1. LOGO 1 โดย นศ. ภ. กชกร คำอินต๊ะ นสภ. พฒนพงศ์ ทรัพย์พิริยะอานันต์ Academic in service Principle of pharmacotherapy in Stroke

2. 2 Stroke

3. 3  Stroke is a "Brain Attack"  Stroke is an emergency!  Time is brain

4. 4 Stroke’s Outline  Introduction  Classification  Cause of stroke  Treatment & Prevention  Ischemic stroke  Homorrhagic stroke  Stroke scale and clinical Assessment tools

5. 5 Introduction  Cause of hemiplegic and decrease the quality of life  ในประเทศไทย จากสถิติสาธารณสุข พ. ศ. 2548 พบว่าเป็นสาเหตุการเสียชีวิตอันดับ 3 ใน ประชากรไทย  มีแนวโน้มสูงขึ้นในแต่ละปี  WHO :  สาเหตุการเสียชีวิตอันดับ 1 ในเพศหญิง  สาเหตุการเสียชีวิตอันดับ 2 ในเพศชาย

6. 6 Classification of Stroke

7. 7 Cause of stroke  Large vessel occlusion : 32%  Cerebral embolism : 32%  Small vessel occlusion,lacuna : 18%  Intracerebral hemorrhage : 11%  Subarachnoid hemorrhage : 7%

8. 8 Ischemic stroke  Risk factor  Unmodified risk factor Age,race,sex and family history  Modifiable risk factor Hypertension Heart disease Smoking DM Hyperlipidemia Elevated fibrinogenlevel

9. 9 Early Management  Airway, Ventilatory Support, and Supplemental Oxygen  Temperature  Cardiac Monitoring and Treatment  Arterial Hypertension  Hypoglycemia and Hyperglycemia ACC/AHA 2007 Guidelines for the Early Management of Adults With Ischemic StrokeA Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups

10. 10 Medication  Intravenous Thrombolysis  Anticoagulants  Antiplatelet Agents  Volume Expansion, Vasodilators, and Induced Hypertension  Neuroprotective Agents  Surgical Interventions ACC/AHA 2007 Guidelines for the Early Management of Adults With Ischemic StrokeA Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups

11. 11 Class I reccommendation  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 (Class I, Level of Evidence A)  New recommendation :rtPA should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B).  exclusion criteria: Patients older than 80 years taking oral anticoagulants with an international normalized ratio 1.7 National Institutes of Health Stroke Scale score 25 history of stroke and diabetes. Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator ใ Stroke 2009

12. 12 Class I reccommendation  The oral administration of aspirin (initial dose is 325 mg) within 24 to 48 hours after stroke onset is recommended for treatment of most patients (Class I, Level of Evidence A)

13. 13 Secondary prevention  Antiplatelet Therapy  Aspirin (50 to 325 mg/d) monotherapy, the combination of aspirin and extended-release dipyridamole, and clopidogrel monotherapy are all acceptable options for initial therapy (Class I, Level of Evidence A  New recommendation: The combination of aspirin and extended-release dipyridamole is recommended over aspirin alone (Class I, Level of Evidence B). Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack ใ Stroke 2006;37;577-617 Update to the AHA/ASA Recommendations for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack ใ Stroke 2008;39;1647-1652

14. 14 Secondary prevention (cont.)  Anticoagulant for Cardioembolic Stroke Types  Long term anticoagulant ;target INR 2.0-3.0 Persistent or paroxysmal AF (class I, level of evidence A) Acute MI and LV thrombus (class IIa, level of evidence B) Cardiomyopathy (class IIb, level of evidence C) Rheumatic mitral valve disease (class IIa, level of evidence C) Bioprosthetic heart valve (class IIb, level of evidence C)  Long term anticoagulant ;target INR 2.5-3.5 Patients with mechanical heart valve

15. 15 Secondary prevention (cont.)

16. 16 Modifiable Behavioral Risk Factors Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack Stroke 2006;37;577-617

17. 17 Hemorrhagic stroke  Hemorrhagic stroke  Intracerebral Hemorrhage (ICH) Hypertension Cerebral amyliod angiopathy Vascular abnormality Other nonhypertensive cause Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults 2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023

18. 18 Hemorrhagic stroke (cont.)  Subarachnoid Hemorrhage (SAH) Hypertension Substances abuse (alcohol,tobacco,cocaine) Oral contraceptive use Pregnancy lumbar puncture and cerebral angiography Unrupture aneurysms Advanced age Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults 2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023

19. 19 Early management  Recommendations for Initial Medical Therapy Class I  Monitoring and management of patients with an ICH should take place in an intensive care unit setting because of the acuity of the condition, frequent elevations in ICP and blood pressure, frequent need for intubation and assisted ventilation, and multiple complicating medical issues (Class I, Level of Evidence B).  Appropriate antiepileptic therapy should always be used for treatment of clinical seizures in patients with ICH (Class I, Level of Evidence B).  It is generally agreed that sources of fever should be treated and antipyretic medications should be administered to lower temperature in febrile patients with stroke (Class I, Level of Evidence C).  As for patients with ischemic stroke,93 early mobilization and rehabilitation are recommended in patients with ICH who are clinically stable (Class I, Level of Evidence C) Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults 2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023

20. 20 Early management (cont.)  More aggressive therapies to decrease elevated ICP, such as osmotic diuretics (mannitol via ventricular catheter, neuromuscular blockade, and hyperventilation, generally require concomitant monitoring of ICP and blood pressure with a goal to maintain CPP >70 mm Hg (Class IIa, Level of Evidence B)  Evidence indicates that persistent hyperglycemia (>140 mg/dL) during the first 24 hours after stroke is associated with poor outcomes, and thus it is generally agreed that hyperglycemia should be treated in patients with acute stroke Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults 2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023

21. 21 Control BP Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults 2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023

22. 22 Secondary prevention  Recommendations for Prevention of Recurrent ICH  Class I  Treating hypertension in the nonacute setting is the most important step to reduce the risk of ICH and probably recurrent ICH as well (Class I, Level of Evidence A)  Smoking, heavy alcohol use, and cocaine use are risk factors for ICH, and discontinuation should be recommended for prevention of ICH recurrence (Class I, Level of Evidence B) Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults 2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023

23. 23 Stroke scale and clinical Assessment tools  Facial Droop  Normal: Both sides of face move equally  Abnormal: One side of face does not move at all Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.” Ann Emerg Med 1999 Apr;33(4):373-8

24. 24 Stroke scale and clinical Assessment tools (cont.)  Arm Drift  Normal: Both arms move equally or not at all  Abnormal: One arm drifts compared to the other Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.” Ann Emerg Med 1999 Apr;33(4):373-8

25. 25 Stroke scale and clinical Assessment tools (cont.)  Speech  Normal: Patient uses correct words with no slurring  Abnormal: Slurred or inappropriate words or mute  Time  FAST track Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.” Ann Emerg Med 1999 Apr;33(4):373-8

26. 26 FAST track  If you suspect that someone is having a stroke, think F.A.S.T.  F = FACE Ask the person to smile. Does one side of the face droop?  A = ARM Ask the person to raise both arms. Does one arm drift downward?  S = SPEECH Ask the person to repeat a simple phrase. Does the speech sound slurred or strange?  T = TIME If you observe any of these signs, it’s time to call 9-1-1 http://www.nsmc.partners.org/web/press_room_detail/news_item=e6a11420- a0bd-4860-88e4-01fc60fbf000

27. 27 Our trip

28. 28

29. 29 정말 감사합니다 ขอบคุณมากๆค่ะ มีความสุขทุกคน คับ