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Management of acute ischaemic stroke: new guidelines from the American Stroke Association and Europe

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Title: Management of acute ischaemic stroke: new guidelines from the American Stroke Association and Europe


1
Management of acute ischaemic stroke new
guidelines from the American Stroke Association
and European Stroke Initiative
  • The Lancet NeurologyVolume 2 Number 11
    November 2003

2
Background
  • 02 of the population each year
  • Important cause of death and Dependency
  • 1/6 patients die in the first month

3
Background
  • 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

4
Recent 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)

5
Recent developments Guidelines
  • Remarkably similar, even regarding Controversial
    issues
  • Evidence-based medicine and a major Step

6
Recent 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

7
Diagnosis
  • Clinical history and examination
  • CT brain scan most important to Exclude
    non-vascular, structural, Intracranial lesions ,
    brain ischaemia And haemorrhage

8
Diagnosis
  • 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

9
Diagnosis
  • 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)

10
Stroke-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

11
Stroke-care delivery Process
  • Specialised, organised, and Multidisciplinary(medi
    cal, nursing, Physiotherapy, occupational
    therapy, Speech therapy, and social work staff)

12
General 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

13
General 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

14
General 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

15
General 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

16
General supportive care to maintain physiological
homoeostasis
  • ASA nicardipine
  • ASA 1015 reduction
  • EUSI intravenous urapidil, Nitroglycerin, and
    oral captopril

17
General 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

18
Reperfusion 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

19
Reperfusion 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)

20
Reperfusion 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 )

21
Reperfusion of ischaemic brain
  • Both intra-arterial thrombolysis of Acute
    basilar artery occlusion is limited

22
Protection of ischaemic brain cells
  • Currently, no agent with putative Neuroprotective
    effects (level I)

23
Augmentation 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

24
Prevention 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

25
Prevention 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)

26
Prevention 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

27
Revascularisation 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

28
Prevention 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

29
Prevention 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

30
Prevention 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

31
Prevention 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)

32
Prevention 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)

33
Prevention 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)

34
Prevention of complications Neurological
complications( Seizures )
  • Prophylactic use is not recommended (level IV)
  • Recurrent seizures should be treated

35
Conclusion
  • 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

36
Conclusion
  • 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
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