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

Stroke In Saudi Arabia: No good studies Estimated to affect 40.000 annually 85% ischemic ½ large artery (cardiogenic or A-A) ½ lacunar Review traditional and non-traditional risk factors. And which ones are modifiable?

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.

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)

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

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

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.

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.

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.

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.

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

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).

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.

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.

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).

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).

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).

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).

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.

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.

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

Outcome with IV-t-PA: Odds Ratios for Favorable Outcome Time Odds Ratio 95% (CI) Interval 0-90 2.8 1.8 - 4.5 91-180 1.5 1.1 - 2.1 181-270 1.4 1.1 - 1.9 271-360 1.2 0.9 - 1.5