Stroke management

2. GUIDELINES ON THE
MANAGEMENT OF ACUTE
ISCHEMIC STROKE
Dr Shanza Amaan
Resident medicine
CMCH larkana

3. STROKE
Stroke is defined as:
• sudden onset focal neurological deficit due to
cerebrovascular origin .
• It is 6th leading cause of death worldwide.

5. PATHOPHYSIOLOGY
• Brain requires constant supply of glucose and
oxygen , supplied by blood.
• Brain receives 15% of resting output, and
consumes 20% of total body oxygen consumption.
• Cerebral blood flow is maintained via
autoregulation, thus brain is highly aerobic tissue
where oxygen is limiting factor .

6. BLOOD FLOW TO BRAIN ;
• If zero - leads to death of brain tissue within 4 to 10
minutes.
• If <16-18ml/hr – infarction within an hour
• If <20ml/100g tissue/min – Ischemia without infarction
unless prolonged for several hours or day.
• Ischemic pneumbra –affected region with decreased or
marginal perfusion (blood flow < 25ml/100g of
tissue/min ).
• Ischemic core –affected regions with cerebral blood flow

13. STROKE SEVERITY ASSESSMENT SCORE

16. THE GOALS OF INITIAL PHASE INCLUDE
;
• Ensuring medical stability, particularly airway, breathing,
circulation.
• Quickly reversing any condition that is contributing to
patients problem.
• Determining weather the Stroke patients are candidates
for IV thrombolysis or mechanical thrombectomy.

17. GENERAL SUPPORTIVE CARE AND EMERGENCY
TREATMENT INCLUDE :

19. AIRWAY, BREATHING, OXYGENATION ;
• Airway support and Ventilatory assistance are recommended
for patients with acute stroke who have decreased level of
consciousness, or who have bulbar dysfunction that causes
respiratory compromise.
• Supplemental oxygen should be provided to maintain
oxygen saturation >94%.
• Supplemental oxygen should not be given to non hypoxic
patients with ischemic stroke .

20. HEAD & BODY POSITION
• Keep the head in neutral alignment with body and
elevate the head of bed to 30° for patients in acute phase
of stroke who are at risk of elevated intracranial pressure,
aspiration , cardiopulmonary decompensation or oxygen
desaturation.
• In absence of these problems keep the head of bed in
position that is most comfortable for patient.
• In addition to this keep the cervical color or central
intravenous IV lines if present, loose enough , so that
they don not occlude venous outflow from brain.

21. BLOOD GLUCOSE
HYPERGLYCEMIA
• Blood glucose level >126mg/dl (>7mmol/l)
• Common in stroke patients (elevated admission blood glucose in
>40%, most frequently in diabetic patients), stress hyperglycemia
may be the most common cause.
• Persistent hyperglycemia is associated with worse outcome than
normoglycemia, AHA guidelines recommend to achieve blood
glucose level between 140-180 mg/dl (7.8 to 10 mmol/l), closely
monitoring for hypoglycemia. Tighter control of blood glycose with
IV insulin does not improve functional outcome in patients with
stroke .

22. HYPOGLYCEMIA
• Blood glucose <60 mg/dl
• It can cause focal neurologic deficit mimicking
stroke, and severe hypoglycemia alone can
cause neuronal injury .
• Correct with IV push of dextrose .

23. TEMPERATURE
• Peak temperature in first 24 hours<37C and >39C associated
with increase risk of in hospital death compared to
normothermia .
• Sources of hyperthermia (>37C) should be identified and
treated and antipyretic medications (e. g Acetaminophen )
should be administered to hyperthermia patients with
ischemic stroke.
• In patients with acute ischemic stroke ,benefit of treatment
with induced hypothermia is uncertain, and studies suggest it
increases risk of infection.

24. FLUIDS
• For most of the patients with acute stroke and volume depletion,
isotonic saline without dextrose is the agent of choice for
intravascular fluid repletion, and maintenance of fluid therapy.
• In general it is best to avoid excess free water (e.g as in ½
isotonic saline), because hypotonic fluids may exacerbate
cerebral edema in acute stroke and less useful than isotonic
solutions for replacing intravascular volume., in addition it is best
to avoid fluid containing dextrose which may exacerbate
hyperglycemia.
• However fluid management must be individualized based on
cardiovascular status, electrolyte disturbances, and other

25. BLOOD PRESSURE
• For patients with ischemic stroke who are not treated with
thrombolytic therapy, BP should not be treated acutely, unless the
HTN is extreme (SBP>210 , DBP >120) or when the patient has active
coronary ischemic disease, heart failure, aortic dissection,
hypertensive encephalopathy, or preeclampsia/eclampsia.
• When treatment is indicated cautious lowering of blood pressure by
15% during first 24 hours of stroke onset is suggested.

26. • Start or restart antihypertensive medications in patients with
stroke who are neurologically stable , unless contraindicated,
as early as within 24 -48 hrs of stroke onset ,with a goal of
gradually controlling HTN within a few days to a week.
• Patients with extracranial or intracranial large artery stenosis
require slower reduction in BP (within 7-14 days ) ,as some
degree of blood pressure elevation is necessary to maintain
blood flow to ischemic brain regions .
• For this reason Do not start antihypertensive agent until
vascular imaging is completed and large artery stenosis is
excluded.

27. CHOICE OF ANTIHYPERTENSIVE AGENT;
• Reversible and titrable IV agent’s are best suited for precise BP
lowering , guidelines suggest IV labetalol, nicardipine, clevidipine as
first line antihypertensive agents if pharmacologic therapy is
necessary in acute phase
• IV nitroprusside should be considered as second line therapy, since
it carries added theoretical risk of increasing intracranial pressure
and affecting platelet function.
• Medications causing prolong and precipitous decline in BP (e.g rapid
acting formulation of nifidipine) should be avoided.

28. BLOOD PRESSURE
• Hypotension and hypovolemia should be corrected to maintain
systemic perfusion levels necessary to support organ function.
• BP with IV alteplase
<185/110 prior to administration,
<180/105 for 24 hrs. after administration,
• When mechanical thrombectomy is planned, it is reasonable to
maintain BP <185/110 prior to procedure .

30. DYSPHAGIA SCREENING
• Post stroke dysphagia is very common.
• It is a risk factor for aspiration pneumonia.
• Dysphagia screening before the patient begins eating,
drinking, or receiving oral medication, is effective to reduce the
risk of aspiration.
• For patients with dysphagia, initially use NG tubes for feeding
in Early phase of stroke (within first 7 days), and place
percutaneous gastrostomy tubes in patients with longer
anticipated persistent inability to swallow safely (>2 to 3
weeks).
• Enteral diet should be started within 7 days of admission after
an acute stroke.

31. REPERFUSION THERAPY
• Goal or reperfusion therapy ( thrombolysis with IV alteplase
or mechanical thrombectomy) is to restore bold flow to the
regions of brain that are ischemic but not yet infarcted.
• IVT improves outcome at three to six months for
appropriately selected patients, when given within 4.5 hours
of onset of ischemic stroke.
• Mechanical thrombectomy improves functional outcome at
three months in appropriately selected patients when given
treatment is started within 24 hours after the patient was
last known well.

32. THROMBOLYTIC THERAPY FOR ACUTE
ISCHEMIC STROKE
• It is the mainstay of treatment for acute
ischemic stroke, provided that it is started
within 4.5 hours of symptom onset time, or
within 4.5 hours of time the patient was last
known to be well.
• As benefit is time dependent so eligible
patients should be treated as quickly as
possible.

33. • ALTEPLASE, a recombinant tissue plasminogen activator
(tpa), initiates local fibrinolysis, by binding to fibrin in
thrombus (clot) , and covering entrapped plasminogen
into plasmin, in turn plasmin breaks up the thrombus.
• TENECTEPLASE, it is a fibrinolytic agent that is more fibrin
specific, having evidence that it has similar efficacy and
safety outcomes compared with alteplase, but in United
States yet it is not licensed for IV thrombolysis.

34. “ADMINISTRATION OF THROMBOLYTIC THERAPY “

35. PREPARING FOR TREATMENT
Prior to treatment all patients require confirmation of
following;
• Diagnosis is acute ischemic stroke
• Treatment is commencing within 4.5 hrs time window of
symptoms onset
• There is persistent, measureable, disabling neurological
deficit
• Eligibility criteria are met
• Serum glucose must be checked to rule out hypoglycemia
as a cause of neurological deficit.
• Non contrast CT or MRI is without hemorrhage
• BP criteria are met

36. MANAGEMENT OF BLOOD PRESSURE
• Blood pressure must be at or below 185 mm/hg
systolic,and 110 diastolic before administration of
thrombolysis.
• Patients with blood pressure above this range should be
treated with IV agents such as labetalol, or nicardipine,or
clevidipine.
• Once thrombolytic therapy has been administered BP
must be maintained below 180/105 mm/hg during and
for 24 hrs following therapy .

38. ELIGIBILITY CRITERIA

41. “DOSING AND MONITORING “

43. TENECTEPLASE DOSE:
• Dose of tenecteplase is 0.25 mg/kg (maximum
total dose 25mg) given in a single IV bolus
over 5 seconds followed by a saline flush.

44. MANAGEMENT OF COMPLICATIONS
FOLLOWING IV ALTEPLASE THERAPY
• Symptomatic intracranial bleeding occurring within 24
hours after administration of IV alteplase for treatment
of acute ischemic stroke.
• orolingual angioedema associated with IV alteplase
administration.

47. “MECHANICAL THROMBECTOMY “

48. • Mechanical thrombectomy is indicated for patients with
acute ischemic stroke due to large artery occlusion in
anterior circulation who can be treated within 24 hours of
the time last known to be well.
• Two issues may limit widespread use of MT, First only
estimated 10% of patients have proximal large artery
occlusion in anterior circulation and present early enough
to qualify for MT, second only few stroke centers have
enough resources and expertise to deliver this therapy.

49. • However eligible patients should receive standard
thrombolysis therapy if they present in hospitals where MT
is not an option, and those with qualifying Anterior
circulation stroke from large artery occlusion should then
be transferred, if possible, to tertiary stroke centers, in
which intraartrial thrombectomy is available, a strategy
called “drip & ship. ”

50. WHO TO TREAT !?
• Brain imaging using non contrast CT or MRI excludes
hemorrhage.
• CTA or MRA demonstrate a proximal large vessel occlusion in
anterior circulation.
• Patient has persistent potentially disabling neurologist deficit
(NIHSS score >6).
• Thrombectomy can be started within 24 hours of the time the
patient was last known to be well.

51. WHO NOT TO TREAT !?
• Presence of large established hypodensity on head CT beyond
early ischemic changes .
• No ischemic pneumbra identified on CT perfusion.
• Large core infarct (infarct core volume>50ml) with severe pre
stroke comorbidities.

52. • Posterior circulation stroke – although the benefit are
uncertain, Mechanical thrombectomy may be a
reasonable treatment option for patients with acute
ischemic stroke caused by occlusion of basilar artery,
vertebral arteries, or posterior cerebral arteries, when
performed at centers with appropriate expertise.

53. PROCEDURE
• General anesthesia or conscious sedation may be used for the
procedure of mechanical thrombectomy, depending upon
local preference and experience. Stent retriever or catheter
aspiration devices can be used for MT.
• Catheterization is commonly performed with femoral artery
puncture, catheter is guided to internal carotid artery, and
beyond to the site of intracranial large artery occlusion. The
stent retriever is then inserted to reach the clot. The stent
retriever is deployed and grabs the clot, which is removed as
the device is pulled back. Initial goal is to achieve reperfusion
as early as possible.

54. ADVERSE EFFECTS
• Device related serious adverse events are uncommon, but
include access site hematoma and pseudo aneurysms, arterial
perforation and arterial dissection.
• MT in general is not associated with increased rates of
symptomatic Intracranial hemorrhage or mortality.

55. APPROACH TO TANDEM LESSION
• 15-30% of patients eligible for MT present with tandem lesions,
charaterised by extra cranial carotid artery stenosis and occlusion,
and a downstream ipsilateral intracranial large vessel occlusion.
• MT is directed at revascularization of intracranial vessel occlusion,
but the best approach to extra cranial carotid lession is uncertain.
• Options include acute treatment of extra cranial carotid lession with
stent placement, angioplasty alone, versus deferred
revascularization ( Carotid endarterectomy or carotid stenting) or no
revascularization.

56. BLOOD PRESSURE MANAGEMENT
• Optimal Blood pressure range with MT are not well defined.
Admission systolic BP does not seem to impact benefit of MT.
• Through some studies it is suggested to keep SBP between 150
and 180 mmHg prior to reperfusion. SBP 150 mmHg may be
useful to maintain collateral blood flow during the time large
artery remains occluded.

57. RESCUE THERAPY FOR FAILED MT
• Approximately 8-30% of patients fail to achieve
substantial reperfusion with MT, in such cases
urgent rescue therapy with intracranial angioplasty
or stenting is sometimes attempted , bit limited
data suggest that these interventions are safe.

58. IMMEDIATE ANTITHROMBOTIC
TREATMENT OF ACUTE ISCHEMIC
STROKE

62. REGIMEN
• Aspirin (160 mg or 325 mg loading dose) followed by
50 to 100 mg daily ) plus clopidogrel ( 300 to 600 mg
loading dose followed by 75 mg daily) for short term
DAPT.
• An alternative is Aspirin (300 to 325 mg on the first
day followed by 100 to 75 mg daily) plus ticagrelor (
180 mg loading dose followed by 90 mg twice daily.

63. LIMITED ROLE OF EARLY
ANTICOAGULATION
In agreement with the national guidelines,
recommendation is not using full-dose parenteral
anticoagulation (e.g., intravenous heparin) for treatment
of unselected patients with acute ischemic stroke
because of minimal efficacy and an increased risk of
bleeding complications. Instead, they recommend early
antiplatelet therapy for most patients with acute
ischemic stroke or TIA.

64. PATIENTS ALREADY ON ANTICOAGULATION;
• Uncomplicated minor stroke – long term anticoagulation can be
restarted when patient is stable such as at hospital discharge, or 24-
48 hrs after stroke onset.
• Large acute infarction- start aspirin in the interim if there are no
significant bleeding complications, oral anticoagulants can be
resumed according to indication, and aspirin stopped after one to
two weeks if patient stable.
• TIA – anticoagulation can be started or resumed immediately.
• Minor ischemic stroke and persistent neurologic deficit – started or
resumed at 3rd day or >3 day after onset .

65. • Ischemic stroke and moderate neurologic deficit –
anticoagulation started or resumed at 6-8 day after onset.
• Ischemic stroke and severe neurologic deficit –anticoagulaton
can be started or resumed on 12-14 days.
(in both cases repeat brain imaging should be obtained to exclude
hemorrhagic transformation within 24 hrs prior to starting or
resuming anticoagulation)

66. CONTRAINDICATIONS TO
ANTICOAGULATION:
• hemorrhagic infarction
• Large size infarct
• Severe uncontrolled hypertension (SBP>185, DBP>110)
• Other bleeding disorders/conditions

67. CAROTID ARTERY REVASCULARIZATION
It include carotid endarterectomy or Carotid stenting,
patients likely to benefit from this include;
• Severe (70-99%) symptomatic internal carotid artery
stenosis.
• Moderate (50-69%) symptomatic internal carotid artery
stenosis.
• When performed within two weeks of symptoms onset.
Patients unlikely to benefit are having stenosis less than
50%, severe comorbidity due to medical or surgical illness,
strike associated with severe neurologic deficit and

68. DVT PROPHYLAXIS
• VTE prophylaxis with thigh length intermittent
pneumatic compression, for patients within 72 hours of
onset of stroke who have restricted mobility.
• Pharmacologic VTE prophylaxis for select patients within
48 hours of acute ischemic stroke onset, who have
restricted mobility.
• This recommendation applies only to patients in whom
the assesed benefit of anticoagulation outweigh the risk
of bleeding.
• Graduated compression stockings not recommended in
settings of acute stroke onset.
• Most of DOACs have not been evaluated for VTE
prophylaxis in acute ischemic stroke , further studies are
needed to determine their utility in this setting .

70. OTHER ;
• Depression screening in post stroke patients.
• Avoid prophylactic antibiotics.
• Avoid routine placement of indwelling bladder
catheters.
• Perform regular skin assessment.
• Perform good skin hygiene.
• Lipid control – target cholesterol lowering LDL
<100mg/dl and for high risk patient with
multiple factors <70mg/dl, reduces the risk of
stroke.

71. REHABILITATION

74. ACUTE COMPLICATIONS
• Brain swelling
• Seizures

78. THANK YOU !