Evidence-based Stroke Care Charles S. Yanofsky,MD Grand Rounds September 25, 2008 Pinnacle Health EVIDENCE-BASED STROKE CARE EVIDENCE-BASED STROKE CARE Charles S. Yanofsky, MD Pinnacle Health Neurology Sept. 25, 2008
Early admission of most patients to a unit that has a specialized interest in the treatment of stroke is strongly recommended (Level of Evidence I, Grade A Recommendation). A team of physicians, nurses, and technicians that is devoted to the early care of patients with stroke should be assembled. Rapid transfer of a patient to a hospital that has a specialized stroke care unit is strongly recommended.
In 624 patients studied within 3 hours after symptom onset, the chance of a total or near total recovery for a patient in the tissue plasminogen activator (t-PA [Activase]) group was 1.7 times greater than in the placebo group.
During cerebral angiography it has been found that it is possible to thread a fine guidewire and infusion catheter to and through an intravascular clot. It has been effective in the internal carotid artery or its branches and in the vertebrobasilar system for administration of intra-arterial thrombolytic agents to restore blood flow.
Sasaki O, Takeuchi S, Koike T, et al. Fibrinolytic therapy for acute embolic stroke: intravenous, intracarotid and intraarterial local approaches. Neurosurgery. 1995; 36:246-253
If thrombolytic therapy is not feasible, treatment should be carefully evaluated by repeated neurologic examination over the next few hours to be sure the stroke is not progressing. If there is progression, anticoagulants may be considered after a repeat CCT to be certain the cause is progression and not hemorrhage.
Effect: The PROGRESS trial, including 6105 patients, demonstrated that an ACE inhibitor and a diuretic, mainly in combination, are beneficial after ischemic and hemorrhagic stroke. The relative risk of stroke is reduced by 28 %, and the relative risk of major cardiac events by 26 % over 4 years (Grade B evidence).
An elevation of blood pressure may be a compensatory response to maintain cerebral perfusion pressure in a patient with a markedly elevated intracranial pressure. In such instances antihypertensive agents, particularly those that induce cerebral vasodilation, are avoided.
In general, antihypertensive drugs should be withheld unless the calculated mean blood pressure (the sum of the systolic pressure plus double the diastolic pressure, divided by three) is greater than 130 mm Hg or the systolic blood pressure is greater than 220 mm Hg
Elevated blood pressure usually declines spontaneously over the first 24 hours after stroke onset and overzealous use of a calcium antagonist and other antihypertensive drugs should be avoided because they can further reduce cerebral perfusion.
Minimal or no treatment of mildly to moderately elevated blood pressure during the first hours of ischemic stroke is supported by human and animal data. Because of the partial or complete loss of autoregulation in ischemic brain, cerebral blood flow in these regions depends almost entirely on the arterial blood pressure to maintain cerebral perfusion
There is general agreement to recommend treatment of the sources of fever and use of antipyretics to control an elevated body temperature (Levels of Evidence III through V, Grade C). There are insufficient clinical data about the use of hypothermia to recommend this therapy.
NNT = 18 (14 to 27). (18 patients treated with warfarin 1.6 years to prevent one stroke. Also one-year NNTs to prevent one stroke of 37 for primary prevention, 12 for secondary prevention for adjusted dose warfarin compared with placebo.
All-cause mortality was decreased by 1.6% a year in patients receiving warfarin.
Early mobilization and measures to prevent the subacute complications of stroke (aspiration, malnutrition, pneumonia, deep vein thrombosis, pulmonary embolism, decubitus ulcers, contractures, and joint abnormalities) are strongly recommended
The best candidates for surgery may be patients with moderate to large hematomas who are still awake. At the present time there is no definitive proof of the value of early evacuation of deep intracranial hematomas.