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Academic in service
Principle of
pharmacotherapy in Stroke
โดย
นศ.ภ. กชกร คำอินต๊ ะ
นสภ. พฒนพงศ์ ทรัพย์พริ ิยะอำนันต์
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Stroke
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Stroke
Stroke is a "Brain Attack"
Stroke is an emergency!
Time is brain
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Stroke’s Outline
Introduction
Classification
Cause of stroke
Treatment & Prevention
 Ischemic stroke
 Homorrhagic stroke
Stroke scale and clinical Assessment tools
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Introduction
Cause of hemiplegic and decrease the quality of life
ในประเทศไทย จำกสถิตสิ ำธำรณสุ ข พ.ศ. 2548 พบว่ ำเป็ นสำเหตุกำรเสี ยชีวติ
อันดับ 3 ในประชำกรไทย
มีแนวโน้ มสู งขึน้ ในแต่ ละปี
WHO :
 สำเหตุกำรเสี ยชีวติ อันดับ 1 ในเพศหญิง
 สำเหตุกำรเสี ยชีวติ อันดับ 2 ในเพศชำย
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Classification of Stroke
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Cause of stroke
Large vessel occlusion : 32%
Cerebral embolism : 32%
Small vessel occlusion ,lacuna : 18%
Intracerebral hemorrhage : 11%
Subarachnoid hemorrhage : 7%
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Ischemic stroke
Risk factor
 Unmodified risk factor
• Age ,race ,sex and family history
 Modifiable risk factor
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•
•
•
•
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Hypertension
Heart disease
Smoking
DM
Hyperlipidemia
Elevated fibrinogenlevel
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Early Management
Airway, Ventilatory Support, and Supplemental Oxygen
Temperature
Cardiac Monitoring and Treatment
Arterial Hypertension
Hypoglycemia and Hyperglycemia
ACC/AHA 2007 Guidelines for the Early Management of Adults With Ischemic StrokeA Guideline From the American Heart
Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and
the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups
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Medication
Intravenous Thrombolysis
Anticoagulants
Antiplatelet Agents
Volume Expansion, Vasodilators, and Induced Hypertension
Neuroprotective Agents
Surgical Interventions
ACC/AHA 2007 Guidelines for the Early Management of Adults With Ischemic StrokeA Guideline From the American Heart
Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and
the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups
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Class I reccommendation
Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is
recommended for selected patients who may be treated within 3
hours of onset of ischemic stroke (Class I, Level of Evidence A)
 New recommendation :rtPA should be administered to eligible
patients who can be treated in the time period of 3 to 4.5 hours after
stroke (Class I Recommendation, Level of Evidence B).
 exclusion criteria:
•
•
•
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Patients older than 80 years
taking oral anticoagulants with an international normalized ratio 1.7
National Institutes of Health Stroke Scale score 25
history of stroke and diabetes.
Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen ActivatorใStroke 2009
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Class I reccommendation
The oral administration of aspirin (initial dose is 325 mg) within 24
to 48 hours after stroke onset is recommended for treatment of
most patients (Class I, Level of Evidence A)
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Secondary prevention
Antiplatelet Therapy
 Aspirin (50 to 325 mg/d) monotherapy, the combination of aspirin
and extended-release dipyridamole, and clopidogrel monotherapy
are all acceptable options for initial therapy (Class I, Level of
Evidence A
 New recommendation: The combination of aspirin and extendedrelease dipyridamole is recommended over aspirin alone (Class I,
Level of Evidence B).
Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic AttackใStroke 2006;37;577-617
Update to the AHA/ASA Recommendations for the Prevention of Stroke in Patients With Stroke and Transient
Ischemic AttackใStroke 2008;39;1647-1652
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Secondary prevention (cont.)
Anticoagulant for Cardioembolic Stroke Types
 Long term anticoagulant ;target INR 2.0-3.0
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•
•
•
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Persistent or paroxysmal AF (class I, level of evidence A)
Acute MI and LV thrombus (class IIa, level of evidence B)
Cardiomyopathy (class IIb, level of evidence C)
Rheumatic mitral valve disease (class IIa, level of evidence C)
Bioprosthetic heart valve (class IIb, level of evidence C)
 Long term anticoagulant ;target INR 2.5-3.5
• Patients with mechanical heart valve
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Secondary prevention (cont.)
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Modifiable Behavioral Risk Factors
Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack Stroke
2006;37;577-617
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Hemorrhagic stroke
Hemorrhagic stroke
 Intracerebral Hemorrhage (ICH)
•
•
•
•
Hypertension
Cerebral amyliod angiopathy
Vascular abnormality
Other nonhypertensive cause
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults
2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the
Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023
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Hemorrhagic stroke (cont.)
 Subarachnoid Hemorrhage (SAH)
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•
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Hypertension
Substances abuse (alcohol,tobacco,cocaine)
Oral contraceptive use
Pregnancy
lumbar puncture and cerebral angiography
Unrupture aneurysms
Advanced age
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults
2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the
Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023
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Early management
 Recommendations for Initial Medical Therapy Class I
 Monitoring and management of patients with an ICH should take place in an
intensive care unit setting because of the acuity of the condition, frequent elevations
in ICP and blood pressure, frequent need for intubation and assisted ventilation, and
multiple complicating medical issues (Class I, Level of Evidence B).
 Appropriate antiepileptic therapy should always be used for treatment of clinical
seizures in patients with ICH (Class I, Level of Evidence B).
 It is generally agreed that sources of fever should be treated and antipyretic
medications should be administered to lower temperature in febrile patients with
stroke (Class I, Level of Evidence C).
 As for patients with ischemic stroke,93 early mobilization and rehabilitation are
recommended in patients with ICH who are clinically stable (Class I, Level of
Evidence C)
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults
2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the
Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023
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Early management (cont.)
More aggressive therapies to decrease elevated ICP, such as osmotic
diuretics (mannitol via ventricular catheter, neuromuscular blockade,
and hyperventilation, generally require concomitant monitoring of ICP
and blood pressure with a goal to maintain CPP >70 mm Hg (Class IIa,
Level of Evidence B)
Evidence indicates that persistent hyperglycemia (>140 mg/dL) during
the first 24 hours after stroke is associated with poor outcomes, and
thus it is generally agreed that hyperglycemia should be treated in
patients with acute stroke
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults
2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the
Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023
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Control BP
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults
2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the
Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023
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Secondary prevention
Recommendations for Prevention of Recurrent ICH
Class I
 Treating hypertension in the nonacute setting is the most important
step to reduce the risk of ICH and probably recurrent ICH as well
(Class I, Level of Evidence A)
 Smoking, heavy alcohol use, and cocaine use are risk factors for
ICH, and discontinuation should be recommended for prevention of
ICH recurrence (Class I, Level of Evidence B)
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults
2007 Update A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the
Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38;2001-2023
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Stroke scale and clinical
Assessment tools
Facial Droop
 Normal: Both sides of face
move equally
 Abnormal: One side of
face does not move at all
Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.” Ann Emerg Med 1999
Apr;33(4):373-8
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Stroke scale and clinical
Assessment tools (cont.)
Arm Drift
 Normal: Both arms
move equally or
not at all
 Abnormal: One
arm drifts
compared to the
other
Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.” Ann Emerg Med 1999
Apr;33(4):373-8
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Stroke scale and clinical
Assessment tools (cont.)
Speech
 Normal: Patient uses correct words with no slurring
 Abnormal: Slurred or inappropriate words or mute
Time
FAST track
Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.” Ann Emerg Med 1999
Apr;33(4):373-8
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FAST track
 If you suspect that someone is having
a stroke, think F.A.S.T.
 F = FACE Ask the person to
smile. Does one side of the face
droop?
 A = ARM Ask the person to raise
both arms. Does one arm drift
downward?
 S = SPEECH Ask the person to
repeat a simple phrase. Does the
speech sound slurred or strange?
 T = TIME If you observe any of
these signs, it’s time to call 9-1-1
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