management of stroke

1. A Lecture delivered on the 6th of August 2012 at the
REVISION / UPDATE COURSE
Organized by
The West African College of Physicians
on
MANAGEMENT OF STROKE
By
Prof. Yomi Ogun
BSc (Hons); MBChB; Cert. Neurol. (Lond); FWACP; FACP.
Professor of Internal Medicine / Neurology
Consultant Physician / Neurologist.
Provost Obafemi Awolowo College of Health Sciences
Olabisi Onabanjo University Teaching Hosp. Sagamu
Venue: University College Hospital; Ibadan
11/7/2022 1

2. Management of stroke
Cerebral Infarction (CI),
Intracerebral Haemorrhage (ICH)
Sub – Arachnoid Haemorrhage (SAH)
11/7/2022 2

3. What is stroke?
Historical remarks:
 Hippocrates (460 – 370BC) “first describtion of phenomenon of
sudden paralysis”
 Greek word “Apoplexy” ( “struck by violence”),
 spiritual attacks
 Witch theory / Step-mum theory / Wicked Mother in law
offended the gods /godesses (unable to speak, move part of the
body; “Agbero”; “Ofa” “Ota”, “Ita”)
3

4. Definition – new concept
• The 24 hrs time based no longer acceptable: confusing;
misleading; outdated
• It does not suggest a medical emergency (Brain attack) and the
mantra “time’s neuron
• (cf Time’s muscle by cardiologist)
• Does not take into cognizance the use of thrombolytics within 270
mins (4 ½ hrs) in CI or Recombinant activated factor VII within 4
hours in ICH
• TIA no longer considered as benign
• Risk of developing stroke- 10% in one wk; 15% in one month,
20% in 90 days;
• (½ of these in 24 –48 hrs.)
• age ; D.M; > 10 mins; weakness; impaired speech
• TIA and stroke = One hour
• Most (90%) TIA lasts 10 mins; resolve in 30 mins. If symptoms last
> I hr; chances of resolution:15%
4

5. TIA / Stroke – new definition
Tissue – based / Time – based definition
• TIA: No objective evidence of acute infarction in
the affected region of brain or retina; < I hour
• Stroke : objective evidence of infarction
irrespective of duration of clinical symptoms.
• (Compared to Angina pectoris vs Myocardial
infarction )
• CT/MRI necessary to increase diagnostic accuracy
• CITS = RIND.
5

6. Stroke types / subtypes
• Types: CI/ICH/SAH
• Subtypes:
• Lacunar strokes
• Cardioembolic stroke
• Large vessel disease
• Small vessel disease: ant / post circulation
Biswangers,Branch Arteromatous disease
(BAD);VCI(Vascular Cognitive Impairment.
• Undetermined aetiology
• others
11/7/2022 6

7. THREE STROKE TYPES
Ischemic
Stroke
Clot occluding
artery
Intracerebral
Hemorrhage
Bleeding
into brain
Subarachnoid
Hemorrhage
Bleeding
around brain
Focal Brain Dysfunction
Diffuse Brain
85% 10% 5%

8. Stroke types

9. STROKE EMERGENCY BRAIN IMAGING:
NONCONTRAST CT SCAN
Acute (4 hours)
Infarction
Subtle blurring of gray-white
junction & sulcal effacement
Subacute (4 days)
Infarction
Obvious dark changes &
“mass effect” (e.g.,
ventricle compression)
R
R L L

10. Epidemiology
• Stroke is a common neurological problem
• 1 out of every 6 adults would develop stroke in a lifetime
• Every 12 seconds, one adult develops stroke in the world.
• (six adults in every one minute)
• 15 million cases yearly (2/3rd developing world)
• 6 million deaths yearly; Second leading cause of all deaths
worldwide
• Leading cause of disability in adults (5 million).
• One of the most costly disease in low and middle income
countries (T he inverse burden-knowledge relationship)
• 1 person dies of stroke every 6 seconds in the world,
• Account 4.5-17% of all admissions in hospital based studies- Nig
• 2.8 – 4.5% of deaths case fatality: = 35% (14.9 – 77%)
• community prevalence = 58 – 400/ 100,000
10

11. Known Risk factors - CI
• Known:
• Hypertension / DM
• Dyslipidaemia / Obesity (Metabolic Synd)
• Age (50 –59) /T.I.A
• > PCV (polycythemia)
• SCD / Oral Contraceptives
• Hormone replacement therapy
• PVD(Periph. Vasc. dx)/ Carotid stenosis
• Heart disease /Atrial fibrillation
• MTD(Malignant Trophoblastic Disease)
• HIV ; Hyperhomocysteinaemia
11

12. Possible Aetiology/ Risk factors - CI
• Migraine / Cigarette
• Hyperlipidaemia / Obesity
• Lack of exercise (physical inactivity)
• Hypotension / Dehydration
• Hypothyroidism / Hyperuricaemia
• Hypercoagulable states – anti-phospholipid syndrome ;
Protein C / S def.; Anti-thrombin 1 def.
• CCF / Severe Anaemia ; Low S – E status (unknown
hypertensive; undernutrition; infectn) Black race; male
sex; positive family hx ; HIV ;
12

13. Aetiology / Risk factors - CI
Modifiable
Well documented HTN, DM, Smoking, non-valvular
atrial fibrillation, asymptomatic carotid stenosis,
hyperlipidemia, sickle-cell dx.
Less well documented / potentially doc;
Alcohol abuse, obesity, physical inactivity,
hyperhomocystenemia, drug abuse, hypercoagulable
state, HRT, OCP and inflammatory processes.
non-modif. age, race, sex, family hx stroke/ TIA
severity of stroke at onset; comorbidities
13

14. Stroke in the Young
• Age grp: 15-45yrs; (40% Haemorrhagic)
• Migraine ;
• Heroine, cocaine, methamphetamine, oral
contraceptives ;
• prothrombotic state; Coagulopathies vasculitis
/ connective tissue dx
• Haemoglobinopathy
• HIV
11/7/2022 14

15. Stroke in the young
• Arteritis (Takayasu ,kawasaki)
• Moyamoya syndrome
• Cardiac: - congenital cardiac lesions atrial
ventricular and pulmonary vascular shunting,
Mitral valve prolapse ;
• Patent foramen ovale;
• Tetralogy of Fallot’s
• Cardiomyopathies
• Dissection and traumatic vascular injuries
• Cerebral venous thrombosis
• Infection of the endothelium
11/7/2022 15

16. Stroke and HIV
AIDS patients - higher risk for CI than ICH.
cerebral ischemia
 non-bacterial thrombotic endocarditis
 CI ( stroke-like syndrome: stroke mimics)
 concomitant opportunistic CNS infection
 Cryptoccocoma; Tuberculoma; Toxoplasma abscess;
Kaposis sarcoma;cerebral lymphoma
Intra cerebral haemorrhage
 thrombocytopenia/Thromboasthenia
(Thrombocytopathy),
primary CNS lymphoma or metastatic kaposis sarcoma.
11/7/2022 16

17. Stroke and HIV
Pathobiology – ? clear
Vasculitis - HIV associated vasculopathy
 > deposition of circulating Ig complexes
direct toxic effect of virus on the vascular
endothelium.
 Anti-phospholipidsantibodies,including
anticardiolipin antibodies - high frequency
11/7/2022 17

18. ICH : Risk factors
• Age, male sex, hypocholesterolaemia / low
Triglyceride
• Alcohol abuse,(SAH: Linear; ICH: U; CI: J)
• illicit drugs, iatrogenic
• Diet high in salt and saturated fat intake
• Diet low in K+, polyunsaturated fatty acids and
fish oil.
• Physical inactivity , stressful life events; Low
socio-economic class
• The association is strong, dose related and
consistent
11/7/2022 18

19. Potential new Risk factors
 Genetic polymorphisms
(e.g phosphodiesterase 4D, 5-lipoxygenase activating
protein, methylane tetrahydrofolate reductase
(MTHFR) C677T, angiotensin-converting enzyme,
Factor V Leiden Arg 506 Gln, prothrombin G 20210
A, and apolipoprotein E),
 Inflammatory markers (C- reactive protein ,
interleukins [e.g IL-6, IL-18]), soluble CD 40 ligand,
leucocyte count, monocyte count, serum amyloid A),
11/7/2022 19

20. Potential new Risk factors
11/7/2022 20
 Infectious agents (cytomegalovirus,
Chlamydia pneumonia, Helicobacter
pylori, herpes simplex virus, peridontal
disease)
 Lipid-related factors (apolipoproteins B
and A1, LDL particle size, small dense low
density lipoprotein [LDL], lipoprotein (a),
oxidized LDL),

21. Potential new Risk factors
 Haemostasis/thrombosis markers (fibrinogen, protein Z, von
Will-brand factor antigen, plasminogen activator inhibitor 1,
tissue-type plasminogen activator, factor V, VII and VIII; D-
dinner, fibrinopeptide A, prothrombin fragment 1 and 2
antiplatelet drug resistance).
 Behavioural factors (alcohol, inactivity, poor nutrition,
obesity).
 Pyschosocial factors (depression, social isolation, lack of social
support)
 Other factors (homocysteine, microalbuminuria/renal disease,
metabolic syndrome, obstructive sleep apnoea)
11/7/2022 21

22. Genetics of stroke - Polygenic
• Majority of px- Genetic factors may interact with other risk
factors (aging, hypertension) to increase risk of ICH
• Confers only a low risk to1st degree relatives
• Huge genetic heterogeneity wth wide spectrum of low risk
alleles involved
• 2 genes identified in ICELAND: - No practical clinical
implication
• Search for a stroke gene continues: Loci on chromosomes 5
and 19 (Apolipoprotein E); KRITI gene mutation are assoc wth
vascular events / malformations.
• A) PDE4D (Phosphodiesterase 4D)
• B) 5 Lipooxygenase activating protein (ALOX5AP)
11/7/2022 22

23. Stroke genetics - CI
• A familial dx with unclear genetic risk
factor
• +ve family hx - increase the odds of
having stroke by about 30%
• Hereditary of stroke is heterogeneous
across ischemic stroke subtypes, with
cardioembolic stroke being least
heritable.
23

24. Stroke genetics: Monogenic
• Minority
• confers high risk to mutation carriers and relatives
• > 50 varieties reported in small and large artery
diseases, CTD, Prothrombotic disorders, carvernous
malformation
• CADASIL, CAA = Monogenic autosomal dominant
varieties
• SAH : marfans, polycstic kidney disease coarctation
of the Aorta Connective Tissue disease
• Locus 7q11
11/7/2022 24

25. Risk factors – ICH - genetic
Inherited amyloidopathies
• Vascular malformations
• Coagulopathies
• Polymorphism in apolipo protein E gene
(ApoE) - major risk factor for lobar ICH
• ApoEe4 allele increase risk of ICH in CAA
11/7/2022 25

26. Pathophysiology / genesis
progression and extent of ischemic injury
is influenced by;
• Health of systemic circulation
• Status of collateral circulation
• age
• co-existing metabolic abn (hyperglycaemia)
• Premorbid medicationn + confounding factor
• The rate of onset and duration,-
• Hematological factors,-
• Temperature
• glucose metabolism.
26

27. Virchow’s triad
• Flow: stasis
• Wall: endothelium (largest organ in d body) -
vascular injury
• Blood cellular components: viscosity/coagulablty
• white clots: platelets + fibrin (slow circltn)
• red clots: rbc+fibrin(damaged endothl + fast circl
• CI is an heterogenous entity: Interactn bt platelets,
plasma proteins (embolism; homostatic coagulation
abnormality)
• and vascular wall (penetrating small A. vasculopathy
+ vascular irregularity)
11/7/2022 27

28. EXTRACRANIAL / INTRACRANIAL
EXTRACRANIAL
• endothelial plaque / plaque
rupture
• Common in whites
• Common in males
• Associated with
hyperlipidaemia
• Smoking
• Assoc PVD and CAD
• > CRP (? Genetics)
INTRACRANIAL
• Insitu thrombus
• Smaller vessels
• Common in blacks and
Hispanics
• Commoner in females
• Associated with
hypertension
• Associated with D.M /
Metabolic Syndrome.
11/7/2022 28

29. 11/7/2022 29

30. Pathophysiology
• Global disruption of brain metabolic process
Energy substrate delivery:O2 / glucose / blood flow
Stroke is flow; Everything about stroke is flow
• Haemorrheology : RBC concentration/ aggregation
/deformability; platelet aggregation/ adhesiveness;
fibrinogen level /Plasma/whole blood viscosity
• 023.5ml/100/min; glucose5mg/100g/m
• 2% body wt: 20% blood vol; 20%Oxygen
• Autoregulation
11/7/2022 30

31. Pathophysiology
Normal blood flow  55ml/100g/min
75ml/100g  grey; 30ml/100g  white
<25ml – EEG diffusely slowed (met.enceph
<15ml  electrical activity ceases
functional threshold: fn ceases (penumbra)
(apoptosis – caspace)
reversal of ischaemia: Therapeutic window
• 2-3 hrs (animal); 5-6 hrs (primates)
• <10ml  irreversible : morphological threshold: cell
death ensue necrosis (Umbra): necrosis - lysosomal
protease )
• CPP = MAP – ICP; CPP = 70-100; MAP=100-130.
31

32. Clinical features
• Depends on location/extent
• CLINICAL
• PATHOLOGICAL
• AETIOLOGICAL
• ANATOMICAL Diagnosis
11/7/2022 32

33. Pathological: WHO Criteria
C.I C.H
• L.O.C. -ve +ve
• Headache - ve +ve
• Vomiting - ve +ve
• T.I.A. +ve - ve
• Gradual onset +ve -ve
• Activity -ve + ve
• HBP mild /-ve mod/severe
• Bldy csf -ve + ve
• Meningeal signs -ve +/-ve
11/7/2022 33

34. Table 1 :PHASES OF CONTEMPORARY MANAGEMENT OF STROKE
Phases Period from onset Activities Prefered location
1Acute (emergency)
care:
Hyperacute: 4.5hrs
Acute : 48hrs
1st-7th day a)Assessment
b)Early supportive
care
Stroke Unit
Hospital
2 Early sub-
acute(supportive)
care
2nd-4th week a) prevention and
treatment of
complications
Hospital
3 Late sub-
acute(maintIanance)
care
2nd-6th month a)Rehabilitation
b)Psychological
support
c)Prevent recurrence
Hospital/Community
4.Long-term (chronic)
care
7th month onwards a) Rehabilitation
b)Psychological support
c)Social support
d)Prevent recurrence
Community
11/7/2022 34

35. Treatment
11/7/2022 35

37. Act FAST
• What is FAST? FAST requires an assessment of 3 spp.
symptoms of stroke:
• Facial weakness - can the person smile? Has their
mouth or eye drooped?
• Arm weakness - can the person raise both arms? Is one
arm or leg weak?
• Speech problems - can the person speak clearly and
understand what you say?.
• Time to call or go straight to the hospital.
• If failed any one of these 3 tests , act fast.

38. “Brain attack”
Time is brain is the key concept Time lost = Brain
lost 200 billion neurons in the brain 2 million
neurons lost per minute Age 3.6 years per hour of
hypoxia
Lost / hr : 830 billion synapses (14 billion
synapses /min)
Lost / hr: 714 km of myelinated fibres
(12 km fibres / min)

39. TIME IS BRAIN;
TIME IS NEURONE
• TIME IS BRAIN;
• TIME IS NEURONE
11/7/2022 39

40. Acute Neuro-Vascular Syndrome:
Stroke care
• Pre-hospital: Train emergency paramedics
Pre-arrival notification
• Emergency dept
• Stroke unit
• acute care:
• in a vascular unit (includes CI; MI; TIA, PE) or
Neuro ICU
11/7/2022 40

41. Treatment
Aims to
Rx underlying disease process if possible
Protect ischemic brain tissue from necrosis
attempt to reverse/limit the degree of brain
dysfunction
Prevent and treat complications
Rehabilitate the disabled patient physio /ccupational
/speech / swallow therapy
Prevent reoccurrence
11/7/2022 41

42. Treatment
• Thrombolytic therapy
• Early antithrombotic treatment
• Treatment of elevated intracranial pressure
• Prevention and management of complications
• No 2 strokes are alike / same for 2 individuals
• Need to individualize Rx
• Response not the same for 2 individuals
11/7/2022 42

43. Treatment
• Traditional: ‘wait and see’
• Now: ‘Watch and intervene as appropriate’
• Stroke unit:
– multidisciplinary committed professional staff: Physician:
neurosurgeon; physiotherapist; occupational / Speech (largo
paedics) swallow therapist; nursing staff and social worker
– < mortality; < morbidity in survivors (> 20%)
– < need for institutional care; < dependency
43

44. Stroke Unit
• All stroke pts: irrespective of gender, age, stroke
type, subtype and severity,
• dedicated / geographically defined part of a hospital
/ specialised staff with coordinated multidisciplinary
expert approach to Rx/ care
• Keep > = 24 hrs
• Assessment and diagnosis (exclude mimics)
• Early assessment of nursing and therapy needs
• Early mobilization, prevention of complications, Rx of
hypoxia, >glycaemia, pyrexia and dehydration.
• Ongoing rehabilitation; Coordinated multidisciplinary team
care; early assessments of needs > discharge
11/7/2022 44

45. Stroke Unit
• diagnostic tests to df types of stroke, assess underlying
cause of CI, prognosis, rule out other brain diseases or
stroke mimics, identify concurrent diseases or
complications
• Assessment of neurological and vital functions parallels Rx of acutely
life-threatening conditions.
• Hx on risk factors for arteriosclerosis/cardiac dx
• Initial o/e: breathing and pulmonary function
• BP / HR; Targeted neurological examination
• Observation of early signs of dysphagia
• arterial oxygen saturation; clinical chemistry, coagulation ;
haematology
11/7/2022 45

46. Assessment
• All pts: Brain Imaging: CT or MRI
• Chest X-ray; ECG; Echocardiography;
• FBC; platelet count, PT or INR, PTT; CRP/ESR electrolytes,
glucose; LFT / Renal fn
• correlation between lacunar stroke and HB, None
between Hb and non-lacunar; leucocytosis is associated
with poor prognosis
• Urinalysis - Microalbuminuria predicts haemor
transformation in CI– endothelial dysfunctn
• In selected patients: Duplex / Doppler ultrasound MRA or
CTA
• Diffusion and perfusion MR or perfusion CT
• Pulse oximetry and arterial blood gas analysis
• Lumbar puncture; EEG ;Toxicology screen
11/7/2022 46

47. Stroke bio-markers
• Cf cardiac specific Troponin, CPK, LDH)
• Serum S 100 β - CI (Astroglial protein)
• Serum Glial fibrillary acidic protein (GFAP) -
ICH
• H –fatty acid binding protein (H-FABP)
• Apo lipoprotein CI (Apo CI) - CI
• Apo lipoprotein C III (Apo C III) - CI
• Serum Amyloid A (SAA)
• Antithrombin III (AT-III) fragment
47

48. Ischaemic

49. Haemorrhagic
stroke

50. Subarachnoid
Haemorrhage

51. Subdural hematoma

52. Trauma and extradural hematomas

53. Massive Bilateral Epidural Haematoma
: misdiagnosed as stroke
53

54. Brain tumours

55. Giant Meningioma
• The patient was
mismanaged as post
stroke seizure disorder .
206

56. Giant Pitutary Adenoma
• The patient was
mismanaged as stroke
56

57. Brain abscess and infections

59. Virchow’s triad and mech of action of
antithrombotics
• Clot bursters + inhibit Clot
formation
• Endothelial wall repair
• Stasis management:
physiotherapy
59

60. Treatment
<infarct size (umbra) – Rxic time window
Reperfusion vis a vis recanalisation.
• 1) restore blood flow + nutrients (glu + 02)
• Thrombolysis within 1st 4.5 hrs (3-15% pts)
• rtPA, alteplase; streptokinase; urokinase,
desmoteplase, (Reteplase, Tenecteplase)
• Door to needle < 1 hr.
20% success rate: recanalisation / unblocking.
Needs more agents:
• hemodilution / induced HBP/ hyperbaric 02
• encephabol0 (Piritinol) – cerebral steal effect.
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61. rtPA
• iv rtPA : 0.9 mg/kg BW, maximum 90 mg), with 10%
of the dose given as bolus followed by a 60-minute
infusion)
• BP >= 185/110 must be lowered; < 80 yrs
• ia Rx: < 6hrs : MCA / Basilar occlusion.
• Contraindication wake –up stroke
– DM + previous stroke
– pts on oral anticoagulants
– BP > 185 / 105 (>> haem risk)
– age > 80 years; minor stroke ????
11/7/2022 61

62. rtPA
• > bleeding risk: > glucose, hx of DM / CCF
• baseline symptom severity, advanced age, increased
time to Rx, previous aspirin use.
• 3-15% qualify; One out of 3 recover
• > ½ not fully recover. rtPA not panacea
• Complete recanalisation: 20%
• Partial recanalisatn:30% No recanalisatn: 25%
• TCD / DSA: Recanalisation not equal to reperfusion
(different scales); reperfusion better
• MRI/CTscan perfusion mismatch at 24hrs
11/7/2022 62

63. Desmotelpase
• Fd in saliva of Vampire bats
• 80% recanalisation achieved
• Time 8hrs
• < Risk benefit ratio
• No phase 3 evidence yet
• No BBB damage
• Not neurotoxic (cf Alteplase)
• No age restrictions
11/7/2022 63

64. Other treatment options
• Newer Anti-thrombotics
• Neuroprotectants (Mg So4) – vasodilator)
• +IV cooling with iced saline via IVC
• USS clot lysis
• Endovascular Rx.
• Mechanical recanalisation
11/7/2022 64

65. Antithrombotics
• Aspirin/ Trifluzal 600 mg/dly : structurally related;
no > B.time; efficacy same. Prasogrel
• within 48hrs – reduce risk of mortality/ disability
• Binding site of platelets with fibrin: GP inhibitors
Abciximab-antibody: GPIIB / III A receptor inhibitor < 5hrs
• Phase 3 trial stopped b/c of > bleeding
• Thienopyridines : Ticlopidine; clopidogrel
• (prevents binding of PL to fibrinogen/inhibits PL aggregation/prevents ADP binding to PL receptor: & impair ADP
mediated action of GP Iib/IIIa complex): impair PL degranulation). not block GP receptor)
• Binding site of platelets to endothelium:
– PDI: Dipyridamole (PDE5) ; Cilostazole (PDE3)
(suppress cAMP degradation; > cAMP= inhibit PL aggregation; vasodilatation +)
11/7/2022 65

66. Dipyridamole
PDE 5 inhibitor: expands the therapeutic window
> dose dependent endothelial tPA release
• Pro endothelial: protective effects,
• > prostacycline (vasodilatation)
• < CRP
• < Lipid peroxidation (anti-oxidant)
• < smooth muscle cell proliferation
• < platelet aggregation
• Inhibits Von Willibrand factor
• Anti-inflammatory / -atherogenic / -thrombotic
• Headache- (drug working)
11/7/2022 66

67. Other reperfusion strategy
• rtPA non responders
• Epifibatide (EP): glycoprotein IIb /IIIa receptor
antagonist
• combine with rtPA
• Argatroban = rtPA + EP
• Combine IV (4.5hrs) / IA rtPA (6 hrs)
• Lacks scientific validation.
• ? risk of intracranial haemorrhage
11/7/2022 67

68. Other antithrombotic agents in stroke Rx
and prevention
• Unfractionated heparin
• Low molecular weight heparin (not beneficial)
• Heparinoids
• Warfarins
• Ancrod – < circulating fibrinogen - beneficial
11/7/2022 68

69. New antithrombotic agents in stroke Rx
and prevention
• Ximelagatran – direct thrombin (? Trypsin) inhibitor –
• prevent clot formation, propagation and embolisation.
• Not require frequent monitoring of coagulation or dose
adjustment Risk of bleeding is reduced compared with warfarin.
• Withdrawn b/c of hepatotoxity .
• DABIGATRAN is recommended.
• Not cross BBB; not hepatotoxic
• Cardioembolic stroke:
• (30 days case fatality: 25%;1 year case fatality: 50%)
11/7/2022 69

70. statins
• < platelet aggregation: < thrombus formation
• < BP (prevent haemorrhage)
• Neuroprotectives
• Plaque stabilisation
• improve endothelial function
• Anti-inflammatory
• Upregulate Nitric oxide synthase
• ( > HDL: Niacin; exercise; red wine; ? Life style
modification)
• Aim: High risk: < LDL100; v hg risk: <70
• > ?? Haemorhagic stroke
11/7/2022 70

71. Neuroprotective agents (Neuroprotectants)
• Neurorestorative / Neuroregenerative
• Neuroprotective / Neuroproliferative
Protect N from adverse milleu created by the biochemical changes triggered
by ischaemia:
attenuate neuronal injury
• free radical scavengers – Vit C ; E ; 21-aminosteroid ; antioxidants
tirilazad
• inhibitors of excitatory A.A. (NMDA receptor blockers – MK – 801)
Glutamate antagonists
• Caspace (apoptosis) inhibitors
• Lysosomal protease (necrosis) inhibitors
• Ca2+ antagonist – nimodipine
• Barbiturates; hypothermia; steroids (<met. Demand)
• Citicoline
11/7/2022 71

72. Neuroprotectants
• Naftidrofuryl
> efficiency of substrate use;
< lactate level; >supply of ATP
• lengthens the window period
NO (Nitric oxide) synthase inhibitors
(neuronal / inducible)  cytotoxic
endothelial  vasodilate  protective
Repinotan - 5 HT1a Agonist - CI
Mg failed; Citicoline promising
11/7/2022 72

73. Neuroprotectants
• Cerebrolysin: a peptide with neurotrophic effect
• BDNF: (Brain Derived Neurotrophic Factor)
• one of the “Neurotrophin” family of growth factors th
regulates neuronal survival and protects from
glutamate induced damage.
• encourages proliferatn,differentiatn of new Neurons
• BDNF pathways are involved in cell survival, neuron –
protection, brain plasticity and neurogenesis.
• Neuronal cells require BDNF to regenerate
11/7/2022 73

74. Stem cell transplantation
• Rationale:Replace necrotic cell / take over fn
• Secrete trophic factors to maintain marginally surviving cells or
enhance local environment
• Sprouting new axons and synapse formation .
• Sources:
– Fetal stem cells
– Neuroprogenitor cells (fd in periventricular region of developing/adults B. –migrates to area of
injury and differentiate. autologous neural progenitor: paracrine / indirect effecteg: adipose
tissue derived is minimally invasive
– Bone marrow stromal cells: diffrentiate to multiple cell types including N
– Multipotential cells: from umbilical cord blood
– Immortalised cell line : Human embryonic carcinoma derived cell lines.
11/7/2022 74

75. Stem cell transplantation
• PD: dopaminergic cell replacement.
• Stroke: multiple cell types and neurotransmitters
lost.
• Several Potential pitfalls;
• Success in animals yet to translate to humans
• Cautious optimism and healthy skeptical reserve;
• Ethical concerns
• Depends:Subtypes of Stem cell/time after ictus
11/7/2022 75

76. Experimental sonothrombolysis:
• USS has thrombolytic potentials and can be
used for pure mechanical thrombolysis or
facilitate enzymatic mediated thrombolysis
• TCD use for 3hours (2 hrs whilst on rtPA and I
hr thereafter).
• Operator independence: hand held TCD
11/7/2022 76

77. Surgical treatment – CI
• CI: Embolectomy;
• vascular reconstruction;
• thromboendarterectomy
• Hemicraniectomy (Malignant MCA occlussin)
• Devices
11/7/2022 77

78. Devices
• Microwires / micro catheters
• Ballon snare
• Ballon stent
• Sunction thrombectomy
• Clot retriever (aligator clot retrieval device)
• Any above + low dose urokinase
• Stents – use only aspirin b/c no endothelial
attachment
11/7/2022 78

79. Hemicraniectomy
• Malignant MCA occlusion / CI – usually bilateral
• 100 % mortality: Options:
• 50% mortality :20% mild disability
• 30% moderate disability.
• Family choice.
• Age below 60 years
• Dominant hemisphere (Aphasia + depression vs hemi-
neglect)
• Surgery within 48 hrs; > 12 cm diameter
• Replace flap 6-8 /52. (Do not misplace)
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80. stroke Rx :summary
 Anti-platelet agents (proved by EBM)
 Thrombolysis (proved by EBM)
 Anti-coagulation (limited efficacy)
 Neuroprotection (not proved by EBM):
 citicoline ; cerebrolysin.
 Knives for Stroke treatment: (surgical treatment)
 Decompressive craniotomy (unacceptable complications)
 Carotid endarterectomy (limited indications)
 EC/IC bypass surgery (it works, but does not help)
 Clamp the aneurysm (limited to SAH)

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81. Stroke treatment
Alternative and Complementary
Treatment in China
Herbal Medicine
 Ginkgo
 Ginseng
 Ligusticum
Acupuncture
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