1. Acute Stroke Management
Dr. FAWAZ AL-HUSSAIN FRCPC, MPH(HTA)
May 25th/10
For
Internal Medicine Residents

2. Stroke In Saudi Arabia:
No good studies
Estimated to affect annually
85% ischemic
½ large artery (cardiogenic or A-A)
½ lacunar
Review traditional and non-traditional risk factors. And which ones are modifiable?

3. Could it be a stroke?
60 y/o man with sudden difficulty in talking without focal weakness or numbness.
55 y/o lady with sudden diplopia.
25 y/o man with headache, N/V, P/P and Rt arm weakness.
68 y/o man with sudden confusion.
52 y/o woman with sudden decrease vision in both eyes.

4. Common acute stroke presentation based on arterial distribution:
ACA
MCA  M1
Supperior M2
Inferior M2
PCA
Basilar
Sup. Cerebellar artery
Wallenberg (lateral medulary syndrome)
AND
5 Kinds of lacunar strokes (motor, motor & sensory, sensory, ataxic hemiparesis, and dysarthria-clumbsy hand syndrome)

5. Acute Stroke Care: Prehospital management
Emergency evaluation and diagnosis
Acute treatment: thrombolytics and endovascular intervention
Anticoagulants/ antiplatelets
General acute treatment, including hypertension
Treatment of acute neurological complications
Secondary stroke prevention

6. Pre-hospital Mx: Guidelines for EMS Management of Patients with
Suspected Stroke:
• Manage ABCs
• Cardiac monitoring
• Intravenous access
• Oxygen (keep O2 sat >92%)
• Assess for hypoglycemia
• NPO
• Alert receiving ED
• Rapid transport to closest appropriate facility capable of treating acute stroke
Not Recommended:
• Dextrose-containing fluids in non-hypoglycemic patients
• Excessive blood pressure reduction
• Excessive IV fluids

7. EMERGENCY EVALUATION AND DIAGNOSIS OF ACUTE ISCHEMIC STROKE
Class I Recommendations:
1. Organized protocol for the emergency evaluation of pts
with suspected stroke. Goal is to complete evaluation
and decide treatment within 60 minutes of pt arrival in
ED (Head CT within 25 minutes of ED arrival, study
interpretation within 20 minutes). Careful clinical
assessment, including neuro exam.
2. Use of stroke rating scale, preferably NIHSS.

8. EMERGENCY EVALUATION AND DIAGNOSIS OF ACUTE ISCHEMIC STROKE
Class I Recommendations:
3. Limited number of hematalogic, coagulation, and
biochemistry tests are recommended during initial
emergency evaluation CBC, lytes, cr, INR,PTT, Trop.,glucose
• Time is critical: thrombolytic tx should not be delayed
while waiting for results of PT/PTT or platelet count,
unless bleeding abnormality/thrombocytopenia
suspected, pt taking warafarin and heparin, or
anticoagulation use suspected.

9. EMERGENCY EVALUATION AND DIAGNOSIS OF ACUTE ISCHEMIC STROKE
Class I Recommendations
4. Pts with clinical or other evidence of acute cardiac or pulmonary dz may warrant chest x-ray.
5. ECG recommended because of high incidence of heart disease in pts with stroke.

10. Emergency evaluation and diagnosis
Class I recommendations:
1. Imaging of brain recommended before initiating any
specific tx to treat acute ischemic stroke
CT(brain) is still preferred availability, time, easier to R/O hge
Limitation: pregnancy
Class II recommendations:
1. Data insufficient to state (except for hemorrhage) that
any specific CT finding should preclude treatment of
TPA.

11. Acute stroke imaging:
Hypo-attenuation of brain tissues
Loss of sulcal efffacement
Insular ribbon sign
Obscuration of lentiform nucleus
Hyperdense sign (MCA>basilar>PCA)

19. THROMBOLYTICS: IV-TPA
Class I recommendations: 1. IV-TPA is recommended for selected pts who may be treated within 4 1/2 hours of onset of sxs of ischemic stroke. 2. Besides bleeding complications, physicians should be aware of potential side effect of angioedema that may cause partial airway obstruction (new recommendation).

20. THROMBOLYTICS: IV-TPA
Original NINDS trial: • Absolute difference in favorable outcome of tPA versus placebo was 11-13% across the scales • Depending upon the scale, the increase in relative frequency of favorable outcome in patients receiving tPA ranged from 33% to 55%. • The effect of tPA was independent of stroke subtype, with beneficial effects seen in those with small vessel occlusive, large vessel occlusive and cardio-embolic induced ischemia.

21. Original NINDS trial: • Approximately 6% of the r-tPa treated patients sustained a symptomatic ICH within 36 hours following treatment compared with 0.6% of patients receiving placebo. • Half of the tPA associated symptomatic hemorrhages were fatal, however tPA treatment was not associated with an increase in mortality in the three-month outcome analysis.

22. THROMBOLYTICS: IV-TPA
Class I recommendations: 1. IA thrombolysis is an option for treatment of selected patients who have major stroke of <6 hours’ duration due to occlusion of MCA, and who are not otherwise candidates for IV-TPA. 2. Tx requires pt to be at experienced stroke center with immediate access to cerebral angiography and qualified interventionalists (new recommendation).

23. THROMBOLYTICS: IA-TPA
Class I recommendations: 1. IA thrombolysis is an option for treatment of selected patients who have major stroke of <6 hours’ duration due to occlusion of MCA, and who are not otherwise candidates for IV-TPA. 2. Tx requires pt to be at experienced stroke center with immediate access to cerebral angiography and qualified interventionalists (new recommendation).

24. THROMBOLYTICS: IA-TPA
Class II recommendation:
1. IA thrombolysis is reasonable in patients who have
contraindication to use of IV-TPA, such as recent
surgery (new recommendation).

25. Mechanical Disruption:
Class II recommendations:
MERCI device is reasonable intervention for extraction of
intra-arterial thrombi in carefully selected patients, but panel
recognizes that utility of device in improving outcomes after
stroke is unclear (new recommendation).

26. Anticoagulation:
Class III Recommendations: 1. Urgent anticoagulation with goal of preventing early recurrent stroke, halting neurological worsening, or improving outcomes after acute ischemic stroke not recommended. 2. Urgent anticoagulation not recommended for pts with moderate to severe strokes because of increased risk of serious ICH complications. 3. Initiation of anticoagulant tx within 24 hours of IV-TPA not recommended.

27. Antiplatelet Rx:
Class I recommendation: 1. Oral administration of ASA 325 mg within 24 to 48 hours after stroke onset is recommended for tx of most pts.

28. BP management: For IV-tPA: follow NINDS guidelines 185/110
Not candidate for thrombolysis:
220/120
Use Labetalol IV 10 mg Q 30 min. PRN
Avoid quick reduction in BP and look for bradycardia.
Alternative: Hydralazine IV
Avoid strong vasodialtors

29. Outcome with IV-t-PA:
Odds Ratios for Favorable Outcome Time Odds Ratio 95% (CI) Interval