Updated Ischemic Stroke Guidelines นพ.ส ชาต หาญไชยพ บ ลย ก ล นายแพทย ทรงค ณว ฒ สาขาประสาทว ทยา สถาบ นประสาทว ทยา กรมการแพทย กระทรวงสาธารณส ข
Emergency start at community level: Prehospital care Acute stroke is emergency condition regardless of severity of neurological deficit The priority is the same level as MI, Serious trauma Transfer the patients to hospital in the shortest time possible ASA Guidelines. Stroke 2013 2
Emergency Department Based Care Action Door to physician Door to stroke team Door to CT initiation Door to CT interpretation Door to drug (rtpa) Door to stroke unit admission Time 10 minutes 15 minutes 25 minutes 45 minutes 60 minutes 3 hours ASA Guidelines. Stroke 2013 3
Emergency Evaluation and Diagnosis of Ischemic Stroke An organized protocol for the emergency evaluation of patients with suspected stroke is recommended (I-B) Stroke rating scale, preferably the National Institutes of Health Stroke Scale (NIHSS), is recommended (I-B) 4
Emergency Evaluation and Diagnosis of Ischemic Stroke Limited number of hematologic, coagulation, and biochemistry tests are recommended during the initial emergency evaluation Only the assessment of blood glucose must precede the initiation of intravenous rtpa (I-B) -Revised 5
Emergency Evaluation and Diagnosis of Ischemic Stroke Baseline electrocardiogram assessment is recommended but should not delay initiation of intravenous rtpa (I-B) -Revised Baseline troponin assessment is recommended but should not delay initiation of intravenous rtpa (I-C) -Revised 6
Emergency Evaluation and Diagnosis of Ischemic Stroke The usefulness of chest radiographs in the hyperacute stroke setting in the absence of evidence of acute pulmonary, cardiac, or pulmonary vascular disease is unclear If obtained, they should not unnecessarily delay administration of fibrinolysis (IIb-B) )_Revised 7
Emergency Evaluation and Diagnosis of Ischemic Stroke 8
Emergency Evaluation and Diagnosis of Ischemic Stroke 9
Early Diagnosis: Brain and Vascular Imaging Emergency imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke (I-A) In most instances,non contrast-enhanced CT will provide the necessary information to make decisions about emergency management. 10
Early Diagnosis: Brain and Vascular Imaging Either non contrast-enhanced CT or MRI is recommended before intravenous rtpa administration to exclude intracerebral hemorrhage (absolute contraindication) and to determine whether CT hypodensity or MRI hyperintensity of ischemia is present (I-A) -Revised 11
Early Diagnosis: Brain and Vascular Imaging Intravenous fibrinolytic therapy is recommended in the setting of early ischemic changes (other than frank hypodensity) on CT, regardless of their extent (I-A) _Revised If frank hypodensity involves more than one third of the middle cerebral artery territory, intravenous rtpa treatment should be withheld (III-A)_Revised 12
General Supportive Care and Treatment of Acute Complications Cardiac monitoring is recommended to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. Cardiac monitoring should be performed for at least the first 24 hours (I-B)_Revised 13
General Supportive Care and Treatment of Acute Complications Patients who have elevated blood pressure and are otherwise eligible for treatment with intravenous rtpa should have their blood pressure carefully lowered so that their systolic blood pressure is <185 mm Hg and their diastolic blood pressure is <110 mm Hg (I-B) before fibrinolytic therapy is initiated If medications are given to lower blood pressure, the clinician should be sure that the blood pressure is stabilized at the lower level before beginning treatment with intravenous rtpa Maintained below 180/105 mm Hg for at least the first 24 hours after intravenous rtpa treatment. 14
General Supportive Care and Treatment of Acute Complications Airway support and ventilatory assistance are recommended for the treatment of patients with acute stroke who have decreased consciousness or who have bulbar dysfunction that causes compromise of the airway (I-C) Supplemental oxygen is not recommended in nonhypoxic patients with acute ischemic stroke (III-B) Supplemental oxygen should be provided to maintain oxygen saturation >94% (I-C) -Revised 15
General Supportive Care and Treatment of Acute Complications Sources of hyperthermia (temperature >38 C) should be identified and treated, and antipyretic medications should be administered to lower temperature in hyperthermic patients with stroke (I-C) 16
General Supportive Care and Treatment of Acute Complications In patients with markedly elevated blood pressure who do not receive fibrinolysis, a reasonable goal is to lower blood pressure by 15% during the first 24 hours after onset of stroke. Consensus exists that medications should be withheld unless BPs >220 mm Hg or BPd >120 mm Hg (I-C)_Revised 17
General Supportive Care and Treatment of Acute Complications Hypovolemia should be corrected with intravenous normal saline, and cardiac arrhythmias that might be reducing cardiac output should be corrected (I-C) -Revised 18
General Supportive Care and Treatment of Acute Complications Hypoglycemia (blood glucose <60 mg/dl) should be treated in patients with acute ischemic stroke. The goal is to achieve normoglycemia (I-C) Revised It is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dl and to closely monitor to prevent hypoglycemia in patients with acute ischemic stroke (IIa-C)_Revised 19
General Supportive Care and Treatment of Acute Complications Initiation of antihypertensive therapy within 24 hours of stroke is relatively safe. Restarting antihypertensive medications is reasonable after the first 24 hours for patients who have preexisting hypertension and are neurologically stable unless a specific contraindication to restarting treatment is known (IIa-B) _Revised 20
Intravenous Fibrinolysis Intravenous rtpa (0.9 mg/kg, maximum dose 90 mg) is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (I-A) 21
Intravenous Fibrinolysis In patients eligible for intravenous rtpa, benefit of Rx is time dependent Treatment should be initiated as quickly as possible. The door-to-needle time should be within 60 minutes from hospital arrival (I-A) -New recommendation 22
Intravenous Fibrinolysis Intravenous rtpa (0.9 mg/kg, maximum dose 90 mg) is recommended for administration to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke onset (I-B) The criteria for Rx this time period are similar to those for people treated at earlier time periods within 3 hours, with the following additional exclusion criteria: 23
Intravenous Fibrinolysis (3-4.5 hours) Additional exclusion criteria: patients >80 years old taking oral anticoagulants regardless of INR baseline NIHSS score >25 imaging evidence of ischemic injury > 1/3 of the middle cerebral artery territory history of both stroke and diabetes mellitus -Revised- 24
Intravenous Fibrinolysis Intravenous rtpa is reasonable in patients whose blood pressure can be lowered safely (to below 185/110 mm Hg) (I-B) For fibrinolytic therapy, physicians should be aware of and prepared to emergently treat potential side effects, including (I-B) -Revised Bleeding complications Angioedema 25
Intravenous thrombolysis 2.5 Adjusted odds ratio 2 1.5 1 0.5 0 60 90 120 150 180 210 240 270 300 330 360 Interval from stroke onset to start of treatment (min) Odds ratio for favourable outcome at 3 months Hacke W, et al. Lancet 2004; 363: 768-74 26
Patients with ischemic stroke within 3 hours who could be treated with rt-pa Inclusion criteria 1.Measurable neurological deficit 2.Onset of symptoms < 3 hours 3.Age 18 years ASA Guidelines. Stroke 2013 27
Patients with ischemic stroke within 3 hours who could be treated with rt-pa Exclusion criteria 1. Significant head trauma or prior stroke in previous 3 months 2. Symptoms suggest SAH 3. Arterial puncture at non compressible site in previous 7 days 4. History of previous intracranial hemorrhage 5. Intracranial neoplasm, AVM, or aneurysm 6. Recent intracranial or intraspinal surgery ASA Guidelines. Stroke 2013 28
Patients with ischemic stroke within 3 hours who could be treated with rt-pa Exclusion criteria 7. Elevated BP (systolic > 185 or diastolic >110 mmhg) 8. Active internal bleeding 9. Acute bleeding diathesis, including but not limited to platelet < 100,000 /mm 3 10. Heparin received within 48 hours, resulting in elevated aptt 11. Current use of anticoagulant with INR > 1.7 0r PT >15 seconds ASA Guidelines. Stroke 2013 29
Patients with ischemic stroke within 3 hours who could be treated with rt-pa Exclusion criteria 12. Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (ie. aptt, INR, platelet count, ECT, TT or appropriate factor Xa activity assay) 13. Blood glucose concentration < 50 mg% 14. CT shows multilobar infarction (hypodensity > 1/3 cerebral hemisphere) ASA Guidelines. Stroke 2013 30
Patients with ischemic stroke within 3 hours who could be treated with rt-pa Relative exclusion criteria* 1. Only minor or rapid improving stroke symptoms 2. Pregnancy 3. Seizure at onset 4. Major surgery or serious trauma within previous 14 days 5. Recent GI or Urinary tract hemorrhage within previous 21 days 6. Recent acute MI within previous 3 months *Patients may received rtpa despite 1 or more relative contraindication, consider risk to benefit carefully ASA Guidelines. Stroke 2013 31
Intravenous Fibrinolysis The usefulness of intravenous administration of tenecteplase, reteplase, desmoteplase, urokinase, or other fibrinolytic agents and the intravenous administration of ancrod or other defibrinogenating agents is not well established Should only be used in the setting of a clinical trial (IIb-B) _Revised 32
Intravenous Fibrinolysis The intravenous administration of streptokinase for treatment of stroke is not recommended (III-A) -Revised 33
Intravenous Fibrinolysis In patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended Unless sensitive laboratory tests such as activated partial thromboplastin time, INR, platelet count, and ecarin clotting time, thrombin time, or direct factor Xa activity assays are normal Or the patient has not received a dose of these agents for >2 days (III-C) -New recommendation- 34
Antiplatelet Agents Oral aspirin (initial dose is 325 mg) within 24 to 48 hours after stroke onset is recommended for treatment of most patients (I-A) Aspirin is not recommended as a substitute for other acute interventions for treatment of stroke, including intravenous rtpa (III-B) Clopidogrel for the treatment of acute ischemic stroke is not well established (IIb-C) -Revised 35
Antiplatelet Agents The administration of aspirin (or other antiplatelet agents) as an adjunctive therapy within 24 hours of intravenous fibrinolysis is not recommended (III-C) -Revised 36
Admission to the Hospital and General Acute Treatment Comprehensive specialized stroke care (stroke units) that incorporates rehabilitation is recommended (I-A) Suspected pneumonia or UTI should be treated with appropriate antibiotics (I-A) -Revised Standardized stroke care order sets is recommended to improve general management (I-B) Assessment of swallowing before the patient begins eating, drinking, or receiving oral medications is recommended (I-B) 37
Admission to the Hospital and General Acute Treatment Routine placement of indwelling bladder catheters is not recommended (III-C) Decompressive surgical evacuation of a space-occupying cerebellar infarction is effective in preventing and treating herniation and brain stem compression (I-B)_Revised Decompressive surgery for malignant edema of the cerebral hemisphere is effective and potentially lifesaving (I-B)_Revised 38
Conclusions Acute stroke is emergency condition Administration of fibrinolysis (IV) should not be delayed Fibrinolysis may be considered carefully in some patients with previous relative contraindication Additional exclusion criteria are need for patients presented within 3-4.5 hours Intravenous fibrinolysis, Stroke unit, ASA within 48 hours are still standard treatment Good management, Written care protocol are important 39