Stroke ESO.org. Csiba László.
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1 Stroke ESO.org Csiba László
2 Global mortality
3 Cause of death Dept. of Neurology? Tumor Stroke Tumor Infect. Stroke
4 Normal lifestyle After MI 70-80% After stroke 10%
5 Differential diagnosis---ct/mri!!! ischemia Agyi infarktus 80% 80% sp. Vérzés Hemorrhage 20% 10-15% Subarachnoidal bleeding 5
6 ischemia Agyi infarktus 80% 80% Vérzés 20% 6
7 62 yrs stroke at admission CT One day later 2 days later
8 Large vessel occluded? Less chance for successful intravenous lysis.. Alexandrov, J Int. Medicine 267;
9 Ischemic Stroke 700 km axon/hour 2 millió neuron/min Time is brain!
10 Ischemic Stroke
11 Symptoms
12 Cincinatti scale 1. Neurológia Klinika, Debrecen 12
13 Cincinatti scale 2. Neurológia Klinika, Debrecen 13
14 Cincinatti scale 3. Slurred speech, aphasia Neurológia Klinika, Debrecen 14
15 Forebrain Ischemia (ICA/MCA) Netter, 1986
16 Vertebro basilar (verteb. basilar) Netter, 1986
17 TIA (TRANSIENT ISCHEMIC ATT.) Transient symptoms Minutes No residual tissue deficit (MRI) TIA is emergency!!! High risk of devastating stroke
18 The neuroprotective drugs failed in acute stroke trials: What to do? To open the obstructed artery as soon as possible! with iv. thrombolysis (tissue plasminogen activator- t-pa) Ia. Intraarterial mechanical thrombectomy combination of them
19 Ischemic Stroke 700 km axon/hour 2 millió neuron/min Time is brain!
20 1 1,5 3 4,5 6 hours after stroke Open the artery as soon as possible 45 patients 21 patients 9 patients 2 patients 4 patients
21 Lysis. Within 3 hours between 3-4,5 hours worse worse improved better
22 Lysis in acute stroke: USA Lee H. Schwamm et al. Circ Cardiovasc Qual Outcomes. 2013;6:
23 iv. Thrombolysis in Debrecen (%) % 23% More than 1300 iv. lysis!
24 Debrecen stroke care stroke Ambulance! CT-! CT+CT angio! Personalised: Iv? intraarterial? iv+ia? mechanical thrombectomy Stroke unit
25 The neuroprotective drugs failed in acute stroke trials: What to do? To open the obstructed artery as soon as possible! with iv. thrombolysis (tissue plasminogen activator- t-pa) Ia. Intraarterial mechanical thrombectomy combination of them
26 The neuroprotective drugs failed in acute stroke trials: What to do? To open the obstructed artery as soon as possible! with iv. thrombolysis (tissue plasminogen activator- t-pa) Ia. Intraarterial mechanical thrombectomy combination of them
27 time Time window? depends on the vessel and time elapsed after stroke? Within 4,5 hours (some subgroups 3 hours) Iv. lysis if small vessel occlusion 6-8 hours IF ICA or MCA occlusion:intraarterial or mechanical thrombectomy BUT start with iv.!! 12 h if basilar artery occluded either iv or ia. lysis
28 If out of time window? mg aspirin Monitoring of BP and ECG Do NOT decrease BP till 220/110 Hgmm! Pulsoximetry, 2-4 lit oxigen, if less 94% Normoglycemia LMWH or heparin to prevent DVT deep venous thromb. Nasogastric tube if dysphagia Antipyretic ther. If seizure antiepilept. antibiotics
29 After desoblieration therapy, the next question: cause of stroke?
30 Imaging Stroke: diagnosis CT MRI Diff. WI TCD DSA angiogr. Carotid, vertebr- ultrasound CT AG MRA DSA Blood Blood counts Glucose, ions Coagulation? lipids Immunol. tests ultrasound Heart Function BP monitoring ECG Holter ECG morphology TTE TEE 30
31 How to prevent the 2 nd stroke?
32 Recurrent stroke 1 mo 30% 1 year 10% then 6-8%
33 How to prevent the 2nd stroke 1. Antiplatelet therapy asp+dp>aspirin mono clopidogrel 75 mg triflusal 2. Antihipertensive th. ACE inhib+diureticum E.g.perindopril+indapamide 3. Statin 4. AF or cardiogenic source of emboli AC INR Carotid stenosis stent or CEA in 2 weeks 70-99% stenosis Only if TIA and minor stroke Occlusion NO!! Plegic?NO!!!!!
34 1. Antiplatelet 2x aspirin (25mg)+ ER dipyridamol (200 mg) prevents 1 pts/100 pts in 1 year aspirin + Clopidogrel? No!
35 How to prevent the 2nd stroke 1. Antiplatelet therapy asp+dp>aspirin mono clopidogrel 75 mg triflusal 2. Antihipertensive th. ACE inhib+diureticum E.g.perindopril+indapamide 3. Statin 4. AF or cardiogenic source of emboli AC INR Carotid stenosis stent or CEA in 2 weeks 70-99% stenosis TIA and minor stroke
36 2. BP stroke risk if more than 115 Hgmm If 10/5 Hgmm BP stroke risk 30-40% Target? 120/80 or Diuretics alone +ACE inhib
37 How to prevent the 2nd stroke 1. Antiplatelet therapy asp+dp>aspirin mono clopidogrel 75 mg triflusal 2. Antihipertensive th. ACE inhib+diureticum E.g.perindopril+indapamide 3. Statin 4. AF or cardiogenic source of emboli AC INR Carotid stenosis stent or CEA in 2 weeks 70-99% stenosis TIA and minor stroke
38 3.Statin Statin if LDL 2.6 mmol/l or signs of atherosclerosis target: LDL < 1.8 mmol/l Niacin or gemfibrosil if HDL-C low
39 How to prevent the 2nd stroke 1. Antiplatelet therapy asp+dp>aspirin mono clopidogrel 75 mg triflusal 2. Antihipertensive th. ACE inhib+diureticum E.g.perindopril+indapamide 3. Statin 4. AF or cardiogenic source of emboli AC INR Carotid stenosis stent or CEA in 2 weeks 70-99% stenosis TIA and minor stroke
40 Netter, 1986
41 4. If AF post-stroke Aspirin is NOT enough---if possible -----AC with warfarin or NOAC (dabigatran, rivaroxaban, apixaban, edoxaban----all as good as warfarin but less bleeding and no need for INR control)
42 How to prevent the 2nd stroke 1. Antiplatelet therapy asp+dp>aspirin mono clopidogrel 75 mg triflusal 2. Antihipertensive th. ACE inhib+diureticum E.g.perindopril+indapamide 3. Statin 4. AF or cardiogenic source of emboli AC INR Carotid stenosis stent or CEA in 2 weeks 70-99% stenosis TIA and minor stroke
43 Carotid Stent or CEA after TIA or minor stroke >70 y CEA>CAS If Periprocedural stroke+mort. <6% <70 év BUT! Analyse the carotid plaque!!!!
44 sp. Hemorrhage 10-15% Agyi infarktus 80% Vérzés 20% 44
45 45 Netter, 1986
46 46 Netter, 1986
47 ICH neuroimaging with CT or MRI CT angiography and contrast CT may be considered to identify patients at risk for hematoma expansion structural lesions? vascular malformations? tumors?
48 VII FVIIa can limit the extent of hematoma expansion increase in thromboembolic risk with rfviia rfviia is not recommended intermittent pneumatic compression +elastic stockings After cessation of bleeding, low-dose sc. LMW heparin or unfractionated heparin may be considered for prevention of DVT with lack of mobility after 1 to 4 days from onset!!!!
49 Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ASA/AHA 2015
50 0
51 Prevention of Secondary Brain Injury Glucose should be monitored and normoglycemia (range 4.4 to 6,1 mmol/l) seizures should be treated with antiepileptic drugs Prophylactic anticonvulsant medication should not be used
52 Surgery If Glasgow Coma Scale of 8 +clinical evidence of transtentorial herniation, or significant intraventric. Hemorrhage (IVH) or hydrocephalus ventricular drainage in patients with decreased level of consciousness
53 Surgery 2 uncertain exceptions deteriorating cerebellar hemorrhage with brainstem compression and/or hydrocephalus ASAP!
54 Clot removal lobar clots >30 ml and within1 cm of the surface, by standard craniotomy might be considered The effectiveness of minimally invasive clot evacuation stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain no clear evidence
55 Prevention of Recurrent ICH risk factors for recurrence: Lobar location older age, ongoing anticoagulation, presence of the apolipoprotein E ε2 or ε4 alleles, and greater number of microbleeds on MRI!! After the acute ICH period BP <140/90 <130/80 if diabetes or chronic kidney disease, reasonable
56 Agyi infarktus 80% Vérzés 20% Subarachnoidal bleeding 56
57 SAH 10-20/ Thunderclap headache Vomitus, photophobia During physical exercise But not always! Neck rigidity sometimes paresis ACT sometimes negative!! Lp! aneurysma multiplex? Vasospasm 4-11 day 57 Netter 1986
58 SAH
59 59 Netter, 1986
60 60 Netter, 1986
61 61v Netter, 1986
62
63
64
65 65
66
67 Therapy Anti-HT (eg, IV beta block.) if mean BP more than 130 No Nitrite! Hydralazine and calcium calcium blocker ACE Intubation hiperventilation Mannisol furosemide IV steroid (contradict.)
68 Complications Re-bleeding Vasospasm (4-11. nap, Transcran Doppler) nimodipine Hydrocephalus Hyponatremia Seizures Lung edema, MI
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