Management of Ischemic Stroke
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Deals with common issues like management of hypertension and diabetes during stroke, as well as the role of surgical procedures.
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Management of Ischemic Stroke
- 1. Acute Ischemic Stroke Rahul Kumar Consultant Interventional Neurologist Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 2. Why do we need guidelines ? • 2.4 per 1000 people per year • 10,00,000 strokes per year in India • 3000 strokes a day • 2% of all admissions • Crude prevalence rate is 220/100,000. Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 3. Estimated Pace of Neural Circuitry Loss in a typical, large, Supratentorial Ischemic Stroke Neurons Lost Synapses Lost Myelinated Fibers Lost Accelrated Ageing Per Stroke 1.2 Billion 8.3 trillion 7140 Km 36 years Per Hour 120 million 830 billion 714 Km 3.6 years Per Minute 1.9 million 14 billion 12 Km 3.1 weeks Per Second 32,000 230 million 200 meters 8.7 hours Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist Jeffery L Slaver, Stroke, 2006; 37, 263-66
- 4. Which Guidelines to follow ? • • • • • AHA AAN RCOP Australian SA ESA • IAN Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 5. Which Guidelines to follow ? • • • • • AHA AAN RCOP Australian SA ESA • IAN Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist • Guidelines are Guidelines • Individualize • Deviations • Not applicable across the board • Help us in optimizing outcomes • Preventing therapeutic misadventures
- 6. The Continuum of Stroke Care Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 7. How do we approach a patient with suspected stroke ? • Assesment Phase – History, Clinical Evaluation – Imaging – Other Supportive Tests • Treatment Phase – Supportive Treatment – Specific Treatment • Treatment of Complications Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 8. How do we approach a patient with suspected stroke ? • Assesment Phase – History, Clinical Evaluation • Sudden Onset • Time of Onset • Grading of Severity - Clinical Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 9. Stroke Scales • Severity – NIH stroke scale 0-42, 0 = normal valid, reproducible, assists in patient selection, facilitates communication • Functional Scales – m-Rankin – Barthel index – Glasgow outcome 0-5, 0 = normal 100, 100 = normal 0-5, 5= normal • in NINDS t-PA stroke trial, 0 = normal Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 10. Stroke Scales • NIH stroke scale 0-42 0-5 mild/minor in most patients 5-15 moderate 15-20 moderately severe > 20 very severe underestimates volume of infarct in non-dominant (R) hemispheric strokes Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 11. How do we approach a patient with suspected stroke ? • Assesment Phase – History, Clinical Evaluation – Imaging Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 12. Non-contrast CT of the Head • Initial imaging study of choice • Readily available • Very sensitive for blood in the acute phase – blood - 50-85 Hounsfield Units – bone- 120 (70-200) Hounsfield Units • Not sensitive for acute ischemic stroke – nearly 100% sensitive by 7 days • Posterior fossa structures - bone artifact Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 13. Other Imaging Modalities • MRI – standard – DWI/PWI • Xenon CT • Perfusion CT • CT Angiography Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 14. How do we approach a patient with suspected stroke ? • Assesment Phase – History, Clinical Evaluation – Imaging – Other Supportive Tests Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 15. Diagnostic Testing • Laboratory studies – CBC, differential, platelets – electrolyte profile, glucose (finger stick) – INR, aPTT – Troponin • ECG • CXR Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 16. Stroke Mimics – Exclusion Establishes Stroke • • • • • • • • • Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist Hypoglycemia Seizure Migraine with aura Hypertensive encephalopathy Wernicke’s encephalopathy CNS tumor Drug toxicity CNS abscess Psychogenic
- 17. Stroke – General Assessment • Airway – Foreign Bodies, dentures, tongue • Breathing and oxygenation – ABG, Pulse Ox • Circulation- BP, Urine Output, Peripheral Circulation • Glucose > 60 • Temperature - Normothermia Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 18. How do we approach a patient with suspected stroke ? • Assesment Phase – History, Clinical Evaluation – Imaging – Other Supportive Tests • Treatment Phase – Supportive Treatment Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 19. Vascular Access • • • • Two peripheral IVs Use .9NS or .45 NS unless hypotensive Use .9NS if hypotensive Replace blood products as indicated Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 20. Treatment of Hypertension Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 21. Autoregulation • The ability of the vasculature in the brain to maintain a constant blood flow across a wide range of blood pressures Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 22. Autoregulation CBF ml/100mg/min of Cerebral Blood Flow 100 90 80 70 60 50 40 30 20 10 0 Ischemic Normotensive Hypertensive MAP mm Hg Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 23. Hypertension Ischemic Stroke • Treat judiciously if at all • Treatment guidelines - not receiving rt-PA – AHA: MAP > 130 or Sys BP > 220 – NSA: 220/115 Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 24. Hypertension - Ischemic Stroke • Drugs - short acting, titrate • Labetalol IV: 10-20 mg increments, double dose Q 20 min, max cumulative dose 300mg • Enalapril Oral: 2.5 - 5.0 mg/day, max 40mg/day IV : 0.625-1.25 mg IV Q 6hrs, max 5.0 Q 6 hrs Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 25. For how long to allow Hypertension to Continue ? 1 Hr 3 Hr 6 Hr average slow fast Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 26. Hypertension: rt-PA Candidate • Exclude for persistent BP > 185/110 • Check BP q 15 min • May not aggressively lower BP to meet entry criteria • Use Labetolol or Nitropaste Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 27. Hypertension -Ischemic Stroke • Nitroglycerine Paste: 1-2 inches to skin IV Drip: 5mcg/min, increase in increments of 510mcg every 3-5 min • Nitroprusside IV Drip: 0.3 - 10 mcg/min/kg Continuos BP monitoring • AVOID NIFEDIPINE Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 28. Hypotension • • • • • More detrimental than hypertension Seek cause and treat aggressively CVP monitoring may be necessary Use .9 NS first to ensure adequate preload Then add vasopressors if needed Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 29. Treatment of Hyperglycemia Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 30. Glucose • Worse outcome after stroke: – diabetics – acute hyperglycemia at time of infarct • Mechanism uncertain – increase in lactate in area of ischemia – gene induction, – increased number of spreading depolarizations • Insulin is a neuroprotective Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 31. Target Values • Intensive – 80 to 110 • Desirable – 140 to 180 • Not above 200 • How to Achieve • Oral agents • Insulins Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 32. Sliding scale insulin • Abandoned! Retroactive not proactive • Variation in disease state • Dangers of hypoglycemia Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 33. Initiating insulin: New to Insulin For most patients with type 2 diabetes (or being initiated to insulin therapy), total daily insulin dose can be estimated at 0.3 to 0.6 units/kg/day The dosing range represents varying degrees of insulin resistance: dose kg 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 50 5 10 15 20 25 30 35 40 45 50 60 6 12 18 24 30 36 42 48 54 60 70 7 14 21 25 35 42 43 56 63 70 80 8 16 24 32 40 48 56 64 72 80 90 9 18 27 36 45 54 63 72 81 90 20 30 40 50 60 70 80 90 100 100 10 Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 34. Insulin drip Advantages Tightest control Good absorption Rapid adjustments Easy standardized Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist Disadvantages Frequent monitoring (ICU/IMCU needed?) Nursing time! Catheter complications Problems when switching to SQ regimen Rapid Glucose shifts?
- 35. Temperature • Fever worsens outcome: – for every 1°C rise in temp, risk of poor outcome doubles (Reith, Lancet 1996) • Greatest effect in the first 24 hours • Brain temp is generally higher than core • Treat aggressively with acetaminophen, ibuprofen, or both • Search for underlying cause • Hypothermia currently under investigation Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 36. How do we approach a patient with suspected stroke ? • Assesment Phase – History, Clinical Evaluation – Imaging – Other Supportive Tests • Treatment Phase – Supportive Treatment – Specific Treatment Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 37. Recanalization, anti Ischemic Treatment • Recanalization IV rt-PA IA r-proUK (FDA?) • Neuroprotective treatment • Aspirin in first 48 hours • Anticoagulant Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist 37 • Hemodilution • Therapeutic hypothermia • Stroke unit • Craniectomy
- 38. Aspirin (mg) EUSI ASA RCOP (London) Acute treatment 100-300 325 300 2nd prevention 50-325 150-325 50-300 • Role of Clopidogrel, Dypiridamole • Place for Combination therapy Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist 38
- 39. Empirical Aspirin !!! Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 40. Interventional POST Therapy PRE AND Pre Procedure, NIHSS - 18 Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist Post Procedure, NIHSS - 0
- 41. Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 42. How do we approach a patient with suspected stroke ? • Assesment Phase – History, Clinical Evaluation – Imaging – Other Supportive Tests • Treatment Phase – Supportive Treatment – Specific Treatment • Treatment of Complications Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 43. Treatment of neurological complication • Seizures • Cerebral edema and increased intracranial pressure, Hemorrhagic transformation Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist 43
- 44. Seizures • Occur in 5% of acute strokes • Usually generalized tonic-clonic • Possible causes: severe strokes cortical involvement unstable tissue at risk spreading depolarizations hx of seizure disorder Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 45. Seizures • Protect patient from injury during ictus • Maintain airway • Benzodiazepines: – lorazepam (1-2 mg IV) – diazepam (5-10 mg IV) • Phenytoin: – 15 mg/kg loading dose, at 25-50 mg/min infusion with cardiac monitor • No need for prophylaxis Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 46. Cerebral edema and increased intracranial pressure • Applicable only in large artery strokes and in some cerebellar strokes • • • • • Elevated head of the bed 20- 30 degrees Avoid “Jugular vein” compression Avoid hypotonic solution Avoid hypoxia, consider intubation Hyperventilation keep pCO2 30-35 mmHg Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 47. Cerebral edema and increased intracranial pressure • Consider osmotherapy 20% Mannitol 0.25-0.5 g / Kg IV in 20 mins 4-6 times / day or 10% Glycerol 250 ml IV in 30-60mins 4 time / day or 50% Glycerol 50 ml oral 4 time / day and / or Furosemide 1 mg / kg IV • Avoid steroid • Consider decompressive surgery Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist 47
- 48. Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 49. Hemicraniectomy not Performed Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 50. Hemicraniectomy performed within 4 hours of onset Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 51. Hemicraniectomy performed within 24 hours of onset Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 52. Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 53. Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 54. Conclusions • Acute stroke is an emergency condition, is the same level as MI, serious trauma • Emergency management is need • rt-PA & Interventional therapies, are the major advances • Appropriate general care are also need • To improve the quality of care : Multidisciplinary/ network approach Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 55. Take Home Message… • • • • • • • Manitain ABC, low threshold for intubation Hypertension better than Hypotension Normoglycemia No Role of Empirical Antiplatelets Use of Statins recommended Try to administer reperfusion if within window More widespread use of surgical and interventional procedures • Treatment of Complications Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist
- 56. Thank You. Rahul Kumar MD, DNB, DM, DNB, FINR Consultant Interventional Neurologist