Unit I herbs as raw materials, biodynamic agriculture.ppt
Manage ischemic stroke pts
1. 1
Management of Acute Ischemic
Stroke Patients
Jiann-Shing Jeng, MD, PhD
Stroke Center & Department of Neurology
National Taiwan University Hospital, Taipei, Taiwan
2. Stroke Types: NTUH, 1995~2007
2
Large artery
atherosclerosis
12% Small artery lacune
Subarachnoid 22%
hemorrhage
6%
Cardioembolism
14%
Cerebral
hemorrhage Other determined
22% Undetermined 4%
20%
3. Stroke Chain of Survival
3
Detection Recognition of stroke signs/symptoms
Dispatch Call 119 and priority EMS dispatch
Delivery Prompt transport and prehospital notification to hospital
Door Immediate ED triage
Data ED evaluation, prompt laboratory studies, and CT imaging
Decision Diagnosis and decision about appropriate therapy
Drug Administration of appropriate drugs or other intervention
4. EMS in Acute Stroke
4
Rapid identification of acute stroke
Elimination of comorbid conditions mimicking stroke
Stabilization
Rapid transportation
Notification of receiving institution
6. Los Angeles Prehospital Stroke Screen
(LAPSS)
6
Last time patient known to be symptom free
Screening criteria
1. Age >45 y
2. No history of seizure or epilepsy
3. Symptom duration less than 12 hours
4. No previously bedridden or wheelchair bound
5. Blood glucose 60-400 mg/Dl
6. Exam:
Facial smile/grimace: normal, droop
Grip: normal, weak grip, no grip
Arm strength: normal, drifts down, falls rapidly
7. LOS ANGELES MOTOR SCALE
(LAMS)
7
Normal Right Left Total
Facial Ͱ Droop (1) Ͱ Droop (1)
Ͱ (0)
smile/grimace
Ͱ Weak grip (1) Ͱ Weak grip (1)
Grip Ͱ (0)
Ͱ No grip (2) Ͱ No grip (2)
Ͱ (0) Ͱ Drifts down (1) Ͱ Drifts down (1)
Arm strength
Ͱ Falls rapidly (2) Ͱ Falls rapidly (2)
TOTAL Score
8. Cincinnati Prehospital Stroke Scale
8
Facial droop
Normal : both sides of face more equally
Abnormal : one side of face does not move as well as the
other
Arm drift
Normal : both arms move the same or both arms do not move
at all
Abnormal : one arm either does not move or drift down
compared to the other
Speech
Normal : says correct words with no slurring
Abnormal : slurs words, says the wrong words, or is unable to
speak
9. How to approach a patient with
probable acute stroke?
9
New onset of acute Subsequent hospital
neurological deficit management
Differential diagnosis of other Acute stroke
non-stroke diseases
management
Establish cause of
Initial ER assessment and stroke
management Stroke risk factors
Vital signs, sugar Dysphagia screening
Consciousness: GCS Early rehabilitation
Non-contrast head CT PT, OT, ST
Stroke severity: NIHSS Plan for secondary
Stroke type and location prevention of stroke
Hyperacute management
Thrombolytic therapy
Craniectomy
Intensive care/monitoring
10. History for initial diagnosis of acute stroke
10
Rapid, accurate history taking
Often from the family members
Key elements of history
Onset time: the last time of normal neurological status
Onset mode: sudden, acute, subacute
Onset symptoms: focal or generalized symptoms
Course: progression of symptoms
Co-morbid diseases: HTN, DM, Heart diseases, etc.
Use of medications: antiplatelets, anticoagulants,
antihypertensives, insulin, etc.
11. Misdiagnosis of Acute Stroke
~ NTUH experience
11
No. %
Acute stroke 2226 87.6
Misdiagnosis of acute stroke 316 12.4
Possible neurovascular disorders 57 2.2
Other neurological disorders 209 8.2
Non-neurological disorders 50 2.0
Total 2542 100.0
12. Differential Diagnosis of Acute Stroke
12
Old cerebrovascular disease
Craniocerebral/cervical trauma
Meningitis/encephalitis
Hypertensive encephalopathy
Intracranial mass (tumor, subdural/epidural hematoma)
Seizure with persistent neurological signs (Todd’s paralysis)
Vestibulopathy
Spinal cord or peripheral nerve lesions
Migraine with persistent neurological signs
Metabolic:
Hyperglycemia
Hypoglycemia
post-cardiac arrest hypoxia
Infection
Drug overdose, etc.
13. NTUH ER Stroke Assessment:
History
13
Stroke/TIA Onset Time: 確定 年 月 日 時 分 不確定
Stroke/TIA Onset Symptoms:
drowsiness, stupor, delirium, coma, headache, vomiting, neck stiffness,
seizures, anopia, aphasia ( sensory, motor), apraxia, vertigo,
dizziness, dysarthria, dysphagia, diplopia, ataxia, incontinence
left side weakness ( face, upper limb, lower limb),
right side weakness ( face, upper limb, lower limb),
left side numbness ( face, upper limb, lower limb),
right side numbness ( face, upper limb, lower limb),
Others:
Stroke/TIA Onset Mode: sudden, acute, fluctuating course
Activity at Stroke/TIA Onset: strenuous activity, ordinary activity, rest, sleep
Stroke in Progression: yes (symptoms progression>1 hour), no
14. NTUH ER Stroke Assessment: NIHSS
14
1a. Level of Consciousness (LOC) 4. Facial Palsy 7. Limb Ataxia
□ 0= Alert □ 0= Normal □ 0= Absent
□ 1= Not alert, but arousable □ 1= Minor □ 1= Present in one limb.
□ 2= Not alert, obtunded □ 2= Partial □ 2= Present in two limbs
□ 3= Uunresponsive □ 3= Complete 8. Sensory
1b. LOC Questions 5a Left Motor Arm □ 0= Normal
□ 0= Answers both questions □ 0= No drift □ 1= Mild to moderate sensory loss
correctly □ 1= Drift □ 2= Severe
□ 2= Some effort against gravity
□ 1= Answers one question correctly 9. Best Language
□ 3= No effort against gravity
□ 2= Answers neither question □ 4= No movement □ 0= normal
correctly 5b. Right Motor Arm □ 1= Mild to moderate aphasia
1c. LOC Commands □ 0= No drift □ 2= Severe aphasia
□ 0= Performs both tasks correctly □ 1= Drift □ 3= Mute, global aphasia
□ 1= Performs one task correctly □ 2= Some effort against gravity 10. Dysarthria
□ 2= Performs neither task correctly □ 3= No effort against gravity □ 0= Normal
2. Best Gaze □ 4= No movement □ 1= Mild to moderate
□ 0= Normal 6a. Left Motor Leg □ 2= Severe
□ 1= Partial gaze palsy □ 0= No drift 11. Extinction and Inattention
□ 2= Forced deviation or total gaze □ 1= Drift □ 0= Normal
paresis □ 2= Some effort against gravity □ 1= One sensory modality
3. Visual □ 3= No effort against gravity □ 2= More than one sensory modality
□ 0= No visual loss □ 4= No movement
□ 1= Partial hemianopia. 6b. Right Motor Leg
□ 2= Complete hemianopia □ 0= No drift Total Score:
□ 3= Bilateral hemianopia □ 1= Drift
□ 2= Some effort against gravity
□ 3= No effort against gravity
□ 4= No movement
16. Head images for acute stroke
diagnosis
16
Everyone with suspected stroke
CT without contrast
Some patients required stroke mechanism realization
or treatment consideration
MRI
MRA
CTA
Ultrasound (duplex, transcranial Doppler, Echocardiography)
Conventional angiography
17. Early CT signs in acute MCA stroke
17
Left and middle: Hyperdense left MCA sign (yellow arrow), hypoattenuated left basal
ganglia (red arrow), and cortical swelling (blue arrows) in the same patient. Right:
Dot sign (yellow arrow) in the left sylvian fissure.
18. Alberta Stroke Program Early CT Score (ASPECTS)
Quantify the extent of CT hypodensity in acute
stroke
A
M1
C
I
L
M2
IC
M3
P
Barber et al. Lancet. 2000;355:1670-4.
19. Diagnosis of Acute Stroke
19
Stroke vs. non-stroke
Infarction or hemorrhage
Infarction
Location diagnosis
Arterial territory diagnosis
Pathophysiology diagnosis
Etiology diagnosis
20. Location Diagnosis of Stroke
20
Supratentorial site
Hemisphere side
Cortical or subcortical areas
Frontal, parietal, temporal lobe
Infratentorial site
Midbrain, pons, medulla, cerebellum
21. Arterial Territory Diagnosis of Stroke
21
ICA: more than MCA territory
ACA
MCA
Lenticulostriate artery
Cortical branches
Internal borderzone area
PCA
External borderzone area
V-B system
Extracranial VA
Intracranial
VA, BA, PICA, AICA, SCA
22. Acute Stroke Case
22
A 70-year-old, right-handed man has been known to
have previous history of poorly controlled hypertension,
diabetes, and cardiac arrhythmia. He developed abrupt
onset of left-sided weakness after dinner at 7 pm.
What should you do?
23. Acute Stroke Case
23
He brought to a medical center ER by the EMS at
8:30 pm.
On initial ER arrival, his consciousness was awake,
blood pressure was 210/120 mmHg, pulse rate was
120/min irregularly, respiratory rate was 20/min, body
temperature was 37°C and blood sugar was 320 mg/dL.
What should you do if you are on duty at ER ?
24. Acute Stroke Case
24
Neurologically, he had flaccid hemiplegia and right-
sided gaze preference with dense left-sided hemineglect.
The NIHSS score was 17. Head CT scan revealed
effacement of cortical sulcal marking in the right middle
cerebral artery territory and hyperdense MCA sign.
What is your diagnosis of the stroke ?
What are the next you will do ?
25. Diagnosis of Acute Stroke
25
Stroke confirmed by history and
images
Infarction confirmed by head CT
Location right MCA territory (>1/2)
Arterial territory right MCA, main trunk
Pathophysiology embolism
Etiology cardioembolism, atrial
26. Arterial Occlusion
Embolism Site
Microembolus
Atheroma
27. Stroke Evaluation Targets for Potential
Thrombolytic Candidates
27
Time Target
Door to doctor 10 minutes
Door to CT completion 25 minutes
Door to CT read 45 minutes
Door to treatment 60 minutes
Assess to neurological expertise 15 minutes
Assess to neurosurgical expertise 2 hours
Admit to monitored bed 3 hours
28. Acute Ischemic Stroke Protocol
28
ER arrival
Triage nurse confirm stroke onset time < 4 hours
ER Resident performs
Rapid evaluation (5 minutes) Neurology Resident receives
1.exact time of onset ER stroke page and
2.important history proceeds to ER
3.quick neurological evaluation brief history & physical exam
STAT CT and blood work Page Stroke VS
Head CT findings, laboratory data, NIH stroke scale
Confirm the criteria fulfilling thrombolytic therapy for ischemic stroke
Family’s agreement for thrombolytic therapy
Stroke onset < 3 hours Stroke onset 3-6 hours Call Neuroradiologists
IV-tPA treatment IA thrombolytic therapy IA thrombolysis
Patient is admitted to Stroke ICU for intensive monitoring/care
29. Essentials of Acute Stroke Care
29
Acute stroke team
Multi-disciplinary care
Stroke units
Intensive care of stroke patients
Standardized protocol of acute stroke management
Early rehabilitation of acute stroke patients
30. Acute Stroke Teams
30
Acute stroke team consists of health care
professional with experience and expertise in
stroke
Available 24 hours everyday, within 15
minutes of the call
At a minimum, a qualified acute stroke
physician and another health care
professional
31. Stroke Units
31
A setting designed for the care of
stroke
Admission/discharge criteria, patient census
and outcome data
Staffed and directed by personnel (physicians,
nurses, etc.) with training and expertise in
caring for patients with cerebrovascular
disease
Equipment and written protocols for stroke
patient care: Neuro, Cardiac, B/P monitoring
32. Potential Benefits of Stroke Units
32
50
Cases saved from death and dependency
45
40
35
per 1,000 events
30
25
20
15
10
5
0
Stroke unit ASA tPA <3h tPA <6h Neuroprotective
agents
Gilligan et al. Cerebrovasc Dis. 2005;20:239-44.
33. Goal of Acute Ischemic Stroke Care
33
Treatment goals Therapeutic strategies
To reverse brain ischemia before it cause Recanalization, esp.
permanent brain injury thrombolysis
To prevent stroke in evolution and recurrence Antithrombotic agents
To optimize the patient’s medical condition and Homeostasis of the brain
prevent the common medical sequelae that
occur after stroke or after a stroke intervention
To optimize functional recovery after the Early rehabilitation
residual permanent injury that has occurred
34. Homeostasis of the Brain
34
Blood pressure SBP 120-220 mmHg, DBP 70-
110 mmHg
Blood glucose level blood sugar 100-150 mg/dL
Body temperature <37.5°C
Oxygen saturation >95%
35. Blood Pre s s ure in Ac ute Is c he mic
S troke
35
A spontaneous increase in BP is common in
patients with acute ischemic stroke, and the
increase in BP tends to be more pronounced in
patients with preexisting hypertension.
Elevations in systolic blood pressure >160 mm Hg
are detected in 60% of patients with acute stroke.
36. C aus e of Ele vate d Blood Pre s s ure in
Ac ute S troke
36
Stress of hospitalization
Stress of the cerebrovascular event
A full bladder, nausea, pain, other body
discomfort
Preexisting hypertension
A physiological response to hypoxia
A response to increased intracranial pressure
37. Blood Pre s s ure in Ac ute Is c he mic
S troke
37
In a majority of patients, BP tends to decline in the
first few days to weeks after stroke onset, even
without pharmacological intervention.
A significant decline in BP can be seen in
approximately a third of patients in the first few
hours after stroke onset.
38. Blood Pre s s ure in Ac ute Is c he mic
S troke
38
BP often falls spontaneously when the patient is
moved to a quiet room, the patient is allowed to rest,
the bladder is emptied, or the pain is controlled.
In addition, treatment of increased intracranial
pressure may result in a decline in BP.
39. Time course of blood pressure (MAP) with
acute ischemic stroke
39
Christensen et al. Acta Neurol Scand 2002;106:142-7.
40. Admission Blood Pressure and Outcome
~ International Stroke Trial
40
Leonardi-Bee et al. Stroke 2002;33:1315-20.
41. High Blood Pressure in Acute Stroke and
Outcome
41
For every 10-mm Hg increase >180 mm Hg, the risk
of neurological deterioration increased by 40% and
the risk of poor outcome increased by 23%
42. Cerebral Perfusion Pressure
42
Cerebral perfusion pressure (CPP) = Mean
arterial blood pressure (MABP) – intracranial
pressure (ICP)
Maintain CPP >60 mm Hg to ensure
cerebral blood flow
In case of elevated ICP, elevated BP is
required for maintaining adequate CPP.
43. Management of Elevated BP in Acute
Ischemic Stroke
43
Current recommendation based on the type of stroke
Antihypertensive therapy in acute ischemic stroke
Aggressive antihypertensive therapy may lower the cerebral
perfusion pressure and lead to stroke worsening
Acute stroke patient may have exaggeration of response to
antihypertensive agents
For nonthrombolytic candidates
Not to treat if SBP <220, DBP <120, or MAP <130
mm Hg.
For thrombolyic candidates
Not to treat if SBP <185, or DBP <110 mm Hg
44. BP Lowe ring in Ac ute Is c he mic
s troke
44
When treatment is indicated, lowering the BP
should be done cautiously.
Some strokes may be secondary to
hemodynamic factors, and a declining BP may
lead to neurological worsening.
45. Blood Pressure Management of Ischemic
Stroke (nonthrombolytic candidates)
45
Blood pressure Treatment
DBP >140 mm Hg Sodium nitroprusside (0.5 ug/kg/min).
Aim for 10-20% reduction in DBP.
SBP >220, DBP >120, or 10-20 mg labetalol IV push over 1-2 min.
MAP >130 mm Hg May repeat or double labetalol every 20 min
to a maximum dose of 150 mg.
SBP <220, DBP <120, or Emergent antihypertensive therapy is
MAP <130 mm Hg deferred in the absence of aortic dissection,
acute myocardial infarction, severe
congestive heart failure, or hypertensive
encephalopathy
46. Intravenous Medications Considered for Control
of Elevated BP in Patients With ICH ~ AHA, 2007
46
Drug Bolus Dose Continuous Infusion Rate
Labetalol 5~20 mg every 15 min 2 mg/min (maximum 300 mg/d)
Nicardipine NA 5~15 mg/h
Esmolol 250 μg/kg IV push loading dose 25~300 μg/kg/min
Enalapril 1.25~5 mg IV push every 6 h* NA
Hydralazine 5~20 mg IV push every 30 min 1.5~5 μg/kg/min
Nipride NA 0.1~10 μg/kg/min
Nitroglycerin NA 20~400 μg/min
Broderick et al. Stroke. 2007;38.
47. Common Intravenous Anti-
Hypertensive Drugs Use in ICU
47
Sodium Nitroprusside (Nipride)
Direct vasodilation
Labetalol (Trandate)
β and α-1 blockade
Nicardipine (Perdipine)
Calcium channel blockade
48. Sodium Nitroprusside
48
Mechanism : Direct artery and vein dilation
Administration : IV infusion
Onset : Seconds
Duration : Continuous, during infusion
Advantage : Balanced ↓ of preload & afterload
Disadvantage : 1. Excessive hypotension
2. Reflex tachycardia
3. Light sensitivity
4. Potential cyanide/thiocyanate toxicity
Dosage : 0.25-10 µg/kg/min IV
49. Labetalol
49
Mechanism : β and α-1 blockade
Administration : Bolus/infusion
Onset : bolus -- 5~30 min, infusion -- 15~60 min
Duration : 2~12 hrs
Advantage : 1. Little change in HR and CO
2. Intra-A or ICU monitoring (-)
Disadvantage : 1. Orthostatic hypotension
2. Urinary retention
3. β-blocker’s contra-indications
Dosage : 10-80 mg IV q10 min up to 300 mg,
IV infusion: 0.5-2 mg/min
50. Nicardipine
50
Mechanism : Calcium blockade, endothelin-1 antagonism
Administration : Bolus/infusion
Onset : 1-5 min
Duration : 3~6 hrs
Advantage : 1. no interference with CBF, CO
2. diuretic effect
3. inhibit platelet aggregation, vasospasm
Disadvantage : 1. hypotension
2. bradycardia
Dosage : 5 mg/h IV, 2.5 mg/h q15 min, up to 15 mg/h
51. Blood Glucose within the first 48
hours after stroke
51
124 patients with ischemic stroke without previously
diagnosed diabetes had blood glucose measured at
least 4-hourly until 48 hours poststroke.
The mean glucose was 6.6 mmol/L throughout the
period of monitoring, with no change over time.
More severe stroke and glucose-lowering therapy to be
associated with higher poststroke glucose levels.
Wong et al. Neurology 2008;70:1036-41.
52. Poststroke Hyperglycemia
52
Persistent hyperglycemia
Definition: mean blood glucose >7 mmol/L (126
mg/dL) or HbA1C >6.2%
An independent determinant of infarct expansion
Associated with worse functional outcome
Baird al. Stroke. 2003;34:2208-14.
53. Intensive Insulin Therapy in the Medical ICU
53
A prospective, randomized, controlled study of 1,200
adult patients admitted to the medical ICU.
Comparison between conventional therapy (insulin
administered when blood glucose >215 mg/dL) and
intensive therapy (blood glucose control within 80-110
mg/dL)
Intensive insulin therapy significantly reduced morbidity
among all patients in the medical ICU.
Van den Berghe et al. N Engl J Med. 2006;354:449-61.
54. Respiratory Failure in Acute Stroke
Patients
54
Major causes Prognosis: poor in
Aspiration pneumonia 49-93%
Impaired central
respiratory drive Respiratory function
Neurogenic pulmonary
Risk for aspiration,
edema
airway obstruction,
Overall stroke: 10%
hypoventilation.
Ischemic stroke: 5-6% Target at O2
ICH: 26-30%
saturation > 95%
SAH: 47%
55. Fever and ischemic stroke
55
Fever correlates with increased severity of stroke,
mortality, and poorer prognosis in patients with ischemic
stroke
Differentiation of the fever causes
central, drug, infection, etc.
Hyperthermia
May accelerate cerebral metabolism and neuronal injury
A marker of severity of stroke or a consequence of large
strokes is unclear
Mild hypothermia
Improve neurological outcome
Reduce elevated ICP
60. Penumbrae of Ischemic Stroke
60
Penumbrae is the target
of any reperfusion
therapy
The fate of brain tissue
depends on
Time
Cerebral blood flow
Occluded arterial flow
Collateral blood flow
Time is brain
61. Outcomes in rt-PA-treated Patients Compared with
Controls at 3 M After Stroke
61
NINDS rt-PA Study Group. NEJM 1995;333:
62. IV Thrombolysis of Acute Ischemic
Stroke
~ Cochrane Meta-Analysis
62
death or dependency (mRS 3-6) death or dependency (mRS 3-6)
treated up to 3 h after stroke treated up to 6 h after stroke
63. Model Etimating OR for Favourable Outcome at 3
M in rt-PA-treated Patients Compared with
Controls
63
Hacke et al. Lancet 2004;363:768-774
65. Outcome in SITS-MOST and Pooled Randomised
Controlled Trials at 3 M After Stroke Onset
65
Wahlgren et al. Lancet 2007;369:275-82.
66. ECASS III : IV rt-PA 3~4.5 hours
Distribution of Scores on the Modified Rankin Scale
66
Hacke et al. N Engl J Med. 2008;359:1317-29.
67. ECASS III : IV rt-PA 3~4.5 hours
Odds Ratios for Functional End Points at Days 90 and 30 after
Treatment
67
Hacke et al. N Engl J Med. 2008;359:1317-29.
68. IV tPA for Acute Ischemic Stroke
~ Inclusion Criteria
68
Ischemic stroke with clearly defined symptom onset
Measurable deficit on the NIH Stroke Scale
Age >18 years
No evidence of intracranial blood on the brain CT scan
Timing from the symptom onset to initiate of IV rt-PA
NINDS (1995) : <3 hours
ECASS-III (2008) : <4.5 hours
69. IV tPA for Acute Ischemic Stroke
~Exclusion Criteria
69
Rapidly improving or minor stroke symptoms (NIHSS <4)
Severe stroke symptoms by clinical (e.g., NIHSS >25) or head
CT scan (> 1/3 MCA low density)
Stroke or serious head trauma within 3 mo
Major surgery within 14 d
History of intracranial hemorrhage
Systolic BP >185 mmHg or diastolic BP >110 mmHg of
treatment initiation
Aggressive BP treatment (i.e., continuous IV infusion of
antihypertensive to achieve above goal)
70. IV tPA for Acute Ischemic Stroke
~Exclusion Criteria
70
Suspected SAH despite a normal CT scan
Gastrointestinal or urinary tract hemorrhage within 21 d
Arterial puncture at a noncompressive site within 7 d
Seizure at the onset of stroke with uncertain new stroke
Use of heparin within 48 h and an elevated PTT-aPTT
Old stroke with diabetes mellitus
Use of warfarin and INR >1.7
Platelet count < 100,000/mm3
Glucose < 50 or > 400 mg/dL
71. Guidelines for IV thrombolysis
~ Care during the first 24 hours after administration of
tPA
71
Admission to a skilled care facility (ICU or acute stroke unit)
Careful monitor and management of BP
Keep SBP<185 mmHg, DBP<110 mmHg
No use of anticoagulants and antiplatelet
Central venous access and arterial punctures are restricted
Placement of an indwelling bladder catheter should be avoided
during drug infusion and for at least 30 minutes after infusion
ends
Insertion of a nasogastric tube should be avoided
Careful neurological evaluation (NIHSS at 1st, 2nd, 24th hours)
72. Risk of hemorrhagic changes
72
Marked hyperglycemia Higher NIHSS score
or DM Longer time to
CT >1/3 MCA recanalization
Increasing stroke Lower platelet counts
severity Higher glucose level at
Low platelet counts admission
~ Circulation. 2002 ~ Stroke. 2002
73. Guidelines for IV Thrombolysis
~ Bleeding Management
73
Head CT should be obtained on an emergent basis whenever
neurological worsening (NIHSS increase >4)
Any life-threatening hemorrhagic complication, including
ICH, should be followed by these sequential steps:
Discontinue ongoing infusion of thrombolytic drug
Obtain blood samples for coagulation tests
HCT, HB, PT/INR, PTT, PLT, Blood type
Obtain surgical consultation, as necessary
Consider other interventions that may be useful, such as transfusion
4 units packed RBC, 2 units FFP, 6 units
cryoprecipitate, 1 unit PLT
74. IV rt-PA in Acute Ischemic Stroke
Case Presentation
72 female, HT, CAD, AF, Sudden left hemiplegia
Initial NIHSS (1 hour): 19
NIHSS 1 week later: 8
Hemorrhagic transformation (asymptomatic) of right MCA territory
75. IV rt-PA in Acute Ischemic Stroke
Case Presentation
65 year-old female, no known major systemic diseases
Acute onset, left hemiplegia, neglect, and hemianopia.
ER arrival in 1 hour. Initial NIHSS: 15
24 hours after IV-tPA therapy: NIHSS: 3
Discharge (10 days later): NIHSS: 0, mRS: 0, Barthel index: 100
78. Intra-arterial Thrombolysis
78
Advantage
Higher recanalization rate
Symptomatic brain hemorrhage
8.3% in the carotid system
6.5% in vertebrobasilar territory
No higher than those in IV thrombolysis
Disadvantage
Ready availability of neuro-interventionalists, a stroke
team, and a stroke ICU
Additional time required to begin treatment compared to
IV thrombolysis
79. Mechanical Clot Disruption and Removal
– 121 patients with MCA infarct less than 6 h
– Some also received IA thrombolysis
– Median NIHSS was 19, 40% had baseline NIHSS >20
– 114 were treated with MERCI device
– Recanalization rate: 54%
– Symptomatic brain hemorrhage: 8%
• 5% with retriever alone, 24% with retriever and IA thrombolysis
– Mortality at 3 mo: 40%
Stroke 2005;36:1432-8.
After the microcatheter transverses the thrombus,
the first loops of the Merci Retriever are delivered
distal to the occlusion site.
The Merci Retriever is pulled back at the contact
of the thrombus, additional loops are delivered within
the thrombus, and the Merci Retriever is torqued to
ensnare the thrombus.
The balloon of the balloon guide catheter (BGC)
(insert) is inflated to control antegrade flow, and
the Merci Retriever is pulled back with the ensnared
thrombus toward the tip of the BGC where it is
aspirated.
80. Ultrasound-Enhanced Thrombolysis
80
Intra-venous rt-PA thrombolysis and continuous 2-MHz
transcranial Doppler ultrasonography <3 hours after stroke onset
Augment arterial recanalization
Increased neurological recovery
Alexandrov A et al. N Engl J Med 2004;351:2170-2178
81. Future Treatment of Acute Ischemic
Stroke
81
New thrombolytic agents
Combined IV+IA thrombolysis
IV tPA within 3 h, IA tPA 3-6 h
Combined thrombolytic agents and antiplatelets
Combined thrombolytic agents and anticoagulant
Neuroprotection agents
MRI diffusion-perfusion mismatch
3-9 h after stroke onset
Clot/thrombus retrieval
84. Antiplatelet in Acute Ischemic
Stroke
84
International Stroke Trial (IST)
19,436 patients, ASA 300 mg/day, <48 hors
Chinese Acute Stroke Trial (CAST)
21,106 patients, ASA 160 mg/day, <48 hours
Combined analysis of ASA vs placebo
Absolute risk reduction reduction of deaths or nonfatal stroke:
0.9%
Absolute risk reduction reduction of early stroke recurrence:
0.7%
Small increase in ICH or systemic hemorrhage: IST (1.1% vs
0.6%), CAST (0.8% vs 0.6%)
Stroke 2002;33:1934-42
85. Effect of various therapies for treatment
of acute ischemic stroke
Agent Trial Outcome Effect
Aspirin IST Hemorrhagic stroke at 2 wk Harm of 1 per 1000 (NS)
Death or nonfatal stroke at 2 wk Benefit of 11 per 1000 (p<0.05)
Dead or dependent at 6 mo Benefit of 13 per 1000 (p=0.07)
CAST Hemorrhagic stroke at 2 wk Harm of 2 per 1000 (NS)
Death or nonfatal stroke at 1 mo Benefit of 7 per 1000 (p=0.03)
Dead or dependent at 1 mo Benefit of 11 per 1000 (p=0.08)
Heparin IST Recurrent ischemic stroke at 2 wk Benefit of 9 per 1000 (p<0.01)
(any dose) Hemorrhagic stroke at 2 wk Harm of 8 per 1000 (p<0.0001)
Major extracranial hemorrhage Harm of 9 per 1000 (p<0.0001)
Pulmonary embolism Benefit of 3 per 1000 (p<0.05)
Death or nonfatal stroke at 2 wk Benefit of 4 per 1000 (NS)
Dead or dependent at 6 mo No effect (NS)
Heparin IST Recurrent ischemic stroke at 2 wk Benefit of 12 per 1000 (p<0.001)
5000 U bid Hemorrhagic stroke at 2 wk Harm of 3 per 1000 (p<0.05)
Major extracranial hemorrhage Harm of 2 per 1000 (NS)
Pulmonary embolism Benefit of 12 per 1000 (NS)
Death or nonfatal stroke at 2 wk Benefit of 12 per 1000 (p<0.05)
Dead or dependent at 6 mo Harm of 2 per 1000 (NS)
87. Decision-making of antithrombotic therapy for
acute ischemic stroke
87
Suspected acute No antithrombotic
ischemic stroke Head CT
Not completed therapy
or reveals ICH
Yes Eligible
Administer t-PA
for t-PA?
Aspirin intolerance
No or high risk of
recurrent stroke Clopidogrel 75 mg/day
Head CT ASA 160-300 mg or ASA 25 mg +
at 24 hours
dipyridamole 200 mg bid
Rapid
diagnostic
evaluation
Cardioembolism Large artery Small artery Arterial Cryptogenic
atherothrombosis occlusion dissection ASA 100 mg/d
Consider anticoagulation
Consider ASA, ASA 100 mg/d Consider ASA,
Warfarin, INR 2-3 If
clopidogrel, or ? anticoagulation
no contraindication,
Extreme high risk ASA+dipyridamole
Consider UFH or ? anticoagulation
LMWH