Management of acute ischemic stroke. To feed the flame! László Csiba

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1 Management of acute ischemic stroke To feed the flame! László Csiba

2 MI and stroke cases 1st year (M Ft) 2nd year (M Ft) MI Stroke

3 In acute stroke :CT or MRI Ischemia 80% Bleeding 10-15% Subarachnoidal Bleeding 2-4% 3

4 Normal lifestyle After MI 70-80% After Stroke 10% 4

5 Diagnosis in stroke Brain imaging CT MRI Diff. WI Perf. WI TCD Angiogr.(DSA, MRA) SPECT, PET Carotid, vertebral ultrasound CT AG MRA DSA From blood BSR, counts glucose, ions hemostasis lipids, homocsyt. Immunological (in youngs) Blood gases TEE Heart Functional BP monitoring ECG Holter ECG Morphological TTE TEE

6 EBM in stroke Stroke unit Iv. thrombolysis aspirin Hemicraniectomy in malignant MCA infarct

7 On site activity in acute stroke 1

8

9

10

11 On site activity in acute stroke 2: ABCDE Airway Breathing Circulation Disability Exposure -nvironment -vents -valuation

12 Heteroanamnesis Autoanamnesis Observation Gen.+Neurol. exam Lab+Imaging etc. Diagnosis

13 1.Hetereoanamnesis 2. Autoanamn. 3.Observation 4. Examination On site activity in acute stroke Defense Bladder? Peristalt? 4.7.position? Sore? Babinski? Severity of paresis?: Upper extr.? Lower extr? total-medium-mild? ANY CHANGE DURING THE OBSERVATION PERIOD? TIME OF ONSET OF PARESIS?? Hőmérséklet? 4.5.RR Pulse Fever auscult 4.4.Bruit? 4.1.Consciousness? (alert-somnolent-stupor-coma?) 4.2.Aphasia? 4.3. Eye, mouth, nose ear Coniugated eyes? Anisocoria? Tongue biting? Rest of medicaments? Lip-cyanosis?

14 Suspect for.. ischemia: vascular risk factors, carotid bruit, onset in the morning, disturbance of consciousness is rare, RR slightly elevated breath normal bleeding hypertension onset at dailly activity severe symptoms, plethora somnolent, forced breathing embolic origin sudden onset, maximal quickly improving symtoms arhythmia, cardiac problems (eg. AF) previous stroke in the other hemipsh. vitium (heart)

15 80% Supratentorial hemiparesis -upper extr.? -lower. extr? -Hemihypaesth -hemianopia -tongue deviation -diff-nasolabial fold -cadaver position -aphasia

16 Vertebrobasilar 20% -vertigo? -ataxia? -dysarthria? -double vision? -swallowing? -paresis?

17 The differential diagnosis seizure with postictal paralysis Hypoglycemia brain tumor Migraine head trauma brain abscess Encephalitis

18 Blood sugar No routinous iv. or per os glucose! First measure! Hypo- or hyperglycemia? (< 2,7 mmol/l or >11 mmol/l), please correct! Avoid hyperglycemia!!

19 Most important question? Is he/she a candidate for thrombolysis or not?

20 ESO Priority transport with advance notification..... personnel be trained to recognise stroke using simple instruments such as the Face-Arm Speech- Test

21 Modified Cincinnati Prehospital Stroke Scale (CPSS) Facial paresis Upper extr. paresis Evaluation X X Lower extr. paresis Speech

22 ESO helicopter transfer...telemedicine. suspected TIA be referred without delay..

23 Activity during transport? Pulsoximetry ECG Blood sugar? Strip (if possible blood sampling) BP at 5-10 min Change of consciousness, paresis? If stable condition directly to CT!!!

24 In the hospital Immediate CT!!!!! Quick labs! Rapid onset of therapy

25 The success of stroke care depends on the stroke chain Awareness of stroke Wellorganised transfer In-hospital pathways Stroke Unit

26 Awareness of stroke Stroke day press, local TV Family physician Wellorganised transfer In-hospital pathways Stroke Unit

27 Awareness of stroke Every acute pt. from our region to our stroke ICU hotline to ambulance 7/24 two neurol. on the ward!!! Wellorganised transfer In-hospital pathways Stroke Unit

28 The success of stroke care depends on the stroke chain Awareness of stroke Wellorganised transfer In-hospital pathways 16% of delay Stroke Unit

29 Awareness of stroke Wellorganised transfer Alert, stable stroke directly to CT!!! Neurol. exam there! In-hospital pathways Quick blood sampling for Lab!!! Stroke Unit

30 Stroke care in Debrecen CT Lysis? CT angio Alert Cardioresp.stabil somnolent Cardioresp.instabil EMD CT Stroke unit 72 h Monit. BP EKC O2 reha

31 Thrombus location and likelihood of its recanalization with systemic tpa. Alexandrov, J Int. Medicine 267;

32 Stroke-care:Team-work Stroke nurse Strokologist Physiotherapeuta Radiologist Logopedist Neuropsychol Social worker Cardiologist 32 Prof. Kaste

33 Time is brain! 700 km axon/hour 2 mi neuron/min Every hour of stroke 3.6 yrs

34 Infarct Survival or death? infarktus hours infarktus

35 Ratio of success Lysis as soon as possible. 60 2!! NNT for 1 symptom-free? 4,0 3,5 3,0 2,5 2,0 1,5 1,0 0, min (Lancet 2004; 363: )

36 Stroke during the week end week-end Week-end Week-end Week-end Week-end 36

37 Táguló időablak: 4,5 h

38

39 Intravenous Alteplase Absolute contraindications Evidence of intracranial hemorrhage on pretreatment evaluation Suspicion of SAH Recent (within 3 mo) intracranial or intraspinal surgery, serious head trauma, or previous stroke History of intracranial hemorrhage Uncontrolled hypertension at time of treatment (> 185 mm Hg systolic or > 110 mm Hg diastolic blood pressure) Active internal bleeding Intracranial neoplasm, AVM or aneurysm oral anticoagulants (e.g., warfarin sodium) if INR 1.7 or a prothrombin time 15 seconds heparin within 48 hours before the onset of stroke and an elevated activated partial thromboplastin time at presentation

40 t-pa (alteplase) alteplase dose 0.9 mg/kg (maximum 90 mg), with a bolus of 10% of the dose administered over 1 minute, and the remainder infused over 60 minutes Significant drug interactions OAC and AP increase the bleeding risk. The greatest risk sympt intracranial bleeding therapeutic heparin, antithrombotics, and OAC are contraindicated within 24 hours after administration of alteplase. Sc. heparin at a daily dose of 10,000 units or less without increased bleeding laryngeal and orolingual angioedema <1%, but urgent airway stabilization. orolingual angioedema was 1.7% (95% confidence interval [CI] %) with angiotensin-converting enzyme (ACE) inhibitor

41 Patient Evaluation and Management in the Emergency Department blood glucose level, serum electrolyte level, complete blood cell count, platelet count, renal function studies, prothrombin time, activated partial thromboplastin time, continuous oxygen therapy with oxygen saturation cardiac monitoring. with a cardiac history electrocardiography

42 Misbelieves in in acute stroke Early signs of ischaemia on CT excludes lysis within the first 3 h NOT TRUE! Hyperdense MCA sign excludes thrombolysis. NOT TRUE! Present anticoagulation excludes lysis. NOT TRUE! except INR 1.7 Epileptic seizure excludes thrombolysis NOT TRUE!

43 Control of intracranial bleeding from fibrinolytic infusion of platelets 6 8 units and cryoprecipitate that contains factor VIII to rapidly correct the fibrinolytic state 10 units of cryoprecipitate be administered rapidly because cryoprecipitate contains fibrinogen, the most specific reversal agent for fibrinolytics To obtain cryoprecipitate, a type and screen is necessary. Neurosurgical evacuation may be warranted.

44 lysis ESO 2008 New! Intra-arterial treatment of acute MCA occlusion within a 6-hour time window is recommended as an option..

45 MERCI Mechanical Embolus Removal in Cerebral Ischemia

46 ESO 2008 MERCI Mechanical Embolus Removal in Cerebral Embolism (MERCI) Recanalisation in 48% (68/141) within 8 hours

47 PPT#444,11,Classification of Evidence

48 Therapy if NO lysis..

49 5-10% lysis 80% Stroke unit CT!!! CT+AG!! Neu. Status labs Op. Isch/ICH Neurosurgery

50

51 If BP >220mmHg use α- and/or β-receptor-blocking (eg. urapidil, metoprolol), careful monitoring of BP (measuring at 5-10 min) Stabilize at 160 Hgmm

52 If NO lysis ESO 2008 aspirin ( mg loading dose) be given within 48 hours after ischemic stroke

53 If NO thrombolysis in acute stroke NOT(!) recommended in acute phase: Early UFH, low molecular weight heparin or heparinoids meta-analysis of 22 trials, 9 recurr isch strokes per 1000 treated pts BUT 9/1000 in sympt intracranial hemorrhages (Cochrane 2006].

54 Incr ICP ESO 2008 New! Surgical decompressive therapy within 48 hours up to 60 y with evolving malignant MCA infarcts New! No recommendation can be given regarding hypothermic therapy in patients with spaceoccupying infarctions

55 Acute ischemic stroke therapy Ih NO lysis : 100 mg aspirin, if NO lysis 2-4 lit/min oxygen if BP 220 Hgmm decrease!!! iv.. thrombolysis 3 h new time 4.5 hours with iv. t-pa 3-4,5 hour interval is NOT valid: 80y 1/3 MCA infarct, 25 NIHS, combin. Of prior stroke+diabetes Intraarterial lysis is an option in MCA till 6 hours, but start with iv. Mechanical thrombus removal (eg.. MERCI, Penumbra etc) MCA occlusion 8 hours Basilar artery occlusio:. Intraarterial or iv. thrombolysis till 12 hours, if the patient worsens Dept. of Neurology Debrecen, Hungary idő

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