Management of Stroke June 2015

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Prof. Kanu BalaMBBS, PhD [USTC], PhD [DU], FRCP [Dublin], FRCP [Edinburgh]

Professor of Medicine

Gonoshasthaya Samajvittik Medical College

Savar, Dhaka, Bangladesh

Management of Stroke

Savar GK Hospital

About 20% of the patients admitted in the medicine wardAcute stroke patients or receiving physiotherapy

What is a Stroke?

• Stroke is classically characterized as a focal neurological deficit for more than 24 hours attributed to an acute focal injury of central nervous system by a vascular cause

What is TIA & Silent Stroke?

• Transient Ischaemic Attack [TIA] is stroke symptoms and signs that resolve within 24 hours

• Silent Stroke is any brain changes identified on neuroimaging or neuropathological examination without any history of stroke or TIA

Who Defined Stroke First?

• Hippocrates (460 to 370 BC) used the term ‘Apoplexy’ to describe very acute non-traumatic brain injuries

• The word ‘Stroke’ was first introduced in 1689 by ‘William Cole’

What is Stroke’s Impact?

• Stroke is the third most frequent cause of death after cancer & coronary artery disease, accounting for 6.4 million deaths (12% in 2013)

• About 3.3 million deaths resulted from ischemic stroke while 3.2 million deaths resulted from hemorrhagic stroke

• In 2010 approximately 17 million people had a stroke (180-300 per 100,000 population annually) and 33 million people had previously had a stroke and were still alive

What is Stroke’s Impact? – contd.

• Between 1990 and 2010 the strokes decreased by 10% in the developed world and increased by 10% in the developing world

• One-fifth of the patients with an acute stroke die within a month, half of those survived have physical disability

• About half of people who have had a stroke live less than one year

• South Asians are at high risk for stroke, accounting for 40% of global stroke deaths

What are the Types of Stroke?

• Ischaemic Stroke [85%]: – Caused by a blockage in the blood vessel of the brain

• Haemorrhagic Stroke [15%]: – Caused by rupture of a weakened blood vessel due to

aneurysm or arteriovenous malformation

What Causes Ischaemic Stroke?

• Thrombus: Formed within the vessel– Thrombosis in situ 20%

• Embolus: A travelling particle – From carotid artery & aortic arch 20%– From heart 20%

What Causes Haemorrhagic Stroke?

• Haemorrhage due to rupture of weakened blood vessel due to aneurysm or arteriovenous malformation :– Brain Parenchyma 10%– Subarachnoid Space 5%

What are the Risk Factors?

What are the Risk Factors? Not Modifiable:

• Age • Sex [Male > Female]• Race [Afro-Caribbean >

Asian > European]• Previous vascular events

– Myocardial infarction– Stroke– Peripheral vascular

• Heredity

Modifiable:

• Blood pressure• Cigerette smoking• Hyperlipidaemia• Heart disease

– Atrial fibrillation– CCF– Infective endocarditis

• Diabetes mellitus• Excessive alcohol intake• Oestrogen drugs• Polycythaemia

What are the Effects of Stroke?

How Stroke Can Be Suspected?

What Are The Stroke Warning Signs?

What Are The Clinical Examinations?

What is the Differential Diagnosis?

Structural Stroke Mimic

• Primary cerebral tumours• Metastatic tumours• Subdural haematoma• Cerebral abscess• Peripheral nerve lesions• Demyelination

Functional Stroke Mimic

• Todd’s paresis• Hypoglycaemia• Migrainous aura• Focal seizures• Meniere’s disease• Conversion disorder• Encephalitis

Investigations: Neuroimaging

Investigations: Vascular Imaging

Investigations: Risk Factors

Diagnostic question Investigation

Is there any cardiac source of embolism ?

ECG24 hour ECGElectrocardiogram

What are the risk factors? Chest X-rayFull blood count, Hb%, ESRLipid profileBlood glucoseBUN, CreatinineElectrolytes Prothrombin time, PTT

Is it subarachnoid haemorrhage? Lumber puncture

Is there an unusual cause? Serum protein electrophoresisClotting/ thrombophilia Syphilis screening

What Is the First Thing To Do?

• Early admission to a specialized stroke unit facilitates coordinated care from a multidisciplinary team

• Reduces both mortality and residual disability amongst the survivors

Pharmacological & Surgical Treatments

Thrombolysis Intravenous thrombolysis with recombinant tissue plasminogen activator [rt-PA]Given within 4.5 hours of symptom onset

Aspirin 300 mg daily started immediately, then 75 mg/dayWhen rt-PA given, withheld for at least 24 hours

Heparin Heparin should not be used routinelyIntracranial haemorrhage must be excluded

Coagulation abnormalities

Coagulation abnormalities should be reversedUse of clotting factors is not useful

Surgery Carotid endarterectomy is most effective with patients with severe stenosis [70-99%]Within first 2 weeks of the TIACarotid angioplasty and stenting not so useful

What is the Role of Treatment?

Treatment Target group Eligible for treatment

Number treat to prevent 1 death

Aspirin Acute ischaemic stroke 90% 80

Thrombolysis with tissue plasminogen activator [rt-PA]

Acute ischaemic strokeWithin 3 hoursWithin 3-4.5 hours

10%10%

Hemicraniectomy Large cerebral infarction <1% 2

Stroke unit care Acute care 80% 20

What Are The Supportive Cares?

• Airway: Examine airway and perform bedside swallow screening and keep patient nothing by mouth if swallowing unsafe and aspiration occurs

• Breathing: Check respiration and oxygen saturation and give oxygen if saturation <95%

• Circulation: Check peripheral perfusion, pulse and blood pressure and treat abnormalities with fluid replacement, anti-arrhythmics and inotropic drugs as appropriate

• Hydration: If signs of dehydration, give fluids parenterally or by nasogastric tube

• Nutrition: Assess nutritional status and provide nutritional supplements if necessary. If dysphagia persists for >48 hours, start feeding via nasogastric tube

• Medication: If patient is dysphagic, consider alternative routes for essential medications

• Blood Pressure: unless there is heart or renal failure, evidence of hypertensive encephalopathy or aortic dissection, do not lower blood pressure in first week

• Blood Glucose: Check blood glucose and treat when levels are >11.1 mmol/L [by insulin infusion or glucose/potassium/insulin]. monitor closely to avoid hypoglycaemia

• Temperature: If pyretic, investigate and treat underlying cause. Control with antipyretics, as raised brain temperature may increase infarct volume

• Pressure Areas: Reduce risk of skin breakdown by treating infection, maintaining nutrition, providing pressure relieving mattress, and turning immobile patients regularly

• Retention, Constipation, & Incontinence: Check for constipation and urinary retention; treat appropriately. Avoid urinary catheterization unless patient is in acute urinary retention or incontinence is threatening pressure areas

• Mobilization: Avoid bed rest & early mobilization is helpful for early recovery

What are the Complications of Stroke?

Complications Prevention Treatment

Chest infection Nurse semi-erect, avoid aspiration, nasogastric tube

Antibiotics, physiotherapy

Epileptic seizures Maintain cerebral oxygenation avoid metabolic disturbances

Anticonvulsants

DVT/ Pulmonary embolism

Hydration, early mobilization, anti-embolism stockings, heparin

Anticoagulats

Painful shoulder Avoid traction injury, support, physiotherapy

Physiotherapy, local corticosteroid inj.

Pressure sores Frequent turning, monitor pressure, avoid urine injury

Nursing care, mattress

Urinary infection Avoid catheterization antibiotics

Constipation Appropriate aperients, diet Appropriate aperients

Depression/ anxiety Maintain positive attitude, provide information

antidepressants

What is the Risk of Further Stroke?

ISCHAEMIC STROKE/ TIA

• 5-10% within 1st week• 15% in the first year• 5% per year thereafter

HAEMORRHAGIC STR.

• 5-10% within 1st week• 15% in the first year• 5% per year thereafter

Secondary Prevention of StrokeINTERVENTIONS

Antiplatelet drugs • Aspirin 300 mg at once, then 75 mg daily• Clopidogrel 75 mg daily if aspirin intolerant

Lower cholesterol • If total cholesterol > 135 mg/dL• Simvastatin 40 mg nocte, after checking LFT

Lower BP • If BP > 130/70 mmHg 1-2 weeks after onset• Thiazide diuretics • ACE inhibitors or other agents

Cartotid endarterectomy • If > 70 % stenosis on symptomatic side

Warfarin • Atrial fibrillation

Lifestyle • Smoking cessation• Lower salt intake• Lower fat intake• Lower excess alcohol intake• Increase exercise• Lose excess weight

Stroke Rehabilitation Team

• Consultant physicians• Nurses• Physiotherapists• Occupational therapists• Speech therapists• Clinical psychologists• Rehabilitation assistants• Social workers

Stroke Rehabilitation

Conclusion

• Supportive care is the cornerstone of stroke management

Thank YouThank You

Poppy Bala25 November 2013

Dr. Poppy Bala

Management of Stroke June 2015

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