disciplines of such a multidisciplinary team are: medical treatment, nursing, physiotherapy, occupational therapy, speech and language therapy and social work. The multidisciplinary team should have a specialist interest in stroke management and work in a coordinated way (through regular meetings to plan patient care). Programmes of regular staff education and training should be in place.
    The typical components of care in the stroke unit trials (Langhorne et al. 2002) were as follows:
    a) Assessment - medical assessment and diagnosis including CT scanning, early assessment of nursing and therapy needs.
    b) Early management policies - early mobilisation, prevention of complications, treatment of hypoxia, hyperglycaemia, pyrexia and dehydration.
    c) Ongoing rehabilitation policies (coordinated multidisciplinary team care, early assessments of needs after discharge).
  • The typical components of care in the stroke unit trials (Langhorne et al. 2002) were as follows:
    a) Assessment - medical assessment and diagnosis including CT scanning, early assessment of nursing and therapy needs.
    b) Early management policies - early mobilisation, prevention of complications, treatment of hypoxia, hyperglycaemia, pyrexia and dehydration.
    c) Ongoing rehabilitation policies (coordinated multidisciplinary team care, early assessments of needs after discharge).
  • Stroke units are described in several categories:
    (1) The acute stroke unit admitting patients acutely and continuing treatment several days but usually less than 1 week.
    (2) The comprehensive stroke unit admitting patients acutely and continuing treatment and rehabilitation for several weeks if necessary.
    (3) The rehabilitation stroke unit admitting patients after a delay of 1 or 2 weeks and continuing treatment and rehabilitation for several weeks or months if necessary.
    (4) A mobile stroke team is a mobile team offering stroke care and treatment to stroke patients at a variety of wards. Such teams are usually established in hospitals where stroke units are not available.
    Of these only the comprehensive stroke unit and the rehabilitation stroke unit have proven effectiveness in terms of reduced mortality and handicap (Stroke Unit Trialists' Collaboration 2002).
    The size of a stroke unit should be adequate to provide specialist multidisciplinary stroke unit care for the whole duration of hospital admission. In practice this is often achieved with a single comprehensive unit (in smaller hospitals) or a combination of acute unit and rehabilitation units (in larger hospitals). Further evidence is needed to recommend type and size of the most effective stroke units in more detail.
  • The time window for treatment of patients with acute stroke is narrow. Acute emergency management of stroke therefore requires parallel processes at different levels of patient management. For example, acute assessment of neurological and vital functions parallels treatment of acutely life-threatening conditions. The selection of special treatment strategies may already be ongoing before the final decision on the subtype of acute stroke has been made. Time is the most important factor, especially the minutes and first hours after stroke onset. The acute stroke patient, even the one with milder symptoms, must be recognised as an urgently ill medical patient [Brott et al., 1994; Brott and Reed, 1989; Adams et al., 1994]. The patient has to be transported to an emergency unit, and the examining physician must assess the stroke patient with the priority for a life-threatening and disabling illness. Only a minority of the stroke patients present with an immediate life-threatening condition, but many have severe abnormalities in basic physiologic functions. Symptoms and signs which may predict later complications such a space-occupying infarction or bleeding, recurrent stroke, and medical conditions such as hypertensive crisis, co-existing myocardial infarction, aspiration pneumonia and renal failure must be recognised early. Also, early assessment of stroke subtypes based on the physical and neurological evaluation as well as on skilled interpretation of the results of CT- and MRI-scanning is essential for the prediction of a high risk of early recurrence.
  • The initial examination includes observation of breathing and pulmonary function, concomitant heart disease, assessment of blood pressure and heart rate, and determination of arterial oxygen saturation using infrared pulse-oxymetry if available. Simultaneously, blood samples for clinical chemistry, coagulation and haematology studies are drawn, and a venous line is inserted. Standard electrolyte solutions are given until clinical chemistry results are available. After the emergency assessment, which in part will be done by emergency nurses or other ER personnel, the neurologist should perform a targeted neurological examination. The examination is supplemented, if possible, by a careful medical history focussing on risk factors for ateriosclerosis and cardiac disease. Especially in young patients, a history of drug abuse, oral contraceptive use, infection, trauma or migraine may give important clues.
  • Cranial computerised tomography (CT) is widely available and not only reliably distinguishes between haemorrhage and ischemic stroke or subarachnoid haemorrhage but can also rule out many other brain diseases. Signs of early ischemia can sometimes be detected as early as two hours after stroke onset, but this may be difficult even for the trained examiner, in particular in very early studies. Early infarct signs include sulcus effacement, swelling of the basal ganglia and the hyper-intense middle cerebral artery sign. Early signs of extensive infarction with intracranial midline shifts indicate a very serious event and a high risk, both for secondary haemorrhage and large malignant oedema formation and may justify repeated imaging after a short interval.
    Parenchymal haemorrhage can be identified almost immediately either in deep structures in patients with hypertension or in atypical areas in patients without hypertension or under adequate treatment, usually due to cerebral amyloid angiopathy. Infratentorial haemorrhage or cerebellar infarcts can be identified similar to supratentorial lesions, but smaller haemorrhages/ischemic infarcts in particular in the brain stem may easily be missed. In addition, CT may detect subarachnoid blood in the majority of cases with subarachnoid hemorrhage. Sometimes haemorrhages may even be interpreted as primary, but indeed are secondary to ischemic events. involvement of clearly defined vascular territories are indicative of such conditions, which are easier to identify in MRI studies. Brain haemorrhages tend to grow in the first 6-12 hours after stroke in about 40%-50% of all patients even without clinical deterioratio, which makes a second early CT study necessary. CT angiography (CTA) is a reliable tool to obtain information on extra- and intracranial arterial patency, and its use in clinical practice often adds value to the diagnostic work-up (Schellinger et al. 2003).
  • Magnetic resonance imaging (MRI) is more sensitive and is increasingly used in referral hospitals with stroke unit expertise as a standard procedure. Recent objections because of a suspected lower sensitivity to identify brain haemorrhages have been overcome by modern MRI techniques such as T2*-weighted imaging, which indeed are even more sensitive than CT scanning for the display of intracerebral hemorrhage. Diffusion-weighted MR is very sensitive for early detection of the damaged brain tissue and combined with perfusion-weighted MR may help in identifying patients who benefit from early thrombolysis. In fact, current concepts suggest that patients with a significant perfusion-diffusion mismatch may benefit from restoration of the ischemic penumbra surrounding an already necrotic core of infarction, whereas those with overlapping areas of diffusion and perfusion deficits have a less favourable benefit risk ratio. These MR techniques are not yet available on a large scale but do seem promising tools for future routine applications. MR angiography can be used to identify occlusions of major intracranial arteries but should carefully be interpreted if studies from extracranial cerebral arteries are missing. In this case ultrasound can be useful to identify severe haemodynamical relevant carotid obstructions, which are likely to produce significant perfusion deficits in small embolic or lacunar strokes and may thus mimic falsely a remarkable perfusion-diffusion mismatch. MR angiography also has a role in evaluating the venous system and aneurysms down to 3mm diameter.
  • Ultrasound studies are routinely performed in stroke centres. The major goal is to identify large obstructive lesions in the extracranial as well as in the intracranial basal arteries. In addition transcranial Doppler may be useful to monitor spontaneous or drug-induced thrombolysis in the majority of patients. In about one quarter of the patients it is not possible or very difficult to get adequate signals through the temporal bone window without application of contrast agents. The detection of rare causes of ischaemic stroke, such as dissections, intimal hyperplasia and other less frequent etiologies is facilitated by the systematic use of ultrasound studies. Trans-oesophageal and trans-thoracic echocardiography frequently is indicated in suspected cardio-embolic stroke but usually is not performed on an emergency basis. It seems useful to have these studies available within the first 24 hours after onset of stroke to choose the best available secondary prevention, in particular in the presence of cardiac sources of embolism. They can also sometimes be identified by means of MCA monitoring if high intensity transient signals are observed.
  • Forty percent of stroke patients need active rehabilitation services. Rehabilitation of a stroke victim is started as soon as he/she is clinically stable. The intensity of the actual rehabilitation program depends on the status of the patient and the degree of the disability. In patients incapable of active training, passive methods may be used to prevent contractions and joint pain and to prevent distress for the patient when active movement is possible. Passive rehabilitation measures also minimise the risk of bedsores and pneumonia. All joints on the paralysed side are moved through the full range of motion several times a day (3-4 times at least). Co-operateíve patients are encouraged to take an active part in the rehabilitation program. Prolonged immobilisation and hemiplegia carry the risk of deep venous thrombosis and pulmonary embolism.
  • Treatment in dedicated stroke rehabilitation wards is based on multidisciplinary team- work consisting of a physician, physiotherapist, speech therapist, occupational therapist, neuropsychologist, social worker and nurse (Stroke Unit Trialists' Collaboration 2002). In such a unitthere is a motivating and encouraging attitude that maintains the patient’s desire to improve. Important is a milieu of an “enriched environment”, where patients feel comfortable, and which supports patient’s efforts and encourages him/her to practise even beyond working hours (Johansson 2000) Elderly stroke patients may equally benefit from the well-organised management of stroke (Kaste et al 1995; Jørgensen at al. 2000).
  • Primary prevention aims to reduce the risk of stroke in asymptomatic people. Recommendations concerning patients with transient ischaemic attacks (TIA) are considered here as secondary prevention.
  • Elevated blood pressure is strongly and directly related to vascular and overall mortality without any evidence of a threshold [Prospective Studies Collaboration 2002]. Lowering high blood pressure substantially reduces this risk, depending on the magnitude by which blood pressure is lowered [ Neal et al 2000, Staessen et al 2001]. Most studies comparing different drugs have not suggested that any class is superior (Neal et al 2000, Staessen et al 2001), except Losartan (50-100 mg) v.s. Atenolol (Dahlof et al 2002) and Chlorthalidone v.s. Amlodipine and Lisinopril [ALLHAT investigators 2002].
  • Since there are other good reasons to treat diabetes appropriately, it seems prudent to do so in those at risk for stroke. Blood pressure should be lowered more aggressively in diabetics to achieve levels below 135/80 mmHg [Turner et al 1999].
    The American Diabetes Association recommends using Aspirin in primary prevention for anyone with diabetes older than 30 years with no known contra-indications (American Diabetes Association, 2000).
  • Three primary or combined primary / secondary prevention trials were unable to show a significant reduction in stroke rate under Pravastatin [ALLHAT investigators 2002, WOSCOP study group 1998, Shepherd et al 2002], despite a tendency (minus 11%) in men [WOSCOP study group 1998]. In the larger Heart Protection Study [2002], the reduction in the event rate under simvastatin was significant even in those with LDL cholesterol below 3.0 mmol/L (116 mg/dL), or total cholesterol below 5.0 mmol/L (193 mg/dL). The annual excess of myopathies was of 1 per 10,000 patients treated [Heart Protection Study 2002].
  • Cohort studies have shown cigarette smoking to be an independent risk factor for ischaemic stroke in men [Abbott et al 1986] and women [Colditz et al 1988]. A meta-analysis of 22 studies indicates that smoking doubles the risk of ischemic stroke [Shinto et al 1989]. Subjects who stop smoking reduce this risk by 50% [Colditz et al 1988].
  • Heavy alcohol drinking (more than 60 g/d) increases the risk of stroke, while light or moderate alcohol consumption may be protective against all strokes and ischaemic strokes [Reynolds et al 2003]. Consumption of up to 12 g of alcohol per day was associated with a reduced relative risk (RR) of all strokes (RR: 0.83), and of ischaemic stroke (RR: 0.80) [13]. Moderate consumption (12 to 24 g. per day) was associated with a reduced risk of ischaemic stroke (RR: 0.72) [Reynolds et al 2003].
  • In men, vigorous exercise was associated with a decreased risk of stroke [Lee et al 1999]. The data suggested that this association was mediated through beneficial effects on body weight, blood pressure, serum cholesterol, and glucose tolerance, and that, apart from these effects, physical activity had no influence on stroke incidence. Substantial evidence supports the use of diets high in non-hydrogenated unsaturated fats, whole grains, fruit and vegetables, fish once a month, and adequate omega-3-fatty acids, to reduce the risk of ischaemic heart disease, and probably stroke [Hu et al 2002, He et al 2002].
  • Stroke rates rise rapidly in women once they become menopausal. However, in an analysis based on a 16-year follow-up of 59,337 postmenopausal women participating Nurses’ Health Study, there was only a weak association between stroke and oestrogen replacement [Grodstein et al 2001]. According to the HERS II trial, hormone replacement in healthy women is associated with an increased risk of ischaemic stroke [Grady et al 2002].
  • A meta-analysis [Hart et al 2000] of the five trials [Peto et al 1988, Physicians Health research group 1989, EDTRS investigators 1992, Hanson et al 1998, Mead 1998] comparing aspirin with no aspirin in 52,251 subjects after a mean follow-up of 4.6 years, found no effect on stroke rate. A further trial found that aspirin (100 mg per day) was associated with in a non-significant reduction in stroke of 33% [de Gaetano 2001]. No data are available on the use of other antiplatelet agents in primary prevention. There is no proof that aspirin is beneficial in patients with asymptomatic internal artery stenosis, but these patients being at increased risk for MI, there is a consensus to use aspirin.
  • Warfarin reduces the rate of ischaemic stroke by 70% in patients with atrial fibrillation (AF), with an optimal International Normalised Ratio (INR) level between 2.0 and 3.0 [EAFT group 1995]. In this group, Aspirin (300 mg per day) reduces stroke by 21% and is significantly less efficacious than warfarin [Hart et al 1998]. As the annual rate of stroke among people with AF is very wide, risk stratification should be used to determine whether patients should be given oral anticoagulation, aspirin or nothing [Fuster et al 2001]. Oral anticoagulation has a higher chance to be effective in patients with AF who have one or more risk factors, such as a previous ischaemic stroke, or TIA or a previous systemic embolism, age over 75 years, high blood pressure, or poor left ventricular function [Fuster et al 2001]. ]. In patients over 75 years, warfarin used with a high INR values (range 3.0 - 4.5) increase the risk of haemorrhage [The Stroke Prevention in Reversible Ischaemia Trial Study Group. 1997]. Patients with AF who have prosthetic heart valves should receive long-term anticoagulation with a target INR based on the prosthesis type, but not less than INR 2 to 3 [Fuster et al 2001].
  • The Asymptomatic Carotid Athero-sclerosis Study (ACAS), reported that patients with an asymptomatic carotid stenosis greater than 60% had a 5-year RR reduction of 53% of ipsilateral stroke if carotid surgery was performed [ACAS Executive Committee 1995]. However, the absolute risk reduction was small (5.9% in five years), as was the rate of ipsilateral stroke in the medically treated group (11.0% in five years, or 2.3% annually). Moreover, these results were achieved with a perioperative rate of complications (stroke or death) of only 2.3%. A meta-analysis of 5 trials of carotid surgery for asymptomatic carotid stenosis concluded that, although surgery reduces the incidence of ipsilateral stroke, the absolute benefit of carotid surgery is small, as the rate of stroke in medically treated patients is low [Benavente et al 1998]. Medical management alone is the best alternative for many asymptomatic subjects.
  • The Asymptomatic Carotid Athero-sclerosis Study (ACAS), reported that patients with an asymptomatic carotid stenosis greater than 60% had a 5-year RR reduction of 53% of ipsilateral stroke if carotid surgery was performed [ACAS Executive Committee 1995]. However, the absolute risk reduction was small (5.9% in five years), as was the rate of ipsilateral stroke in the medically treated group (11.0% in five years, or 2.3% annually). Moreover, these results were achieved with a perioperative rate of complications (stroke or death) of only 2.3%. A meta-analysis of 5 trials of carotid surgery for asymptomatic carotid stenosis concluded that, although surgery reduces the incidence of ipsilateral stroke, the absolute benefit of carotid surgery is small, as the rate of stroke in medically treated patients is low [Benavente et al 1998]. Medical management alone is the best alternative for many asymptomatic subjects.
  • Antiplatelet therapy
    A meta-analysis of 287 trials [Antiplatelet Trialists Collaboration 2002], showed a 25% relative reduction of serious vascular events (non-fatal myocardial infarction, non-fatal stroke, or vascular death) under antiplatelet therapy in patients with previous ischaemic stroke or TIA: when 1000 patients are treated for 2 years, 36 events are prevented among those with previous stroke or TIA, and this benefit substantially outweigh the absolute risks of major extra-cranial bleeding [Antiplatelet Trialists Cooperation 2002]. Another meta-analysis has attributed a more modest 13%RRR under antiplatelet therapy (Algra et al., 2000)
    Aspirin: studies directly comparing the effects of different doses of aspirin failed to show differences in stroke recurrences [Dutch TIA group 1991, Farrell et al 1991]. The risk benefit ratio of adding another antithrombotic drug to aspirin has not been fully studied.
  • Dipyridamole plus Aspirin: the ESPS II study [Diener et al 1996], a randomised, double blind, placebo-controlled trial showed that the combination of aspirin (50mg) plus dipyridamole (400 mg) doubles the effect of aspirin alone, and of dipyridamole alone: the RRR versus placebo were 37%, 18% and 16% respectively.
  • Clopidogrel is slightly more effective than aspirin in preventing vascular events [CAPRIE Steering Committee 1996]. It is the agent of choice in patients with contraindications, or adverse effects, to aspirin, and may be more effective in higher risk patients (i.e. with a previous stroke, peripheral artery disease, symptomatic coronary disease and diabetes) and after coronary surgery [Bhatt et al 2000].
  • Oral anticoagulation (INR 2.0-3.0) reduces the risk of recurrent stroke in patients with non-valvular AF and recent ischaemic stroke [EAF study group 1995, Fuster et al 2001].
    Although evidence from randomised trials is lacking, long-term anticoagulation is routinely used for patients with mechanical prosthetic valves, with a target INR between 3.0 and 4.0 [Cannegieter 1995]. There is no argument supporting oral anticoagulation in non-cardiac ischaemic strokes [Mohr et al 2001], and an excessive mortality and major bleeding in excessively anticoagulated patients (target INR 3.0-4.5) was even found in SPIRIT [The Stroke Prevention in Reversible Ischaemia Trial Study Group. 1997].
  • Oral anticoagulation (INR 2.0-3.0) reduces the risk of recurrent stroke in patients with non-valvular AF and recent ischaemic stroke [EAF study group 1995, Fuster et al 2001].
    Although evidence from randomised trials is lacking, long-term anticoagulation is routinely used for patients with mechanical prosthetic valves, with a target INR between 3.0 and 4.0 [Cannegieter 1995]. There is no argument supporting oral anticoagulation in non-cardiac ischaemic strokes [Mohr et al 2001], and an excessive mortality and major bleeding in excessively anticoagulated patients (target INR 3.0-4.5) was even found in SPIRIT [The Stroke Prevention in Reversible Ischaemia Trial Study Group. 1997].
  • A meta-analysis from 9 randomised controlled trials on antihypertensive drugs, in which a small number of stroke survivors had been included, led to an estimated RRR for stroke of 29% (95% CI: 5-47%) [The INDIANA Collaborators 1997]. Indapamide (2.5 mg daily), a diuretic, reduces the risk of recurrent stroke by 29% (absolute reduction 2.9%) after 3 years, in patients with high blood pressure and recent stroke or TIA [PATS collaborating group 1995]. The HOPE Study showed an effective prevention of secondary ischaemic events by an ACE-inhibitor (ramipril), in high-risk patients including those who had already had a stroke [Yusuf et al 2000], despite a modest reduction in blood pressure. The PROGRESS trial showed that patients who had had a stroke or TIA within 5 years, and received Perindopril (4 mg daily) plus Indapamide (2 to 2.5 mg daily), had a significant 43% reduction in the risk of recurrent stroke [PROGRESS collaborative group 2001]. This benefit was achieved regardless of blood pressure and type of stroke [PROGRESS collaborative group 2001].
  • A significant reduction in stroke risk is seen across all treatment groups [Di Mascio et al 2000]. Most of this effect was driven by trials involving patients with a prior vascular event using a statin, or where a reduction in total cholesterol levels of more than 10% was achieved. In secondary prevention, 57 patients would need to be treated with statins to prevent 1 stroke per year [Straus et al 2002]. The MRC/BHF Heart Protection Study had a subgroup of 1,820 patients with previous stroke or TIA and no previous coronary event: simvastatin (40 mg daily) reduced the risk of recurrent vascular events by 24 % [Heart Protection Study Collaborative Group 2002]. The PROSPER trial showed that a similar reduction in the risk of coronary events was observed under pravastatin in older individuals, without significant effect on stroke or cognition after 3 years of follow-up [Sheperd et al 2002]. Gemfibrozil, a fibrate, can also reduce the risk of stroke [Rubins et al 1999].
    Smoking cessation leads to an early reduction in risk of both coronary events and stroke at any age [Kawachi et al 1993, Wannamethee et al 1995, et al 1988].
    In the Women’s Oestrogen for Stroke Trial, a placebo-controlled randomised trial of oestrogen replacement therapy for the secondary prevention of ischaemic stroke, the risk of fatal stroke was higher (not significant), with oestrogens, and non fatal strokes were associated with worse functional outcomes [Viscoli et al 2001].
  • The NASCET [NASCET collaborators 1991] and the ECST [European Carotid Surgery Trialists Collaborative Group 1995] reported that surgery was efficacious for symptomatic patients with ipsilateral carotid stenosis greater than 70%. Although these trials used different methods of measurement, it is possible to predict the percentage of stenosis from one method to another, and there is little difference in their ability to predict ipsilateral stroke [Rothwell et al 2003]. The NASCET analysis of surgery for symptomatic patients with less than 70% stenosis revealed an ARR of 6.5% and a RRR of 29% for patients with 50-69% stenosis allocated for surgery [Barnett et al 1998]; the overall significance of carotid surgery in preventing ipsilateral stroke was marginal (p = 0.045) and the confidence intervals overlapped in the survival curves.
  • 1.Elderly patients (>75 years) without organ failure or serious cardiac dysfunction benefit from CEA
    2.Women with symptomatic stenosis >70% should undergo CEA. Women with moderate stenosis should be treated medically.
    3.Patients with few risk factors who present with amaurosis fugax only are better off with medical treatment. Patients with severe stenosis and high risk profile should be considered for CEA
    4.Patients with mild to moderate intracranial stenosis and severe extracranial stenosis are ideal candidates for CEA
    5.The benefit from CEA is lower for patients with lacunar stroke
    6.Patients with leuko-araiosis should be made aware of the increased operative risk
  • 1.Occlusion of the contralateral ICA is not a contraindication to CEA but carries a higher perioperative risk
    2.Continuation of aspirin is required until surgery, but heparin may be used in very severe stenosis.
    3.The benefit from endarterectomy is marginal in patients with carotid near-occlusion
    All grading of stenoses should be according to NASCET-criteria.
  • Angioplasty was compared with surgery in the Carotid and Vertebral Artery Trans-luminal Angioplasty Study, a randomised clinical trial [CAVATAS Investigators 2001]: the 30-day death and stroke rate of carotid surgery was 9.9% and that of angioplasty 10.0%. We are currently waiting for the results of on-going trials. The use of carotid angioplasty and stenting should be limited to well-designed, well-conducted, randomised studies.
  • The term ‘general treatment’ refers to treatment strategies aimed at stabilising the critically ill patient, in order to control systemic problems that may negatively influence stroke outcome and to provide an optimum physiological basis upon which specific therapeutic strategies may be applied. There is consensus that the management of general medical problems is the basis for stroke treatment [WHO Task Force, 1989; Brott and Reed, 1989; Adams et al., 1994; Hacke et al., 1995; European Ad Hoc Consensus Group, 1996]. General management of stroke patients includes respiratory and cardiac care, fluid and metabolic management, BP control, and perhaps treatment of elevated intra-cranial pressure. In addition, treatment of seizures and prophylactic measures concerning DVT, pulmonary embolism, dysphagia, aspiration pneumonia, other infections, and decubital ulcer are part of the general treatment of the patients.
    Most authors agree that adequate support of vital functions constitutes basic therapy. On the other hand, one has to keep in mind that even the proposed management of hypertension, hyperglycaemia or fever in stroke patients has never been tested prospectively.
  • In all stroke patients, the neurological status and vital functions (BP, pulse rate and temperature) should be continuously or regularly monitored. The neurological status is best monitored using validated neurological scales, such as the NIH Stroke Scale (Lyden et al., 1994), the Scandinavian Stroke Scale (Lindstrom et al., 1991) and the Glasgow Coma Scale (Teasdale and Jennet, 1976).
    In selected cases with past medical history of cardiac disease and/or arrhythmias and in case of unstable BP, on-line ECG monitoring is desirable. The electrodes for cardiac monitoring can also be used for respiratory monitoring, which is useful to detect respiration abnormalities during sleep (Iranzo et al., 2002; Turkington et al., 2002). When instrumental monitoring is not feasible, repeat ECG, clinical checks of respiratory function and blood pressure measurements with automatic inflatable sphygmomanometry should be performed. Pulse oxymetry is useful for continuous monitoring in stroke units. It provides relevant information on the patient’s respiratory status. A central venous catheter and occasionally central venous pressure monitoring is needed in severe stroke patients treated in specialised wards. Via a central venous catheter, indirect information on intra-vascular volume, cardiac function, and compliance within the venous system can be achieved.
  • Normal respiratory function and adequate blood oxygenation are required for stroke management, being important for the preservation of metabolic function in the ischemic penumbra. Although there is no convincing prospective clinical evidence that oxygen supply at low flow rates is useful in human brain infarction, (Ronning and Guldvog, 1999). Respiratory function has to be monitored in order to detect and treat hypoxia. This may be consequent to extensive brainstem or hemispheric infarction, large brain haemorrhage, sustained seizure activity, or to complications such as severe pneumonia particularly in patients at risk of aspiration, heart failure, pulmonary embolism, or exacerbation of chronic obstructive pulmonary disease. Ventilation may be particularly compromised during sleep (Iranzo et al., 2002). Blood oxygenation is improved by the administration of 2-4 litres of O2 per minute via a nasal tube, when indicated. In the event of a severely compromised respiratory pattern, severe hyp-oxaemia or hyper-carbia, and in the unconscious patient (GCS  8) at high risk for aspiration, early intubation may be necessary. Prognosis of stroke patients undergoing intubation is not invariably bad, [Grotta et al., 1995; Berrouschot et al, 2000] with some series reporting a 1-year survival rate of about one third of the patients [Steiner et al., 1997]. Of course, before intubation is performed, the general prognosis, co-existing life-threatening medical conditions and the presumed will of the patient and his family have to be taken into account.
  • Cardiac arrhythmias secondary to stroke, particularly atrial fibrillation (Broderick et al, 1992; Vingerhoets et al, 1993) are not unusual, while heart failure, acute myocardial infarction (MI) or sudden death, (Bamford et al, 1990; Broderick et al, 1992) may complicate the clinical course. Significant ECG alterations in the ST segments and the T waves and QT prolongation mimicking myocardial ischaemia may appear in the acute phase [Norris, 1983], and cardiac enzymes may be elevated after stroke [Kaste et al., 1978; James et al 2000]. Most of the events related to pre-existing coronary artery disease, (Khechinashvili G, 2002) but there may also be coincidetal MI, with cerebral ischaemia [Furlan, 1987]. However, irrespective of previous cardiac disease, a correlation has been stressed between infarcts involving the insular cortex and cardiac complications. (Oppenheimer et al, 1996)
    Every stroke patient should have an initial ECG while indications on continuous ECG monitoring are reported above.
    Optimizing cardiac output with maintenance of a high normal BP and a normal heart rate is the essential basis of stroke management. The central venous pressure should be maintained at approximately 8–10 cm H2O, and its monitoring, although not frequently used in a normal ward, will give early warning of a volume deficiency or volume overload, which both have negative effects on cerebral perfusion. The intra-vascular volume must be kept stable. Among the ino-tropic agents, Dobutamine has the advantage of increasing cardiac output without substantially affecting either heart rate or BP. Dopamine may be particularly useful in patients with arterial hypotension or renal insufficiency. Increases in cardiac output may increase cerebral perfusion in areas, which have lost their auto-regulative capacity after acute ischaemia. Restoration of normal cardiac rhythm using drugs, cardio-version, or pacemaker support should be performed in co-operation with internists or cardiologists, if necessary.
    Blood Pressure Management
    BP monitoring and treatment is a critical issue, since many patients with acute stroke have elevated BP. (Leonardi-Bee et al, 2002) Some data would favour treatment (Hatashita et al., 1986; Davalos et al, 1990; Bowes et al., 1996; Fagan et al., 1998; Chamorro et al 1998; Ahmed et al., 2001; Leonardi-Bee et al, 2002), but evidence opposing treatment is also available. (Jorgensen et al., 1994; Ahmed et al., 2000; Leonardi-Bee et al, 2002). Cerebral blood flow autoregulation may be defective in an area of evolving infarction (Meyer at al., 1973). Eames et al. (2002) showed that flow in the ischemic penumbra is passively dependent on the mean arterial pressure. Hence, abrupt drops in BP must be avoided if an adequate cerebral perfusion pressure is to be maintained. Moreover, blood pressure increase may be consequent to treatable conditions (Carlberg et al., 1991), and usually BP spontaneously decreases during the first days after stroke onset (Britton et al., 1986; Jansen et al., 1987; Oppenheimer and Hachinsky, 1992; Broderick et al 1993; Harper et al., 1994).
    A target systolic BP of 180 mm Hg and diastolic BP of 100–105 mm Hg is recommended in patients with prior hypertension. In other cases, lower blood pressure values are desirable (160–180/90–100 mm Hg). Obviously, extremely high BP levels are not acceptable. Systolic values over 220 mm Hg or diastolic values over 120 mm Hg (in some centres, especially in North America, thresholds of 240 systolic and 130 diastolic are accepted) constitute an indication for early but cautious drug treatment, avoiding a drastic or abrupt reduction in blood pressure. (Table 8) There are only few other indications for immediate anti-hypertensive therapy. Treatment may be appropriate in the setting of concomitant acute myocardial ischemia (although extreme lowering of BP is deleterious for MI patients as well), cardiac insufficiency, acute renal failure or aortic arch dissection. In patients undergoing thrombolysis or heparin administration BP above 180 mmHg systolic should be avoided. In case the CT scan has shown a non-ischaemic cause of stroke, such as SAH, intracerebral haemorrhage or sub-dural haematoma, antihypertensive treatment may also be started.
    The use of sublingual Nifedipine should be avoided because of the risk of abrupt reduction of blood presure (Grossman et al., 1996), possible ischemic steal (Ahmed et al., 2000; Adams et al., 1994; Graham et al., 1982; Power et al., 1993; Jorgensen et al., 1994) and overshoot hypertension. Oral Captopril (6.25–12.5 mg), may be used instead, but has a short duration of action and can have an abrupt effect. In North America intravenous Labetalol (10 mg) is frequently recommended. Intravenous Urapidil is increasingly used in this situation. Finally, Sodium Nitroprusside is sometimes recommended despite possible major side-effects, such as reflex tachycardia and coronary artery ischaemia.
    A low or normal-low BP at stroke onset is unusual (Leonardi-Bee et al., 2002) and may be consequent to a large infarct, or to cardiac failure or ischemia, or sepsis. BP can be raised by adequate patient re-hydration with crystalloid (saline) or, occasionally, colloid, solutions. Low cardiac output may need ino-tropic support.
  • An increase of serum glucose levels at hospital admission may be frequently found, due to a previous known or unknown diabetes (Toni et al., 1992; Gray et al., 1987) and even in non-diabetic patients (van Kooten et al., 1993). High glucose levels are harmful in stroke [Pulsinelli et al., 1983 ; Davalos et al., 1990; Toni et al., 1994; Weir et al., 1997; Capes et al., 2001). This is true not only for diabetic patients, whose metabolic derangement may be dramatically worsened in the acute stroke phase, but also for non diabetic subjects (Weir et al., 1997; Capes et al., 2001). Hence, temporary insulin treatment may become necessary. A blood glucose of 10 mmol/l or higher justifies immediate insulin titration. Unless the blood glucose is known, no glucose solution should be given to a stroke patient.
    On the other hand, hypo-glycaemia can rarely mimic an acute ischaemic infarction (Huff 2002) and should be treated by i.v. dextrose bolus or infusion of 10–20% glucose, preferably via a central venous line.
  • Experimentally hyper-thermia increases infarct size (Fukuda et al., 1999). Fever is frequent over the initial 48 hours of stroke onset (Corbett et al., 2000) and negatively influences clinical outcome [Reith et al., 1996; Castillo et al., 1999; Hajat et al., 2000]. On the other hand it has to be remembered that infection is a risk factor for stroke (Syrjanen et al., 1988; Grau et al., 1995), and that many patients develop an infection after stroke [Grau et al., 1999; Georgilis et al., 1999). Hence search of a possible infection is recommended in order to start tailored treatment, though empirical antibiotic, anti-mycotic or antiviral treatment is not recommended in immuno-competent patients.
    Small, randomised studies with high dose antipyretics provide contradictory data on the usefulness of this approach, (Dippel et al., 2001; Kasner et al., 2002) but treating an elevated temperature in stroke patients is advisable. Although there are no prospective data, one may consider to treat fever as early as the temperature reaches 37.5°C.
  • Stroke patients should have a balanced fluid and electrolyte status to avoid plasma volume contraction, which may influence brain perfusion and kidney function. Some degree of dehydration on admission is frequent and may be related to bad outcome (Bhalla A et al., 2000). Virtually all acute stroke patients need i.v. fluid therapy, with a more or less positive balance according to level of dehydration. However, uncontrolled volume replacement may lead to cardiac failure and pulmonary oedema.
    A slightly negative fluid balance is recommended in the presence of brain edema. Hypotonic solutions (NaCl 0.45% or glucose 5%) are contraindicated due to the risk of brain oedema increase.
    Serious electrolyte abnormalities are uncommon in patients with ischemic stroke (Diringer et al., 1992). However, electrolytes should be monitored daily and substituted accordingly. A peripheral venous access is usually sufficient for initial fluid management and blood sampling, while a central venous catheter is required in case of infusion of larger volumes of fluids or hyper-osmolal solutions.
  • Thrombolytic therapy with rtPA (0.9 mg/kg body weight) given within 3 h after stroke onset to patients with acute ischaemic stroke significantly improves outcome [The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, NINDS, 1995], with a NNT of 7. Two European trials ECASS and ECASS II tested a 6 hour time window and did not show statistically significant superiority of rtPA for the primary endpoints (Hacke et al 1995, Hacke et al 1998).
    Eight trials have tested rt-PA in 2,889 patients. Overall there was a significant reduction in the number of patients with a poor functional outcome (combined death or dependency) at the end of follow-up (OR 0.83, 95% CI 0.73 to 0.94). The subgroup of patients treated within 3 hours showed a greater reduction in poor functional outcome with thrombolysis (OR 0.58, 95% CI 0.46 to 0.74) with no adverse effect on death. (Hacke et al 1999, Wardlaw and Warlow, 1999, Wardlaw; 2001)
    A pooled analysis of individual data of the 6 rtPA trials confirms that thrombolysis works at least until 4.5 hours and potentially up to 6 h after stroke onset (Brott 2002). Caution is advised before giving intravenous rtPA to persons with severe stroke (NIH stroke scale >25), or if the CT demonstrates extended early changes of a major infarction, such as sulcal effacement, mass effect and oedema.
  • Intravenous Streptokinase has been shown to be associated with an unacceptable risk of haemorrhage and haemorrhage-associated death [The Multicenter Acute Stroke Trial - Europe Study Group, 1996; Donnan et al., 1995].
    Intra-arterial thrombolytic therapy of occlusions of the proximal part of the middle cerebral artery, using pro-urokinase, has been shown to be significantly associated with better outcome in a randomised trial. This treatment is safe and efficacious in a 6-hour time window, but it requires super-selective angiography and is only available in selected centres [Furlan et al., 1999]. Intra-arterial treatment of acute basilar occlusion with urokinase or rtPA is frequently used in selected centres, but has not been subjected to a randomised trial [Hacke et al.,1988; Brandt et al., 1996].
  • A pooled analysis of individual data of the 6 rtPA trials confirms that thrombolysis works at least until 4.5 hours and potentially up to 6 h after stroke onset (Brott 2002). Caution is advised before giving intravenous rtPA to persons with severe stroke (NIH stroke scale >25), or if the CT demonstrates extended early changes of a major infarction, such as sulcal effacement, mass effect and oedema.
    Thrombolytic therapy should only be given if the diagnosis is established by a physician who has expertise in the diagnosis of stroke, and a CT of the brain is assessed by physicians who have expertise in reading this imaging study. Because the use of thrombolytic drugs carries the real risk of major bleeding, the risks and potential benefits of rtPA should be discussed whenever possible with the patient and family before treatment is initiated.
    Intravenous administration of rtPA more than 3 h after stroke should only be given in an institutional protocol as experimental therapy or within a multi-center clinical trial. Continuous auditing of routine use of thrombolytic therapy is advisable. Safety monitoring of treatment (SITS-MOST) is a condition for approval of rtPA in the European Union.
  • Ancrod is a defibrinogenating enzyme which was shown to improve outcome after acute ischaemic stroke if given within 3 h after stroke onset and over 5 days [Sherman, for the STAT Writers Group, 1999]. Recently, a European trial testing ancrod treatment in a 6-hour time window was terminated prematurely and did not confirm the US-findings.
  • The results of two very large randomised, non-blinded intervention studies indicate that aspirin given within 48 h after stroke (IST, CAST) reduces mortality and rate of recurrent stroke minimally, but statistically significantly [International Stroke Trial Collaborative Group. 1997; Chinese Acute Stroke Trial, 1997], with a NNT of 111.
  • Early anticoagulation with unfractionated heparin (UFH) has been used frequently in treatment after acute ischaemic stroke. Unfortunately, none of the early anticoagulation trials that have been performed in the past years selected full anticoagulant doses of UFH as the therapeutic option. Subcutaneous UFH at low- or moderate doses, [International Stroke Trial Collaborative Group, 1997] Nadroparin, [Kay et al., 1995: Hommel et al., 1998] Certoparin, [Diener et al; 2001] Tinzaparin, [Bath et al;2001], Dalteparin [Berge E et al;2000] and i.v. Danaparoid [The TOAST Publication Committee, 1998] failed to show an overall benefit of treatment. While there was some kind of improvement in outcome or reduction in stroke recurrence rates, this was almost always counterbalanced by an increased number of haemorrhagic complications. In addition, most investigators believe that heparin is not a standard therapy for all stroke subtypes. Full-dose heparin may be used when there are selected indications such as cardiac sources with high risk of re-embolism, arterial dissection, or high grade arterial stenosis prior to surgery (Table 9). Some investigators found greater functional recovery the sooner heparin was administered suggesting that in addition to its role to prevent early stroke recurrence, the agent also has therapeutic properties (Chamorro, 2001), including down-regulation of inflammatory markers (Chamorro et al., 2002). Contra-indications for the treatment with heparin include large infarcts (e.g. more than 50% of MCA territory), uncontrollable arterial hypertension and advanced micro-vascular changes in the brain.
  • Several large clinical trials of iso-volaemic haemodilution failed to demonstrate a decline in mortality or disability with treatment [Strand, 1992; Italian Acute Stroke Study Group, 1988; Scandinavian Stroke Study Group, 1987; The Hemodilution in Stroke Study Group, 1989]. Hyper-volaemic haemodilution has been examined in small randomised trials with conflicting results.
    Neuroprotection No neuroprotective trial has shown improved outcome after stroke on its predefined primary endpoint. Currently, there is no recommendation to treat patients with neuroprotective drugs after ischaemic stroke.
  • Acute stroke predisposes to medical complications (Davenport et al., 1996 Langhorne et al., 2000) such as pneumonia, urinary tract infections, malnutrition or volume depletion. Patients may also suffer from deep venous thrombosis and pulmonary embolism. Early supportive care and monitoring of physiological parameters may prevent such complications. This is best done in a dedicated stroke unit with experienced staff and early mobilisation. Immobility may lead to infections, contractions and decubital ulcers.
    Aspiration and Pneumonia
    Bacterial pneumonia is one of the most important complications in stroke patients (Davenport et al., 1996 Langhorne et al., 2000; Weimar et al., 2002), the majority being caused by aspiration (Horner et al 1988). Since aspiration may be detectable by video-fluoroscopy in as many as 50% of patients during the initial days after stroke onset, oral feeding should be withheld until the patient has demonstrated both intact swallowing with small amounts of water and intact coughing to command. Aspiration is frequently found, both in patients with reduced consciousness and in those with swallowing disturbances. Nasogastric tube (NGT) feeding is adequate for short term enteral feeding, but a percutaneous enteral gastrostomy (PEG) should be inserted once it is clear that protracted enteral feeding will be required. As a rule of thumb, a PEG is indicated when abnormal swallowing is predicted for periods longer than one month.
    NGT or PEG-feeding through avoidance of swallowing may be helpful in prevention of aspiration pneumonia. They do not completely reduce the risk, however, since reflux of liquid feed can itself promote aspiration. Other reasons for pneumonia include hypostasis, diminished cough and immobilisation. Frequent changes of the patient´s position in bed and pulmonary physical therapy may prevent this type of pneumonia.
    Urinary tract infection
    Urinary tract infection is incidental in as many as 40% of patients dying from stroke (Silver et al 1984). Urinary retention is frequent in the early phase after stroke and will require insertion of a urine catheter or supra-pubic catheter. Otherwise, incontinent patients should be managed with a condom catheter or ‘pad and pants’. The majority of hospital-acquired urinary tract infections are associated with the use of indwelling catheters. (Gerberding 2002). In non-stroke patients supra-pubic catheters are considered to carry lower risk of infection, (Vandoni et al., 1994) whereas intermittent catheterisation has not been shown to have a reduced risk. Once urinary infection is diagnosed, appropriate antibiotics should be chosen. To avoid bacterial resistance developing, prophylactic antibiotics are best avoided.
    Pulmonary Embolism and DVT
    Pulmonary embolism is the cause of death in up to 25% of patients dying following ischaemic cerebral infarction. Nevertheless, the incidence of symptomatic PE and deep vein thrombosis is now <5% presumably reflecting modern clinical practice and admission to a stroke unit. The risk of deep venous thrombosis and pulmonary embolism can be reduced by early hydration, and early mobilisation. Although graded compression stockings are effective in preventing venous thrombo-embolism in surgical patients, their efficacy after stroke is unproven. Whilst subcutaneous heparin or low molecular weight heparin reduce venous thromboembolism their effect is counter-balanced by an increase in haemorrhagic complications. Prophylaxis with subcutaneous low dose heparin (5000 iu twice daily) or low molecular weight heparines is reasonable in patients at particularly high risk of DVT or PE.
    Decubital Ulcer
    Frequent turning of immobilised patients is useful for prevention of decubital ulcers. The skin of the incontinent patient must be kept dry. For patients at particularly high risk, an air- or fluid-filled mattress system should be used. If decubital ulcers do not respond to conservative therapy, antibiotic therapy may be justified for several days, preceding definitive surgical debridement.
    Seizures
    Partial (focal) or secondary generalised epileptic attacks may occur in the acute phase of ischaemic stroke. Post-stroke epilepsy may develop In 3% to 4% of cases (Olsen 2001)
    Standard iv and oral anti-epileptic drugs are in general used. There is no evidence that prophylactic anticonvulsive treatment is beneficial.
    Agitation
    Agitation and confusion are rarely caused by the stroke, but are more frequently a symptom of other complications such as fever, volume depletion or infection. Adequate treatment of the underlying cause must precede any type of sedation or anti-psychotic treatment.
  • Ischaemic brain oedema occurs during the first 24-48 h after stroke onset and is the main reason for early (Toni et al., 1995; Davalos et al., 1999) and late (Davalos et al., 1999) clinical deterioration. The most worrisome situation is that of younger patients with complete MCA infarction, in whom brain oedema and elevated ICP may lead to herniation within 2-4 days after onset of symptoms and to death in about 80% of cases with standard treatment (Rieke et al., 1995; Hacke et al., 1996, Steiner et al., 2001).
    Medical Therapy
    Basic management of elevated intra-cranial pressure following stroke includes head positioning at an elevation of up to 30°, avoidance of noxious stimuli, pain relief, appropriate oxygenation and normalising body temperature. If ICP monitoring is available, cerebral perfusion pressure should be kept >70mm Hg (Unterberg et al 1997). Although strong evidence is lacking, (Righetti et al., 2002; Bereczki et al., 2001), osmotherapy with 10% glycerol usually given intravenously (4 x 250 ml of 10% glycerol over 30-60 minutes) or intravenous mannitol, 25-50 g every 3-6 h is the first medical treatment to be used if clinical and/or radiological signs of space-occupying oedema occur. Hypertonic saline solutions given intravenously (5X 100 ml Saline 3%) (Shackford et al., 1992; Schwarz et al., 1998; Schwarz et al., 2002), are probably similarily effective, though data at present available are not definitive (Qureshi et al., 1998; Prough et al., 1998). Hypotonic and glucose-containing solutions should be avoided as replacement fluids. Dexamethasone and cortico-steroids are not useful for brain oedema treatment after stroke (Qizilbash et al., 2002). Short-acting barbiturates such as thiopental given as a bolus can quickly and significantly reduce ICP, but the effect is short lived and may be exploited only to treat an acute crisis, e.g. prior to operation. Barbiturate treatment requires ICP and EEG monitoring and careful monitoring of haemodynamic parameters, as a significant blood pressure drop may occur. ICP monitoring is also required when tris (hydroxy-methyl) aminomethane buffer solution is used after osmo-therapy and barbiturate failure (Steiner et al., 2001).
    Volume loading by vaso-pressor induced hypertension may be attempted in case of severely compromised CPP, but hemodynamic monitoring and intensive care facilities are required (Kaste and Roine in press).
    Hypothermia
    Hypothermia was shown to be neuroprotective after cardiac arrest (Bernard et al 2002, The HACA group 2002). Mild hypothermia (i.e. brain temperature between 32 and 33°C) reduces the case fatality rate of patients with severe MCA infarcts, but causes a number of severe side-effects which may be encountered during therapy over several days. (Schwab et al., 1998; Schwab et al., 2002) The number of studied patients is still too small to draw any decisive conclusions, however this method is feasible and will be tested prospectively in randomised trials. One problem is recurrent ICP crisis, which was almost exclusively found during re-warming (Steiner et al 2001). Moreover, in a comparative trial hypothermia had more severe side effects than decompressive surgery for malignant MCA infarction (Georgiadis et al, 2002).
  • The rationale of decompressive surgery is to allow expansion of the oedematous tissue to reduce ICP, to increase perfusion pressure, and to preserve cerebral blood flow by preventing further compression of the collateral vessels. In prospective case series, surgical, decompressive therapy in hemispheric space-occupying infarction lowered mortality from 80% down to 30% without increasing the rate of severely disabled survivors (Hacke and Schwab 1995, Rieke et al 1995, Mori 2001). Early decompressive surgery within the first 24 h after stroke onset can reduce mortality even more markedly (Schwab et al 1998). Prospective, multicenter study protocols have been recently developed and are underway.
    Cerebellar Infarction
    Ventriculo-stomy to reveal hydro-cephalus and decompressive surgery is considered the treatment of choice of a space-occupying cerebellar infarction, although the scientific basis for this is not more solid than for hemispheric infarction. Comatose patients with space-occupying cerebellar infarctions have a mortality of about 80% if treated conservatively. This high mortality can be lowered down to less than 30% if decompressive surgery is performed (Heros 1992; Rieke et al 1993). Like in space-occupying supratentorial infarction, the operation should be performed before signs of herniation are present. The prognosis among survivors is very good, even if they were comatose when the operation was performed. It should be noted, however, that these are the results of open, small or medium-sized case series, one of them being prospective (Rieke et al 1993), the remainder being mostly retrospective. Data from a controlled, randomised trial are lacking.
  • El Ictus

    1. 1. OBJETIVO DE LA EUSI Reducir la incidencia y repercusión del ictus en Europa promoviendo un cambio en su enfoque y tratamiento
    2. 2. RECOMENDACIONES EN EL MANEJO DEL ICTUS 2003
    3. 3. European Stroke Initiative En nombre del European Stroke Council (ESC), European Neurological Society (ENS) y European Federation of Neurological Societies (EFNS) Markku Kaste, Helsinki, Finlandia ( Presidente) Werner Hacke, Heidelberg, Alemania (Secretario y Coordinador de las Recomendaciones) Julien Bogousslavsky, Lausanne, Suiza (Tesorero) Comité ejecutivo de EUSI Michael Brainin, Maria Gugging, Austria; Ángel Chamorro, Barcelona, España; Hubert Kwiecinski, Varsovia, Polonia; Kennedy Lees, Glasgow, Reino Unido; Didier Leys, Lille, Francia; Danilo Toni, Roma, Italia; Miembros del Comité de Redacción Philip Bath, Nottingham, Reino Unido; Christoph Diener, Essen, Alemania; José Ferro, Lisboa, Portugal; Michael Hennerici, Mannheim, Alemania; Peter Langhorne, Glasgow, Reino Unido; Nils Gunnar Wahlgren, Estocolmo, Suiza; Juhani Sivenius, Kuopio, Finlandia; Tom Skyhøj Olsen, Copenhage, Dinamarca;
    4. 4. Recomendaciones en el manejo del ictus • • • • Parte 1: Organizar el manejo del ictus de un modo diferente, Educación, información pública, derivación, organización de servicios de urgencias, neuroimagen y técnicas diagnósticas, unidades de ictus,rehabilitación Parte 2a: Factores de riesgo y prevención primaria Factores de riesgo modificables y no modificables, estilo de vida, prevención primaria médica quirúrgica o intervencionista Parte 2b: Prevención secundaria Médica, antitrombótica, quirúrgica e intervencionista Parte 3: Manejo agudo del ictus Tratamiento general (hipertensión, fisiología general), tratamiento específico (trombolisis, anticoagulación), PIC
    5. 5. Temas y autores • Part 1: Organizando la atención del ictus – Editores por secciones: Michael Brainin y Tom Skyhoj Olsen • Educación Tom Skyhoj Olsen y Peter Langhorne • Servicios de urgencias y derivación José Ferro y Ángel Chamorro • Imagen y diagnóstico • Unidades de ictus • Rehabilitación Correctores Michael Hennerici y Danilo Toni Peter Langhorne y Michael Brainin Juhani Sivenius y Tom Skyhoj Olsen Christoph Diener y José Ferro
    6. 6. Temas y Autores • Parte 2: Prevención – Editores de sección: Julien Bogousslavsky y Hubert Kwiecinski • Prevención Primaria Modificación de factores de riesgo Didier Leys y Phil Bath • Tratamiento Médico Philip Bath y Didier Leys • Tratamiento Quirúrgico e Intervencionista Christoph Diener y Hubert Kwiecinski • Prevención Secundaria • Tratamiento Médico Julien Bogousslavsky y Michael Brainin • Tratamiento Quirúrgico e Intervencionista Markku Kaste y Werner Hacke Correctores Michael Hennerici y Juhani Sivenius
    7. 7. Temas y Autores • Parte 3: Fase aguda – Editores de sección: Danilo Toni y Angel Chamorro • Manejo general Danilo Toni y Markku Kaste • Tratamiento específico Ángel Chamorro y Kennedy Lees • Hipertensión intracraneal Correctores • Werner Hacke y Danilo Toni Nils Wahlgren y Kennedy Lees Manuscritos preliminares, organización, logística, edición final del manuscrito y diapositivas Werner Hacke
    8. 8. Definición de Niveles de Evidencia modificado de Adams et al. 1994 • Nivel I: Nivel de evidencia elevado Fuentes: aObjetivo primario de ECA con tamaño de muestra adecuado b) Meta-analisis de ECAs de buena calidad • Nivel II: Nivel de evidencia intermedio Fuentes: a) Ensayos randomizados pequeños b) Objetivo secundario predefinido de grandes ECAs • Nivel III: Nivel de evidencia bajo Fuentes :a) series prospectivas de casos con control concurrente histórico b) Análisis post hoc de grandes ECAs • Nivel IV: Nivel de evidencia indeterminado Fuentes : a) Series pequeñas de casos sin controles b) Consenso universal pese a la falta de evidencia
    9. 9. El ictus es una Emergencia • Hechos: – El ictus es una emergencia médica y ocasionalmente quirúrgica. – La mayoría de pacientes con ictus isquémico no llegan al hospital de forma rápida. – Una evaluación extrahospitalaria del ictus retrasa el ingreso del paciente: Por el contrario, utilizar el Servicio de Emergencias Médicas lo acorta. – El personal de ambulancias es generalmente capaz de reconocer los signos y síntomas del ictus.
    10. 10. El ictus es una Emergencia • El manejo como una emergencia del paciente con ictus se basa en los siguientes 4 pasos: • Reconocimiento y reacción rápida ante los signos de aviso de ictus • Uso inmediato de los Servicios de Emergencia Médica (SEM) • Transporte prioritario y aviso de llegada al hospital receptor (Código Ictus) • Diagnóstico rápido y tratamiento preciso a la llegada al hospital. • Los errores en el reconocimiento de los síntomas de alarma y una consulta previa en Atención Primaria retrasan la llegada al hospital (Ferro et al 1994; Derex et al 2002; Harraf et al 2002).
    11. 11. Derivación de paciente con ictus • EUS - Recomendaciones 1. Los pacientes con ictus deben ser tratados en Unidades de Ictus. Por tanto, todo paciente con sospecha de ictus deberá ser trasladado sin demora a la Unidad de ictus más cercana o, en su defecto, a un hospital que garantice una atención protocolizada.(Nivel I) 2. Ante los primeros signos de ictus el paciente o su representante legal llamarán a un Servicio de Emergencia Médica. (Nivel III) 3. Los pacientes con hemorragia subaracnoidea serán urgentemente derivados a un centro con Neurocirugía, Neuroradiología intervencionista y Cuidados Intensivos Neurológicos (Nivel I)
    12. 12. Unidades de Ictus • Definición Una unidad de ictus: – Es un área geográficamente determinada del hospital dedicada específicamente al cuidado del paciente con ictus – El manejo y tratamiento del ictus es llevado a cabo por personal altamente especializado, integrado en un equipo multidisciplinar – Compete a distintas profesiones: medicina, enfermería, fisioterapia, terapia ocupacional, logopedia y trabajo social
    13. 13. Unidades de Ictus • Datos (Stroke Unit Trialists’ Collaboration) – El tratamiento en una Unidad de Ictus reduce la muerte y la dependencia así como los cuidados sociosanitarios en centros de larga estancia respecto a una hospitalización convencional.
    14. 14. Unidades de Ictus • Elementos de una unidad de ictus – Evaluación • Evaluación médica y diagnóstico que incluye CT. Valoración precoz de las necesidades terapéuticas y cuidados de enfermería. – Tratamiento precoz • Mobilización precoz, prevención de complicaciones,corrección de la hipoxia, hiperglicemia, fiebre y deshidratación. – Estrategias de rehabilitación temprana • Equipo multidisciplinar coordinado • Valoración precoz de las necesidades al alta.
    15. 15. Unidades de Ictus • Modelos organizativos de la atención del ictus 1. Unidad de ictus aguda • Tratamiento agudo < 1 semana (2-3 días) 2. Unidad de ictus combinada ( aguda y rehabilitación) • Fase aguda + rehabilitación durante varias semanas/ meses 3. Unidad de ictus rehabilitadora • Ingreso 1 o 2 semanas tras el inicio del ictus 4. Equipo móvil de ictus • Atención al ictus en diferentes áreas hospitalarias
    16. 16. Unidades de Ictus • Recomendaciones de la EUSI 1. Los pacientes con ictus deben ser tratados en unidades de ictus (Nivel I) 2. Las unidades de ictus deben ofrecer una atención multidisciplinar coordinada, por parte de médicos, enfermeras y terapeutas especializados en el cuidado del ictus (Nivel I)
    17. 17. Manejo de emergencia • La ventana terapeútica del paciente con ictus es muy breve – El manejo urgente del ictus requiere actuaciones paralelas en diferentes niveles – La evaluación neurológica y de las funciones vitales es paralela al tratamiento de situaciones que amenacen la vida del paciente. El tratamiento específico puede iniciarse incluso antes de que se haya identificado el subtipo de ictus • El tiempo es el factor más importante, especialmente los primeros minutos y horas desde el inicio del ictus
    18. 18. Pruebas diagnósticas en urgencias • Distinguen entre los diferentes tipos de ictus – Orientan hacia la causa subyacente de la isquemia cerebral – Orientan el pronóstico • Asesoran sobre la intensidad de la monitorización posterior del paciente • Identifican enfermedades intercurrentes o complicaciones asociadas con el ictus • Excluyen otras enfermedades cerebrales
    19. 19. Pruebas diagnósticas en urgencias • Exploración inicial – Observar la función respiratoria y ventilatoria, así como la presencia de enfermedad cardiaca concomitante. – Medir la presión arterial y frecuencia cardiaca y determinar la saturación arterial de oxígeno mediante pulsioximetría por infrarrojos cuando sea posible – Obtener muestras de sangre para análisis bioquímico, hematológico y de coagulación. – Exploración neurológica orientada – Historia clínica detallada, centrada en los factores de riesgo arterioscleróticos y de enfermedad cardiaca
    20. 20. Pruebas diagnósticas en urgencias • Tomografía Craneal computerizada (TC) – Distingue entre ictus isquémico y hemorrágico de modo fiable – Detecta signos precoces de isquemia, incluso en las 2 primeras horas del inicio de la clínica – Identifica inmediatamente una hemorragia – Detecta HSA aguda con una sensibilidad del 95% – Puede identificar otras enfermedades neurológicas (p.e. neoplasias)
    21. 21. Pruebas diagnósticas en urgencias • Resonancia magnética (RM) – Además de las secuencias morfológicas (T1), las secuencias de difusión y perfusión pueden ayudar a distinguir entre infarto e isquemia potencialmente reversible – Identifica de un modo fiable lesiones isquémicas de fosa posterior – Detecta de un modo fiable hemorragias cerebrales en secuencias de T2* La angiorresonancia magnétiva(ARM) proporciona información sobre el estado del lecho vascular incluyendo el sistema venoso y puede identificar aneurismas mayores de 3 mm de diámetro
    22. 22. Pruebas diagnósticas en urgencias • Técnicas de ultrasonidos – Sonografía doppler y/o dupplex de onda contínua (cw) o pulsada (pw) de la arterias extracraneales o intracraneales – Identifican estenosis u oclusiones, vasoespasmo, estado de colaterales y recanalización.
    23. 23. Pruebas diagnósticas en urgencias • Electrocardiograma – Alta incidencia de alteraciones cardiacas en pacientes con ictus – Coincidencia de ictus e infarto de miocardio – El ictus puede causar arritmias – Detección de fibrilación auricular como causa posible del ictus
    24. 24. Pruebas diagnósticas en urgencias • Exámenes de laboratorio – Hematología (recuento de hematíes,leucocitos y plaquetas) – Coagulación básica – Electrolitos – Función renal y hepática – Enzimas cardíacos – PCR,VSG
    25. 25. Pruebas diagnósticas en urgencias • Recomendaciones de la EUSI 1. La TC craneal es la herramienta diagnóstica más importante ante la sospecha de ictus para distinguir isquemia de hemorragia. (Nivel IV) 2. Las técnicas de neuroimagen vascular (ultrasonidos, angioTC y angio RM) en fase aguda aportan información adicional sobre el estado vascular intra y extracraneal. Todas ellas deberían realizarse en la fase aguda. 3. Una RM/ARM puede sustituir a una TC si se realiza adecuadamente. Concretamente, secuencias ponderadas en T2* son necesarias para identificar pequeñas hemorragias (Nivel II)
    26. 26. Pruebas diagnósticas en urgencias 1. Recomendaciones de la EUSI 1. 4. La RM de difusión y perfusión puede ser de ayuda adicional para valorar el riesgo/beneficio de una terapia revascularizadora precoz. (Nivel III) 2. 5. Se recomienda la evaluación precoz de constantes vitales, análisis de laboratorio y función cardiaca (ECG,pulsioximetría, radiografía de tórax) en la fase aguda del paciente con ictus (Nivel IV)
    27. 27. Rehabilitación • Rehabilitación precoz – Más del 40 % de los pacientes con ictus necesitan rehabilitación activa – la rehabilitación activa debería comenzar lo antes posible , siempre y cuando el paciente esté clinicamente estable – la rehabilitación pasiva debería realizarse en el caso de pacientes inconscientes o paréticos. – la rehabilitación debe continuarse si se objetiva una mejoría perceptible
    28. 28. Rehabilitación • Promover la recuperación tras el ictus – Se deben evaluar la discapacidad concreta de cada paciente – Consideraciones sobre el lugar de tratamiento • ’Ambiente adecuado’ (unidad de rehabilitación de ictus) • Personal que motive y anime al paciente • Equipo de rehabilitación multidimensional • Solicitar programa diario de fisioterapia – Nuevos métodos de entrenamiento repetitivo e intensivo • p.e. uso forzado de la mano parética, tapiz rodante
    29. 29. Rehabilitación • Programas de rehabilitación - Documentación diaria de la evolución de los pacientes - Implicar y enseñar al paciente y a sus familiares -Visitas del domicilio propio tan pronto como sea posible (facilitan el alta, acrecientan la motivación) - Planear la derivación a centros específicos de rehabilitación si se prevé un largo periodo de rehabilitación
    30. 30. Rehabilitación • Equipo multidisciplinario de rehabilitación – – – – – Médico especializado en ictus Enfermería especializada en la atención del ictus Fisioterapeuta entrenado en la rehabilitación del ictus Terapeuta ocupacional experto en ictus Logoterapeuta familiarizado/a con los problemas del lenguaje del paciente con ictus – Neuropsicología entrenada en la rehabilitación del ictus – Asistente Social familiarizado/a con los problemas de los pacientes con ictus
    31. 31. Rehabilitación • Recomendaciones USI 1. Todo paciente debería tener acceso a una evaluación de su rehabilitación(Nivel I) 2. La rehabilitación debería ser iniciada precozmente tras el ictus.(Nivel I). Los pacientes discapacitados deberian tener acceso a una atención estructurada, incluyendo la institucionalización 3. Los servicios de rehabilitación deberían llevarse a cabo por un equipo multidisciplinar en la unidad de ictus (Nivel I)
    32. 32. Rehabilitación • Recomendaciones EUS 4. La intensidad y duración de la rehabilitación debería adecuarse a cada paciente; lo ideal sería introducir nuevos métodos de rehabilitación (p.e. estimulación repetitiva y uso forzado de la mano) que complementen los métodos ya existentes (Nivel II) 5. Los pacientes con secuelas deberían ser apoyados en su entorno social. Esto conlleva acceso de la familia a un médico , evaluación ambulatoria de los pacientes en servicios de rehabilitación así como prevención secundaria y apoyo psicosocial.(Nivel II)
    33. 33. Prevención primaria • Estilo de vida y situaciones identificadas como factor de riesgo para el ictus Hipertensión arterial Fibrilación auricular Diabetes mellitus Ateromatosis carotídea Enolismo severo Infarto de miocardio Hipercolesterolemia Hiperhomocisteinemia Tabaco Sedentarismo Obesidad
    34. 34. Prevención primaria • Hipertensión arterial – Datos-hechos • Es el factor de riesgo modificable de ictus más importante y prevalente • El descenso de la PA reduce significativamente la incidencia de ictus
    35. 35. Prevención primaria • Diabetes mellitus – Datos • Factor de riesgo independiente para el ictus isquémico • No está establecido que el control estricto de la glucemia prevenga el ictus • Es esencial el control de otros factores de riesgo (hipertensión, colesterol) • PA debería ser <130/80 mmHg en pacientes con DM • Niveles elevados de glucemia en la fase aguda del ictus incrementan la mortalidad y empeoran el pronóstico funcional
    36. 36. Prevención primaria emperoran • Hipercolesterolemia – Se sabe que • La reducción del colesterol en tres ensayos de prevención primaria o prevención primaria/secundaria con pravastatina no ha demostrado prevenir el ictus isquémico • Estudios con mayor número de pacientes, como el Heart Protection Study [2002] la reducción de eventos en los tratados con sinvastatina fue significativa incluso en pacientes con valores normales de colesterol
    37. 37. Prevención primaria • Tabaco – Datos (Estudios de Cohortes) • Factor de riesgo independiente para ictus isquémico en ambos sexos • Riesgo incrementado 2-3 veces respecto a los no fumadores • Reducción del riesgo en un 50% a los 2 años del abandono del hábito tabáquico
    38. 38. Prevención primaria • Consumo de alcohol – Datos • Un consumo moderado (20-30 g/día o 2-3 bebidas al día) disminuye el riesgo de ictus isquémico • Un consumo excesivo aumenta el riesgo de ictus isquémico y/o hemorrágico
    39. 39. Prevención primaria • Actividad física – Datos • El ejercicio regular (al menos 3x30min/semana) disminuye el riesgo de ictus • Existe una relación lineal entre la cantidad de ejercicio y la disminución del riesgo de ictus e infarto de miocardio
    40. 40. Prevención primaria • Terapia hormonal sustitutiva – Datos • La terapia hormonal sustitutiva incrementa el riesgo de ictus (7/1000 por año)
    41. 41. Prevención primaria • Recomendaciones de la EUSI 1. 1. Medir la presión arterial es esencial en todo chequeo médico. La presión arterial debería reducirse a niveles normales (<140 / <90 mm Hg, o<135 / 80 mm Hg en diabéticos) modificando el estilo de vida. La mayoría de pacientes hipertensos precisarán medicación hipotensora para mantener una presión arterial normal (Nivel I) 2. El control estricto de la glucemia en DM no ha demostrado disminuir el riesgo de ictus pero debe recomendarse por su beneficio sobre el resto de complicaciones de la diabetes (Nivel III)
    42. 42. Prevención primaria • Recomendaciones EUSI 3. El tratamiento para reducir el colesterol (simvastatina) se recomienda en pacientes de alto riesgo (Nivel I) 4. El hábito tabáquico debe desaconsejarse.(Nivel II) 5. El consumo excesivo de alcohol debe desaconsejarse mientras que el consumo moderado o leve pudiera prevenir el ictus y el infarto de miocardio (Nivel I) 6. Se recomienda realizar ejercicio físico regularmente (Nivel II)
    43. 43. Prevención primaria • Recomendaciones EUSI 7. Se recomienda una dieta pobre en sal y grasas saturadas y rica en fruta, verduras y fibra. (Nivel II) 8. Las personas con un elevado índice de masa corporal deberían realizar una dieta adecuada (Nivel II) 9. La terapia hormonal sustitutiva (estrógenos/ progestágenos) no debe ser utilizada en la prevención primaria del ictus (Nivel I)
    44. 44. Prevención primaria • Tratamiento antiagregante – Se sabe que • La aspirina no reduce el riesgo de ictus en personas asintomáticas • La aspirina reduce el riesgo de IM en personas con uno o más factores de riesgo vascular (RRR 26%, NNT 1000)
    45. 45. Prevención primaria • Recomendaciones de la EUSI 1. Aunque la aspirina no reduce el riesgo de ictus en sujetos sanos, sí que reduce el riesgo de IM y puede recomendarse en pacientes con uno o más factores de riesgo vascular (Nivel I) 2. Clopidogrel, ticlopidina, trifusal y dipiridamol no han sido estudiados en sujetos asintomáticos, consecuentemente no se pueden recomendar para la prevención primaria del ictus (Nivel IV) 3. Pacientes asintomáticos con estenosis mayor del 50% de la ACI deberían recibir aspirina para reducir el riesgo de IM (Nivel I)
    46. 46. Prevención primaria • Fibrilación auricular (FA) – Datos • La incidencia media de ictus es de 5% por año • La warfarina equivalente a un un INR entre 2 y 3 reduce el ictus isquémico en un 60-70 %. • La anticoagulación con un INR inferior a 2.0 no es efectiva • Con un INR > 3.5 se incrementa el riesgo de complicaciones hemorrágicas
    47. 47. Prevención primaria • Fibrilación auricular (FA) – Datos • 300 mg diarios de aspirina disminuyen el riesgo relativo de ictus en un 21 % • La aspirina es menos eficaz que la warfarina • Los pacientes < 65 años con “FA aislada” tienen un riesgo embólico bajo. Los pacientes mayores de 65 años tienen un riesgo embólico más elevado
    48. 48. Prevención primaria • Recomendaciones EUSI: Fibrilación auricular 1. La anticoagulación oral prolongada ( INR diana 2.5; rango 2.0 - 3.0) debe considerase en pacientes con FA de alto riesgo embolígeno: edad>75 años, o edad >65 años con factores de riesgo tales como HTA, disfunción ventriculo izquierdo o diabetes (Nivel I) 2. Aspirina (325 mg al día) o warfarina a largo plazo para pacientes con FA no valvular con riesgo embolígeno moderado: edad 65-75 sin factores de riesgo añadidos (Nivel I) 3. La warfarina se recomienda para pacientes con edad entre 65-75 años con diabetes o coronariopatía (Nivel I)
    49. 49. Prevención primaria • Recomendaciones EUSI: Fibrilación auricular 4. En pacientes mayores de 75 años, se puede utilizar warfarina con un INR inferior (INR de 2.0; rango 1.6 2.5) para disminuir el riesgo de hemorragia (Nivel III) 5. Los pacientes con FA en los que esté contraindicada la anticoagulación oral deberían recibir aspirina (Nivel I) 6. En pacientes con FA no valvular de bajo riesgo: edad <60 sin factores de riesgo añadidos se recomienda aspirina (325 mg al día) a largo plazo, o ningún tratamiento.(Nivel I) 7. Los pacientes portadores de prótesis valvulares deberán recibir anticoagulación oral prolongada ( INR según el tipo de válvula (como mínimo entre 2 y 3) (Nivel I)
    50. 50. Prevención primaria • Estenosis asintomática de la arteria carótida interna (ACI) – Datos • La endarterectomía carotídea (EAC) continúa siendo controvertida • La EAC reduce el riesgo relativo de estenosis carotídea >60% en un 38-53% • La reducción del riesgo absoluto es de 5.9-12.6% • El NNT para evitar un ictus/año es de 63-166 • El riesgo quirúrgico combinado no debe exceder el 3%
    51. 51. Prevención primaria • Estenosis asintomática ACI:consideraciones específicas – Los pacientes con una oclusión de la ACI contralateral a la carótida intervenida, no se benefician de la endarterectomía [Baker et al 2000, Straus et al 2002] – El riesgo de ictus ipsilateral aumenta proporcionalmente al grado de estenosis[ECST group 1995, Inzitari et al 2000) – Un análisis por subgrupos del ACAS ha demostrado que las mujeres obtienen un beneficio significativamente menor de la cirugía que los hombres. – No hay ensayos prospectivos que investiguen el beneficio del tratamiento antiagregante en pacientes con estenosis carotídea asintomática [Chambers et al 2002]
    52. 52. Prevención primaria • Recomendaciones EUSI: Estenosis asintomática ACI 1. La EAC puede estar indicada en algunos pacientes con estenosis ACI entre 60-99% . El riesgo relativo de ictus y muerte para la EAC debe ser inferior al 3%. Los pacientes con una expectativa de vida de al menos 5 años (o de edad inferior a 80 años) pueden beneficiarse de la cirugía (Nivel II) 2. La angioplastia carotídea, con o sin stent no está recomendada en la estenosis carotídea asintomática. Puede realizarse en el contexto de ensayos clínicos aleatorizados
    53. 53. Prevención secundaria • Fármacos antiagregantes – Aspirina: hechos • Reduce el riesgo relativo de ictus tras AIT o ictus en un 13% • La mayoría de las dosis estudiadas se encuentran entre 50-150mg • La incidencia de trastornos GI con aspirina es dosis dependiente • No existen diferencias de eficacia entre dosis de aspirina bajas (< 160 mg), medias (160 - 325) o altas (500 - 1500 mg)
    54. 54. Prevención secundaria • Fármacos antiagregantes – Dipiridamol + aspirina • ESPS II: la reducción del riesgo relativo de ictus con la combinación es significativamente mayor(23%) que con aspirina
    55. 55. Prevención secundaria • Fármacos antiagregantes – Clopidogrel • CAPRIE: Clopidogrel es discreta pero significativamente más eficaz que aspirina a dosis medias (RRR 8.7%) en la prevención de eventos vasculares en pacientes con ictus, IM o arteriopatía periférica
    56. 56. Prevención secundaria • Fármacos antiagregantes : consideraciones especiales – La incidencia de una hemorragia grave es independiente de la dosis de aspirina – La incidencia de transtornos gastrointestinales con aspirina es dosis dependiente. Dosis menores son más seguras – El manejo del paciente que presenta un evento vascular a pesar de un tratamiento antiagregante está por determinar. En esta situación debe reevaluarse los aspectos fisiopatológicos y los factores de riesgo. Los pacientes sin una fuente cardioembólica que han padecido un evento vascular de repetición durante un tratamiento con aspirina no se benefician de warfarina.
    57. 57. Prevención secundaria • Recomendaciones EUSI: Fármacos antiagregantes 1. Debe administrarse un tratamiento antiagregante adecuado para prevenir la recurrencia de ictus y de otros eventos vasculares (Nivel I) Existen diversas opciones terapeúticas, según las características del paciente todas ellas pueden considerarse de primera elección (Nivel I)
    58. 58. Prevención secundaria • Recomendaciones: Fármacos antiagregantes 2. Puede administrarse aspirina (50-325 mg) para reducir el riesgo de recurrencia de ictus (Nivel I) 3. Si está disponible, la combinación de aspirina (25 mg) y dipiridamol (200 mg) dos veces al día puede administrarse como primera elección para reducir el riesgo de recurrencia de ictus (Nivel I) 4. Clopidogrel es dicretamente más efectivo que aspirina en la prevención de ulteriores eventos vasculares (Nivel I). También puede prescribirse de primera elección o cuando la aspirina o el dipiridamol no sean bien tolerados (Nivel IV), y en pacientes de alto riesgo (Nivel III)
    59. 59. Prevención secundaria • Recomendaciones EUSI: Fármacos antiagregantes 5. Los pacientes con ictus isquémico o AIT y angina inestable o infarto de miocardio sin onda Q deberían ser tratados con clopidogrel 75 mg más aspirina 75 mg (Nivel III) 6. Los pacientes que inicien un tratamiento con derivados de tienopiridina deberían recibir clopidogrel en lugar de ticlopidina dada su menor incidencia de efectos secundarios (Nivel III) 7. Los pacientes que no puedan ser tratados con aspirina o derivados de tienopiridina, pueden tratarse alternativamente con dipiridamol en monoterapia (200mg 2 veces al día) en su fórmula modificada de liberación retardada (Nivel II)
    60. 60. Prevención secundaria • Anticoagulación tras el ictus – Datos • La anticoagulación oral con un INR entre 2-3 reduce el riesgo de recurrencia de ictus en pacientes con FA (EAFT) • La anticoagulación oral está indicada en otras causas de embolismo como recambio de prótesis valvular, valvulopatía reumática, aneurisma ventricular y miocardiopatía • No existe una razón para utilizar AC oral en pacientes con ictus sin evidencia de una fuente cardioembólica (Mohr 2001)
    61. 61. Prevención secundaria • Anticoagulación (AC) tras un ictus tromboembólico: consideraciones específicas – Algunos estudios retrospectivos sugieren que la anticoagulación podría ser beneficiosa en la ateromatosis aórtica [Dressler et al 1998], los aneurismas fusiformes de la arteria basilar (Echiverri et al. 1989) y la disección arterial – Probablemente, la AC oral debería evitarse en pacientes ancianos con leucoaraiosis (The Stroke Prevention in Reversible Ischaemia Trial Study Group 1997) – Es incierto que los pacientes con foramen oval permeable (PFO) se beneficien de la AC oral
    62. 62. Prevención secundaria • Recomendaciones EUSI: Anticoagulación oral 1. 2. 1. La anticoagulación oral (INR 2.0-3.0) está indicada tras un ictus isquémico asociado con fibrilación auricular (Nivel I). La anticoagulación oral no se recomienda en pacientes con comorbilidad como son caídas frecuentes, epilepsia, demencia avanzada o hemorragia gastrointestinal 2. Los pacientes con prótesis valvulares cardíacas deberían recibir anticoagulación a largo plazo con un INR diana entre 2.5 y 3.5 o superior (Nivel II)
    63. 63. Prevención secundaria • Recomendaciones EUSI: Anticoagulación oral 3. Los pacientes con ictus y una fuente cardioembólica demostrada deberían ser anticoagulados con un INR entre 2.0 y 3.0, si el riesgo de recurrencia es alto (Nivel III) 4. La anticoagulación no debería utilizarse tras un ictus no cardioembólico, excepto en algunas situaciones especiales tales como ateromatosis aórtica, aneurismas fusiformes de la basilar o disección arterial cervical (Nivel IV)
    64. 64. Prevención secundaria • Control de la presión arterial (PA) – El tratamiento de la PA en estudios prospectivos aleatorizados frente a placebo (perindopril con indapamida, ramipril) tras el ictus conduce a una disminución del riesgo relativo de recurrencia de ictus del 22-28% (HOPE 2001; Progress 2001)
    65. 65. Prevención secundaria • Control de la presión arterial : Consideraciones específicas • Aunque no existe una evidencia suficiente, no debe reducirse excesivamente la presión arterial en pacientes con riesgo de ictus hemodinámico por ateromatosis carotídea o vertebrobasilar estenótica u oclusiva, o por insuficiencia cardiaca • Los inhibidores de la ECA pueden plantearse en pacientes con reserva hemodinámica cerebral comprometida dado que desplazan la curva de autorregulación del FSC hacia límites normales.
    66. 66. Prevención secundaria • Estatinas – El tratamiento con estatinas disminuye la recurrencia de ictus en un 25% ( RRR) • Tabaco – El abandono del hábito tabáquico a cualquier edad conduce a una reducción precoz del riesgo tanto de eventos coronarios como de ictus (Kawachi et al 1993, Wannamethee et al 1995, et al 1988) • Terapia hormonal sustitutiva – La terapia estrogénica no es efectiva en la prevención secundaria tras un AIT o ictus
    67. 67. Prevención secundaria • Recomendaciones EUSI: Presión arterial, estatinas y tabaco 1. Tras un AIT o un ictus, la presión arterial debe reducirse con un diurético y/o un IECA ,según la tolerancia al tratamiento, independientemente de los niveles de PA (Nivel I) 2. La eficacia de otros fármacos antihipertensivos todavía no ha sido establecida 3. En pacientes que han sufrido un ictus isquémico o un AIT debe plantearse un tratamiento con estatinas (sinvastatina) (Nivel I) 4. La terapia hormonal sustitutiva no está indicada tras un ictus o un AIT(Nivel II) 5. Todo fumador debería de dejar de fumar , especialmente si ha padecido un ictus (Nivel IV)
    68. 68. Prevención secundaria • Endarterectomía carotídea (EAC) – Datos (NASCET, ECST) • La cirugía es eficaz en pacientes con estenosis carotídea sintomática ipsilateral > 70% en centros con una tasa de complicaciones perioperatorias igual o inferior al 6% • Si las complicaciones perioperatorias exceden el 6 % el beneficio de la EAC disminuye; si alcanza el 10%, el beneficio desaparece • También se ha descrito cierta reducción del riesgo en pacientes varones con estenosis carotídea ipsilateral entre 50 - 69% , siempre que el índice de complicaciones sea menor del 3%
    69. 69. Prevención secundaria • Endarterectomía carotídea (EAC): Consideraciones específicas – Los pacientes ancianos (>75 años) sin fracaso orgánico o disfunción cardíaca grave, se benefician de la EAC – En mujeres con estenosis sintomática >70% se debe realizar una EAC; si la estenosis es moderada es recomendable el tratamiento médico – Los pacientes con pocos factores de riesgo que presentan una amaurosis fugax aislada son subsidarios de tratamiento médico. En pacientes con estenosis grave y perfil de alto riesgo se debe considerar la EAC – Los pacientes con estenosis intracraneal leve o moderada o con estenosis extracraneal grave son candidatos ideales para la EAC
    70. 70. Prevención secundaria • Endarterectomía carotídea(EAC): Consideraciones específicas – El beneficio de la EAC es menor en el infarto lacunar – Los pacientes con leucoaraiosis deben ser informados de un mayor riesgo operatorio – La oclusión de la ACI contralateral conlleva un mayor riesgo perioperatorio – La aspirina debe mantenerse hasta la cirugía, si bien la heparina puede utilizarse en las estenosis graves. – El beneficio de la endarterectomía es limitado en pacientes con estenosis carotídea suboclusiva – Toda gradación de una estenosis debe basarse en criterios NASCET
    71. 71. Prevención secundaria Recomendaciones EUSI: EAC 1. La angiografia convencional (Nivel I), y una (o idealmente más de una) de las siguientes exploraciones no invasivas una -ultrasonografia duplex, angiorresonancia magnética (ARM) o angioCT (Nivel III) sirven para identificar y cuantificar la estenosis carotídea 2. La EAC está indicada en pacientes con estenosis entre 70-99% sin secuelas neurológicas graves, y con eventos isquémicos recientes (<180 días). Esto sólo es válido para centros con una tasa de complicaciones perioperatorias menor del 6% (incluídos tanto ictus como muerte)(Nivel I)
    72. 72. Prevención secundaria Recomendaciones: EAC 3. La EAC puede estar indicada en determinados pacientes con estenosis entre 50-69% sin un déficit neurológico grave. Esto es sólo válido para centros con una tasa de complicaciones perioperiatorias (ictus o muerte) menor del 6%. El subgrupo de pacientes que más se benefician de la cirugía es el de varones con síntomas hemisféricos recientes (Nivel III) 4. La EAC no se recomienda en pacientes con estenosis menores del 50% (Nivel I)
    73. 73. Prevención secundaria Recomendaciones EUS: EAC 5. La EAC no se debe llevar cabo en centros que carezcan de una tasa de complicaciones similar a la de los estudios NASCET o ECST (Nivel I) 6. Debe mantenerse el tratamiento antiagregante antes, durante y después de la cirugía (Nivel II) 7. Los pacientes deben ser controlados ambulatoriamente por el cirujano y por el médico de referencia (Nivel IV)
    74. 74. Prevención secundaria • Angioplastia transluminal percutánea (PTA) con o sin stent – Ventajas • Breve estancia hospitalaria • Evita la anestesia general y la incisión quirúrgica • Permite tratar zonas inaccesibles a la cirugía – PTA con stent es el tratamiento más efectivo de la reestenosis tras EAC – Se está pendiente de los resultados de grandes ensayos aleatorizados
    75. 75. Prevención secundaria • EUSI-Recomendaciones: Stent La angioplastia carotidea puede realizarse en pacientes con contraindicaciones para la EAC o en pacientes con estenosis inaccesibles a la cirugía (Nivel IV) 2. La angioplastia carotídea con stent puede indicarse en pacientes con reestenosis tras EAC o estenosis postrádica (Nivel IV) 3. Los pacientes recibirán deben recibir la combinación clopidogrel-aspirina inmediatamente antes, durante y hasta un mes después de la colocación del stent (Nivel IV) 1.
    76. 76. Tratamiento agudo del ictus Medidas generales • Recomendaciones EUSI: Incluyen los siguientes aspectos – – – – – – – Estado clínico Cuidados de la via aérea y sistema respitatorio Presión arterial Temperatura Metabolismo de la glucosa Manejo de sueros y electrolitos, alimentación Prevención de TVP
    77. 77. Medidas Generales • Las bases del tratamiento en fase aguda: – Tratamiento y estabilización del paciente – Terapia específica, recanalización de la oclusión, prevención de mecanismos que conducen a la muerte neuronal en el tejido isquémico (neuroprotección). – Profilaxis y tratamiento de complicaciones tales como hemorragia secundaria, edema ocupante de espacio, crisis, aspiración, infecciones, úlceras de decúbito, trombosis venosa profunda o embolismo pulmonar. – Prevención secundaria precoz (para evitar la recurrencia precoz del ictus) – Rehabilitación precoz
    78. 78. Medidas Generales • Monitorización de funciones vitales y neurológicas – Monitorizacion contínua • Frecuencia cardíaca • Saturación de O2 – Monitorización discontínua • Presión arterial (p.e. esfigmomanometría inflable automática) • Vigilancia-nivel consciencia / GCS, pupilas • Estado neurológico (p.e. escala de ictus NIH o escala canadiense )
    79. 79. Medidas Generales • Función pulmonar y vía aerea – Una adecuada oxigenación puede ser esencial para preservar el área de penumbra – Mejorar la oxigenación sanguínea mediante la administracion de > 2 l O2 (según la SaO2 ) – Vigilar el riesgo de aspiración en pacientes con parálisis pseudobulbar/bulbar y nivel de vigilancia disminuído: decúbito lateral, considerar traqueostomía – La hipoventilación puede estar causada por un patrón respiratorio patológico – Ante el riesgo de obstrucción de la vía aérea (vómitos, hipotonía de la musculatura orofaríngea): protección mecánica de la vía aérea
    80. 80. Medidas Generales • Presión arterial (PA) – Elevada en la fase aguda en la mayoría de pacientes con ictus – La PA desciende espontáneamente durante los primeros días tras el ictus – El flujo sanguíneo que nutre el área de penumbra depende pasivamente de la presion arterial media
    81. 81. Medidas Generales • Presión arterial – No existen estudios aleatorizados, controlados, de tamaño suficiente, que guíen el manejo de la PA – Una PA elevada (p.e.más de 200mmHg sistólica o de 110mmHg diastólica) puede ser tolerada en la fase aguda del ictus isquémico sin que se precise reducirla – La PA puede reducirse si lo requiere la situación cardiaca – El límite superior de la PA sistólica en pacientes que reciben trombolisis es de 180mmHg – Evitar y tratar la hipotensión o las caídas bruscas en la PA
    82. 82. Medidas Generales • Hipertensión arterial – Indicaciones de terapia hipotensora inmediata-urgente en el ictus agudo • Hemorragia intracerebral • Insuficiencia cardiaca • Síndrome coronario agudo • Disección aórtica • Encefalopatía hipertensiva
    83. 83. Medidas Generales • Metabolismo de la glucosa – Datos • Niveles elevados de glucosa en la fase aguda del ictus aumentan el tamaño del infarto y empeoran el pronóstico funcional • La hipoglucemia también empeora el pronóstico • La hipoglucemia puede simular un infarto cerebral agudo – No existen ensayos de tamaño adecuado que orienten el manejo de la glicemia en el ictus – Restringir el uso de sueros glucosados – Considerar el uso de insulina cuando la glucemia exceda los 10 mmol/l
    84. 84. Medidas Generales • Temperatura – Datos • La fiebre influye negativamente en el pronóstico neurológico del ictus • Experimentalmente, la fiebre aumenta el tamaño del infarto • Muchos pacientes desarrollan infecciones febriles durante la fase aguda del ictus – No existen ensayos de tamaño adecuado que guíen el manejo de la temperatura en el ictus – Se debe considerar el tratamiento de la fiebre y su causa cuando la temperatura alcanza los 37.5°C
    85. 85. Medidas Generales • Sueroterapia y electrolitos – Los trastornos hidroelectrolíticos significativos son raros tras el ictus isquémico pero frecuentes tras la HIC y la HSA – Un adecuado manejo de la fluidoterapia y los electrolitos es importante para evitar: • Hipo- e hipervolemia • Contracción del volumen plasmático • Hematocrito elevado
    86. 86. Medidas Generales • EUSI-Recomendaciones (todas Nivel IV ) 1. Se recomienda la monitorización contínua en las primeras 48 desde el inicio del ictus , particularmente en pacientes con : 1. Enfermedad cardíaca previa 2. Antecedente de arritmias 3. Presión arterial inestable 4. Síntomas/signos de insuficiencia cardíaca 5. ECG de base anormal 6. Infarto que afecte al córtex insular 2. Se recomienda la monitorización de la oxigenación
    87. 87. Medidas Generales • EUSI-Recomendaciones (todas Nievel IV ) 3. La administración de O2 se recomienda en caso de hipoxemia (gasometría arterial o pulsioximetría) con satO2t < 92%) 4. Se recomienda la intubación en caso de insuficiencia respiratoria potencialmente reversible 5. No se recomienda el descenso de la PA, excepto en valores muy elevados y confimados repetidamente (>200220 PAS o 120 PAD, en el ictus isquémico y > 180/105, en el ictus hemorrágico)
    88. 88. Medidas Generales • EUSI- - Recomendaciones (todas Nivel IV ) 6. Se recomienda un tratamiento hipotensor inmediato frente a una hipertensión más moderada si coexiste insuficiencia cardiaca, disección aórtica, IAM, insuficiencia renal aguda o trombolisis ,pero siempre de manera cautelosa 7. Valores de PA recomendados en pacientes con HTA previa: 180/100-105 mmHg sin HTA previa: 160-180/90-100 mmHg durante trombolisis: evitar PAS superior a 180 mmHg 8. Fármacos recomendados para el tratamiento de la PA e.v. : v.o. : Labetalol, urapidil, nitroprusiato sódico o nitroglicerina Captopril
    89. 89. Medidas Generales • EUSI - Recomendaciones (todas Nivel IV ) 9. Evitar nifedipina o cualquier descenso brusco de PA 10. Evitar y tratar la hipotensión, particularmente en pacientes inestables mediante una correcta fluidoterapia ( ver más adelante) y, si es preciso, expansores del plasma y/o catecolaminas (epinefrina 0.1-2 mg/h más dobutamina 5-50 mg/h) 11. Se recomienda la monitorización de la glucemia, especialmente en pacientes diabéticos conocidos
    90. 90. Medidas Generales • EUSI- Recomendaciones (todas Nivel IV) 12. No se recomiendan sueros glucosados dados los efectos perjudiciales de la hiperglucemia 13. Se recomienda el tratamiento con insulina ante niveles séricos de glucemia > 10 mMol/L 14. Se recomienda la corrección inmediata de la hipoglicemia con un bolus e.v. de dextrosa o una perfusión de suero glucosado al 10%-20% 15. Se recomienda el tratamiento de una temperatura ≥ 37.5°C
    91. 91. Medidas Generales • EUSI - Recomendaciones (todas Nivel IV ) 16. En caso de fiebre , se recomienda la búsqueda de una posible infección (foco y etiología), para poder iniciar una antibioticoterapia dirigida 17. No se recomienda profilaxis antibiótica, antimicótica o antiviral en pacientes inmunocompetentes 18. Se recomienda la monitorización y la corrección de los transtornos hidroelectrolíticos 19. Las soluciones hipotónicas (NaCl 0.45% o glucosado 5%) están contraindicadas dado que al disminuir la osmolalidad del plasma aumentan el riesgo de edema cerebral
    92. 92. Manejo agudo del ictusTratamiento específico • EUSI –Recomendaciones incluyen: – Terapia antitrombótica aguda • trombolisis • Anticoagulación • AAS – Tratamiento de la hipertensión intracraneal y del edema cerebral • Tratamiento médico • Tratamiento quirúrgico
    93. 93. Tratamiento trombolítico • Trombolisis EV (rtPA) – Datos (NINDS Pt. 1 + 2, ECASS I + II, ATLANTIS) • Autorizado en ventana de 3h , I.V. 0.9mg/kg, max 90mg • El beneficio del uso de rtPA e.v.después de las 3h es menor, pero existente hasta al menos 4.5 horas • Trombolisis EV (SK) – Datos (MAST-I, MAST-E, AST) • Algún efecto beneficioso dentro de las primeras 4 horas, alto riesgo, en desuso
    94. 94. Tratamiento trombolítico • Trombolisis IA (rtPA, UK) – Datos • Sólo existen casos y alguna serie prospectiva no controlada • Trombolisis (rPUK) – Datos (PROACT I y II) • Eficacia demostrada en pequeños ECA, ventana de 6h • No aprobado, y la sustancia no disponible actualmente
    95. 95. Tratamiento Trombolítico • Trombolisis: consideraciones específicas – Un análisis conjunto de los datos individuales de los 6 ensayos confirma que la trombolisis actúa hasta al menos 4.5 horas y potencialmente hasta 6h tras el inicio de los síntomas (Brott 2002) – Se recomienda precaución en la administracion de rtPA ev a pacientes con un ictus grave (NIH stroke scale >25), o si la TC muestra signos precoces de un infarto extenso, tales como borramiento de surcos, efecto de masa o edema – El tratamiento trombolítico sólo lo deberían administrar neurólogos/médicos expertos en ictus, después de que un médico experimentado en neuroimagen haya valorado la TC
    96. 96. Enzimas que disminuyen el fibrinógeno • Hechos – Ancrod es una enzima que disminuye el fibrinógeno y que parece mejorar el pronóstico del ictus si se administra en las primeras 3h desde el inicio de los síntomas, durante 5 días.(Sherman, para the STAT Writers Group, 1999) – Recientemente, un ensayo europeo del tratamiento con ancrod con una ventana de 6h tuvo que interrumpirse prematuramente sin confirmar los datos del estudio americano.
    97. 97. Tratamiento trombolítico • EUS -Recomendaciones 1. rtPA e.v.(0.9 mg/kg; max 90 mg, 10% bolo seguido de perfusión de una hora), es el tratamiento recomendado en el ictus isquémico de menos de 3 horas de evolución. (Nivel I) 2. El beneficio del rtPA e.v. más allá de las 3h del inicio del ictus es inferior, pero persiste hasta las 4.5 horas (Nivel II)
    98. 98. Tratamiento trombolítico • EUSI -Recomendaciones 3. No se recomienda rtPA endovenoso si no se puede asegurar la hora del inicio de los síntomas. Esto incluye a los pacientes que perciben sus síntomas al despertarse (Nivel IV) 4. La administración de estreptokinasa endovenosa es peligrosa y no está indicada en el tratamiento del ictus isquémico agudo(Nivel I) 5. Todavía no se dispone de datos de eficacia y seguridad de otros fármacos trombolíticos endovenosos y no se establecen recomendaciones al respecto.
    99. 99. Tratamiento trombolítico • EUSI-Recomendaciones 6. La estreptokinasa e.v. no está indicada en el tratamiento agudo del ictus isquémico (Nivel I) 7. La oclusión vascular intracraneal aguda puede en pacientes seleccionados, tratarse con terapia intraarterial utilizando rtPA o Urokinasa (Nivel IV)
    100. 100. Tratamiento trombolítico • EUSI –Recomendaciones 8. El tratamiento intra-arterial con pro-urokinasa en las primeras 6 horas de la oclusión aguda de la arteria cerebral media ha demostrado mejorar significativamente el pronóstico (Nivel II) 9. La oclusión aguda de la arteria basilar puede tratarse con tratamiento intra-arterial en centros seleccionados con un protocolo experimental autorizado por un CEIC, o dentro de un estudio multicéntrico (Nivel IV) 10. Ancrod no puede recomendarse en el ictus isquémico excepto en el contexto de ensayos clínicos
    101. 101. Tratamiento en fase aguda: Inhibidores plaquetarios • Aspirina – Evaluada en grandes ECAs en el ictus isquémico agudo (<48 h) (IST, CAST) – Reducción significativa de muerte, dependencia (NNT 70) y recurrencia (NNT 140) de ictus – La reducción de muerte y dependencia durante las primeras 2 semanas fue del 1% (NNT 111) en un análisis combinado de IST y CAST
    102. 102. Tratamiento en la fase aguda • Anticoagulación – Heparina no fraccionada • Ningún estudio disponible que evalúe la administración endovenosa estándar • El IST no mostró un beneficio neto con heparina subcutánea dado el incremento del riesgo de HIC – Heparinas de bajo peso molecular • No mejoran el pronóstico – Heparinoides (orgaran) • Ensayo TOAST neutro
    103. 103. Tratamiento en la fase aguda • Hemodilución – Diversos ECAs no han demostrado eficacia con ninguna forma de hemodilución. – En algunos ensayos, la hemodilución se asoció a un aumento del riesgo • Neuroprotección – En la actualidad, ningún estudio de tamaño muestral adecuado con un agente neuroprotector ha mostrado un efecto significativo en sus objetivos predefinidos
    104. 104. Tratamiento en la fase aguda • EUSI-Recomendaciones : Inhibidores Plaquetarios 1. Se debería administrar aspirina 160-325 mg/día en las primeras 48 horas del inicio del ictus (Nivel I) 2. Si se prevé un tratamiento fibrinolítico, no debe administrarse aspirina 3. Está prohibida la administración de aspirina en las 24 horas siguientes de un tratamiento fibrinolítico
    105. 105. Tratamiento en la fase aguda • EUSI-Recomendaciones : Anticoagulación 4. No existe una recomendación respecto al uso sistemático de heparina, heparinas de bajo peso molecular o heparinoides tras el ictus.(Nivel I) 5. La heparina a dosis plenas puede utilizarse en determinadas indicaciones como fuentes cardioembólicas con alto riesgo de recurrencia, disección arterial, o estenosis graves en espera de cirugía (Nivel IV) 6. La hemodilución no se recomienda en pacientes con ictus isquémico agudo (Nivel I) 7. No se recomienda el tratamiento con ninguna sustancia neuroprotectora en los pacientes con ictus (Nivel I)
    106. 106. Anticoagulación en la profilaxis de TVP y TEP • Profilaxis de trombosis venosa profunda (TVP) y tromboembolismo pulmonar (TEP) – Mecánica • Las medias compresivas no están adecuadamente evaluadas en pacientes con ictus, pero son relativamente seguras – Anticoagulantes • Cualquier tipo de tratamiento con heparina reduce la incidencia de TVP , pero está asociado con un mayor riesgo de hemorragia • En pacientes con un riesgo especialmente elevado de TVP, puede iniciarse el tratamiento con heparina
    107. 107. Prevención de complicaciones • EUSI -Recomendaciones 1. La heparina s.c. a bajas dosis o las heparinas de bajo peso molecular sólo deberían plantearse en pacientes con alto riesgo de TVP o TEP (Nivel II) 2. La incidencia de TEP puede reducirse con una mobilización e hidratación precoz, así como con el uso de medias compresivas (Nivel IV) 3. Las infecciones tras el ictus deberían ser tratadas con antibioterapia adecuada. 4. La neumonía por broncoaspiración no necesariamente se previene con la nutrición por sonda nasogástrica (Nivel IV)
    108. 108. Profilaxis de TVP y TEP • EUSI -Recomendaciones 5. La mobilización precoz ayuda a prevenir numerosas complicaciones tras el ictus, tales como la neumonía aspirativa, la TVP o las úlceras por decúbito (Nivel IV) 6. El tratamiento antiepiléptico para prevenir nuevas crisis es muy recomendable (Nivel III) 7. No se recomienda el tratamiento antiepiléptico profiláctico en pacientes con ictus sin crisis (Nivel IV)
    109. 109. Tratamiento de la hipertensión intracraneal y edema cerebral • Tratamiento médico – Principios generales • Cabecera de cama elevado a 30° • Analgesia y sedación • Agentes osmóticos (glicerol-manitol-salino hipertónico) • Asegurar una ventilación adecuada • Barbitúricos, hiperventilación,o tampones THAM • Conseguir normotermia • Hipotermia: experimental, puede reducir la mortalidad
    110. 110. Tratamiento de la hipertensión intracraneal y edema cerebral • Tratamiento quirúrgico – Drenaje ventricular • Infarto en fosa posterior con efecto de masa – Cirugía descompresiva • Infarto en fosa posterior con efecto de masa • Infarto hemisférico maligno de la ACM – Importante: resultados prometedores en la disminución de mortalidad y dependencia en series prospectivas
    111. 111. Tratamiento de la hipertensión intracraneal y edema cerebral • EUS -Recomendaciones 1. La osmoterapia y la ventilación mecánica, incluyendo hiperventilación moderada pueden plantearse en pacientes con deterioro progresivo por aumento de la PIC ,como pacientes con signos de herniación cerebral (Nivel IV) 2. Están justificados el drenaje ventricular y la cirugía descompresiva en infartos cerebelosos extensos que compriman el tronco cerebral (Nivel III) 3. La cirugía descompresiva en casos seleccionados de infarto hemisférico extenso puede salvar la vida (Nivel III)

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