Title: Management of acute ischaemic stroke: new guidelines from the American Stroke Association and Europe
1Management of acute ischaemic stroke new
guidelines from the American Stroke Association
and European Stroke Initiative
- The Lancet NeurologyVolume 2 Number 11
November 2003
2Background
- 02 of the population each year
- Important cause of death and Dependency
- 1/6 patients die in the first month
3Background
- 1/2 survivors are permanently disabled Despite
best efforts to rehabilitate them and To prevent
complications, recurrent stroke, And other
serious vascular events - Early, and ongoing, management Reduction of
both case fatality and Long-term disability
4Recent developments Guidelines
- Stroke Council of the American Stroke Association
(ASA Adams and co-Workers, Stroke 2003 34
105683) - European Stroke Initiative (EUSI European Stroke
Initiative Executive Committee and Writing
Committee, Cerebrovasc Dis 2003 16 31138)
5Recent developments Guidelines
- Remarkably similar, even regarding Controversial
issues - Evidence-based medicine and a major Step
6Recent developments Guidelines
- ASA Early diagnosis and management
- Of patients in the first 2448 h of
- Ischaemic stroke
- EUSI Primary and secondary stroke
- Prevention, rehabilitation,
- Improvement of public awareness of
- The symptoms of stroke, and the need
- For urgent medical attention after a
- Stroke
7Diagnosis
- Clinical history and examination
- CT brain scan most important to Exclude
non-vascular, structural, Intracranial lesions ,
brain ischaemia And haemorrhage
8Diagnosis
- MRI Contraindicated in metal implants,
- Cardiac pacemakers, or
- Claustrophobia and less widely
- Available, more costly, And less
- Reliable in identifying acute ICH
- MRI Sensitive in the detection of brain
- Infarction
9Diagnosis
- Further research Diffusion and Perfusion MRI,
magnetic resonance Spectroscopy, may be of
additional help For the assessment of the risk to
Benefit ratio for early reperfusion Therapy - Vascular imaging (ultrasound, CT Angiography, and
magnetic resonance Angiography)
10Stroke-care delivery Site
- Stroke unit rather than a general Medical ward
(level I) - Reduces the odds of death or Dependency 22
(95 CI 1132) - Monitoring in an intensive care setting Is not
necessary
11Stroke-care delivery Process
- Specialised, organised, and Multidisciplinary(medi
cal, nursing, Physiotherapy, occupational
therapy, Speech therapy, and social work staff) -
12General supportive care to maintain physiological
homoeostasis
- Despite the absence of reliable evidence For the
effectiveness of interventions Aimed at the
maintenance of Physiological homoeostasis - Airway support and ventilatory Assistancereduced
consciousness or a Compromised airway
13General supportive care to maintain physiological
homoeostasis
- Target O2 saturation EUSI 92 ASA 95
- Antipyretic agents if the body Temperature is
high (high temperature Defined as EUSI 375C
ASA no Temperature threshold stated) - Gradual lowering of high glucose concentrations
(target glucose EUSI about 10 mmol/L ASA
lt1663 mmol/L) with normal Saline and insulin
titration
14General supportive care to maintain physiological
homoeostasis
- Low blood glucose rapidly corrected With
intravenous dextrose bolus or Infusion of 1020
glucose - Hypotonic solutions (NaCl 045 or Glucose 5)
should be avoided
15General supportive care to maintain physiological
homoeostasis
- Management of high BP is Highly controversial
- Lowering of BP unless gt200220 mm Hg systolic
or gt120 mm Hg diastolic in Ischaemic stroke
gt180/105 mm Hg in a patient with haemorrhagic
stroke - Labetalol and sodium nitroprusside
- Avoidance of drugs such as sublingual Nfedipine
16General supportive care to maintain physiological
homoeostasis
- ASA nicardipine
- ASA 1015 reduction
- EUSI intravenous urapidil, Nitroglycerin, and
oral captopril
17General supportive care to maintain physiological
homoeostasis
- EUSI 180/100105 mm Hg (previous HTN), and
160180/90100 mm Hg in Patients (without
previous HTN) - Both lt180/110 mm Hg before Thrombolysis is
potentially indicated
18Reperfusion of ischaemic brain
- IV alteplase (09 mg/kg, at most 90 mg), With 10
as a bolus followed by an Infusion Lasting 60
min selected Patients within 3h of Onset of
ischaemic Stroke - Reduces the odds of death or Dependency at Final
follow-up by 44 - 110 people (50170) from death or Dependency for
every 1000 treated
19Reperfusion of ischaemic brain
- people whose strokes are recognised on waking ?
- Either streptokinase or ancrod (a defibrinating
enzyme) gtgtgt (x) - 3 times, both the risk of symptomatic ICH (10
with alteplase vs 3 with placebo absolute
excess 62 per 1000 patients treated) and of fatal
ICH within 710 days (4 vs 125 per 1000
patients treated level 1)
20Reperfusion of ischaemic brain
- EUSI intra-arterial treatment of acute Middle
cerebral artery occlusion with Prourokinase in a
6 h time window Improved outcome (level II) - ASA more conservative,selected Patients,not
approved by the FDA(no at Least two double-blind,
placebo-Controlled, randomised trials )
21Reperfusion of ischaemic brain
- Both intra-arterial thrombolysis of Acute
basilar artery occlusion is limited
22Protection of ischaemic brain cells
- Currently, no agent with putative Neuroprotective
effects (level I)
23Augmentation of cerebral blood flow
- Isovolaemic haemodilution
- Increasing cerebral perfusion pressure (eg,
hypervolaemic haemodilution) - Both not been established as useful
- ASA risk of serious neurological and
Cardiovascular complications
24Prevention of early recurrent ischaemic stroke
Aspirin
- Within 48 h unless thrombolytic therapy Is
planned (withheld for 24 h ) - 160300 mg/day reduced the odds of Recurrent
stroke during the treatment Period by 13 and of
death or Dependency at the end of follow-up by 5
- ASA no recommendation of other Antiplatelet
drugs in acute ischaemic stroke
25Prevention of early recurrent ischaemic stroke
Heparins
- Do not recommend routine, urgent use Of heparin,
low-molecular weight Heparin, or heparinoids
after ischaemic Stroke - Risk of haemorrhagic transformation
- EUSI cardiac sources with a high risk Of
re-embolism, arterial dissection, or High grade
arterial stenosis before Surgery (level IV)
26Prevention of early recurrent ischaemic stroke
Heparins
- ASA more conservative, does not Recommend urgent
anticoagulation for Patients with
moderate-to-severe stroke Because of a high risk
of serious Intracranial bleeding complications
27Revascularisation procedures
- ASA no definitive data about carotid
Endarterectomy, extracranialIntracranial
arterial bypass, or Endovascular treatments (eg,
stent, Angioplasty, clot removal, suction
Thrombectomy, and thrombolysis Assisted by laser
and power Doppler) Within the first few hours to
days of Acute ischaemic stroke - EUSI does not discuss these
28Prevention of complications Medical
complications
- Not proven by randomised controlled Trials but
suggested by both that early Mobilisation is
favoured to prevent Complications including
aspiration Pneumonia, venous thromboembolism,
Decubital ulcers (pressure sores), and
Contractures
29Prevention of complications Medical
complications
- Infections appropriate antibiotics EUSI NG
tube feeding cant prevent Aspiration pneumonia
(level IV) - Venous thromboembolism early rehydration And
mobilisation, and graded external Compression
stockings (level IV), and that Low dose
subcutaneous heparin or low Molecular weight
heparins should only be Used in patients at high
risk of venous Thromboembolism (level II) by EUSI
30Prevention of complications Medical
complications
- ASA Subcutaneous anticoagulants to Prevent
venous thromboembolism for All immobilised
patients, or the use of Intermittent external
graduated Compression stockings or aspirin for
Patients who cannot receive Anticoagulants
31Prevention of complications Neurological
complications( Brain oedema and high intracranial
pressure )
- Corticosteroids have no place in Cerebral oedema
and may cause IICP (level 1) - Osmotherapy and hyperventilation Condition is
deteriorating secondary to High intracranial
pressure, including Herniation syndromes (level
IV)
32Prevention of complications Neurological
complications( Brain oedema and high intracranial
pressure )
- External ventricular drainage or Ventriculostomy
treat IICP due to Hydrocephalus (level III) - Surgical decompression and evacuation Of large
cerebellar infarctions that Compress the
brainstem and cause Hydrocephalus is justified
(level III)
33Prevention of complications Neurological
complications( Brain oedema and high intracranial
pressure )
- Surgical decompression with evacuation Of a large
hemispheric infarction can be A life-Saving
measure but needs further Investigation - ASA most survivors have severe Residual
Neurological deficits (level III) - EUSI survivors may have residual Neurological
deficit that allows an Independent life (level
III)
34Prevention of complications Neurological
complications( Seizures )
- Prophylactic use is not recommended (level IV)
- Recurrent seizures should be treated
35Conclusion
- Evidence-based, comprehensive, up-to-Date, and
consistent overall - Accurate diagnosis, early reperfusion,
Implementation of effective therapies to Minimise
recurrent stroke and Complications, and maximised
Rehabilitation improve patient Outcome
36Conclusion
- Minor disagreements and Inconsistencies between
the ASA and EUSI 1.acute treatment of particular
Patients with intra-arterial thrombolysis,
Heparin, and craniectomy - 2.Secondary prevention with clopidogrel as a
Substitute for ticlopidine and heparin
Prophylaxis of venous thromboembolism Reflect
different interpretations of unreliable (level
III and level IV) evidence