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MANAGEMENT OF ACUTE ISCHEMIC STROKE Internal Medicine Mini Lecture June 2016 Objectives • Establish the components in diagnosing a stroke • Learn which initial imaging is available in acute stroke • Know the management of acute ischemic strokes Causes • Ischemic stroke (85% of all strokes) • Atherosclerotic disease • Cardioembolic • Other (cervical artery dissection, endocarditis, vasculitis, hypercoagulable state, herniation) • Hemorrhagic stroke (15% of all strokes) • Intracerebral hemorrhage (ICH) • Subarachnoid hemorrhage (SAH) CODE STROKE • Focused history and physical • Including contraindications to thrombolytic therapy • Neurologic assessment • facial paresis, arm drift/weakness, and abnormal speech indicate high positive predictive value for stroke • Vitals, glucose • Noncontrast CT Head STAT • To distinguish intracranial hemorrhage from ischemic stroke National Institutes of Health Stroke Scale (NIHSS) • Provides a structured, quantifiable neurologic examination • NIHSS has 11 parts similar to our neurologic exam • Score between 0 and 42 • NIHSS scores ≥20 indicate a severe stroke • NIHSS score on admission has been correlated to stroke outcome • http://www.mdcalc.com/nih-stroke-scale-score-nihss/ Time is Brain • Time of ischemic stroke symptom onset is critical • If unknown, then time the patient was last awake and free of stroke symptoms Initial Imaging • Noncontrast CT • CT Angiography • visualizes great vessels, occlusion, and can reconstruct circle of Willis and extracranial cerebral arteries • CT Perfusion • areas of hypoattenuation correlates with ischemic brain regions • Use of all 3 combined shows improved detection of acute infarction when compared with noncontrast CT alone Acute treatment • Medically: TPA (intravenous tissue plasminogen activator) • FDA: Within 3 hours • AHA/ASA: Within 4.5 hours • the earlier tPA is administered, the higher the likelihood of a positive neurologic outcome • Endovascular: Intra-arterial mechanical thrombectomy • For proximal large vessel occlusion of anterior circulation (intracranial internal carotid, middle cerebral, anterior cerebral) • Within 6 hours of last-seen normal • Can follow TPA administration Main things to remember for TPA: • Inclusion: within 4.5 hours since onset of symptoms or last known normal • Absolute Exclusion: • Head trauma or stroke in last 3 months • Previous ICH, Intracranial tumor, AVM, or aneurysm • Recent intracranial or intraspinal surgery • Active internal bleeding • Bleeding diatheses (plt<100, heparin in last 48h ie abnormal PTT, current anticoagulant use ie INR>1.7) • More exclusion criteria Blood pressure in ischemic stroke • If receiving lytic therapy • Prior to: Recommend SBP ≤185 mmHg and DBP ≤110 mmHg • Afterwards: stabilize and maintain BP <180/105 mmHg for at least 24 hours after thrombolytic treatment. • No thrombolytic therapy • BP should not be treated acutely unless hypertension is extreme SBP>220 mmHg or DBP>120 mmHg or other acute issues exist* • When treatment is indicated, cautious lowering of blood pressure by approximately 15% during the first 24h Additional Medical Management • Antithrombotic treatment • Aspirin 160 to 325 mg within 48 hours • High dose statin • Atorvastatin 80mg • Anticoagulation: only in cardioembolic stroke • IV not recommended during first 48h after acute ischemic stroke • Warfarin can be started for small or moderate-sized infarct after 24 hours Neurologic symptoms suggestive of acute stroke CT Head noncontrast shows hemorrhage Admit to ICU, reverse coagulopathy, manage BP, call Neurosurgery CT Head noncontrast no hemorrhage within 4.5 hours Within 6 hours No h/o ICH, recent stroke, head trauma, intracranial surgery, or bleeding diatheses, and BP<185/110 IV TPA Refer for endovascular intervention Outside therapeutic window Optimize secondary prevention BP in stroke Ischemic stroke TPA No TPA BP<185/110 prior to giving Permissive HTN to 220/120 BP<180/105 for 24h afterwards Case Vignette • A 57-year-old man is evaluated in the emergency department 45 minutes after developing acute-onset left arm weakness. He has a 50-pack-year smoking history. He has no history of stroke, trauma, bleeding, cardiac disease, or surgery. His only medications is atorvastatin. • On physical examination, blood pressure is 168/98 mm Hg and pulse rate is 86/min and irregular. Neurologic examination reveals left hemineglect, an inferior left visual field deficit, left facial weakness, mild dysarthria, and left arm and leg drift. He scores 6 on the National Institutes of Health Stroke Scale, indicating a moderate stroke. Case Vignette What is the next step? Case Vignette What is the next step? Answer: CT Head without contrast Case Vignette Laboratory study findings shows complete blood count, a comprehensive metabolic profile, and coagulation studies are normal. A noncontrast CT scan of the head shows no acute hemorrhage. Which of the following is the most appropriate next step in treatment? A. High-dose aspirin B. Insulin C. Intravenous heparin D. Intravenous recombinant tissue plasminogen activator Case Vignette Laboratory study findings shows complete blood count, a comprehensive metabolic profile, and coagulation studies are normal. A noncontrast CT scan of the head shows no acute hemorrhage. Which of the following is the most appropriate next step in treatment? A. High-dose aspirin B. Insulin C. Intravenous heparin D. Intravenous recombinant tissue plasminogen activator Case Vignette An electrocardiogram (ECG) shows atrial fibrillation; an ECG obtained 1 year ago was normal. An echocardiogram shows a left ventricular ejection fraction of 50% without valvular disease or wall motion abnormalities. A chest radiograph and a carotid ultrasound show normal findings. MRI of the head shows an acute infarction in the right parietal and frontal lobes involving half of the hemisphere. Which of the following is the most appropriate next step in treatment? A. Aspirin B. Dabigatran C. Intravenous heparin D. Warfarin Case Vignette An electrocardiogram (ECG) shows atrial fibrillation; an ECG obtained 1 year ago was normal. An echocardiogram shows a left ventricular ejection fraction of 50% without valvular disease or wall motion abnormalities. A chest radiograph and a carotid ultrasound show normal findings. MRI of the head shows an acute infarction in the right parietal and frontal lobes involving half of the hemisphere. Which of the following is the most appropriate next step in treatment? A. Aspirin B. Dabigatran C. Intravenous heparin D. Warfarin Summary • Diagnosis of stroke involves focused history and physical, • • • • NIHSS, and CT head noncontrast CT noncon, CTA and CT perfusion combined improves the detection of an acute stroke TPA within 4.5 hours, thrombectomy within 6 hours Aspirin should be given within 48 hours Permissive hypertension to 220/120 is indicated in nonTPA ischemic strokes only References • Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Jauch et al., on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology Stroke. 2013;44:870-947 • 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Powers et al. on behalf of the American Heart Association Stroke Council Stroke. 2015 • Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Antithrombotic Trialists' Collaboration. BMJ. 2002 January 12; 324(7329): 71–86. • Uptodate: • Initial assessment and management of acute stroke (http://www.uptodate.com/contents/initial- assessment-and-management-of-acute-stroke) • Neuroimaging of acute ischemic stroke (http://www.uptodate.com/contents/neuroimaging-ofacute-ischemic-stroke) • Antithrombotic treatment of acute ischemic stroke and transient ischemic attack (http://www.uptodate.com/contents/antithrombotic-treatment-of-acute-ischemic-stroke-andtransient-ischemic-attack)