1 management of ischemic stroke somchai towanabut md. prasat neurological institute department of...
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Management of Ischemic Stroke
Somchai Towanabut MD.Somchai Towanabut MD.Prasat Neurological InstitutePrasat Neurological InstituteDepartment of Medical ServicesDepartment of Medical ServicesMinistry of Public HealthMinistry of Public Health
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Burden of stroke
STROKE: Epidemiology, Burden of disease
Global Disease Mortality 2002Global Disease Mortality 2002
World Health Organization. The World Health Report 2003: Shaping the Future. 2003.
0 5 10 15 20Mortality (millions)
Cardiovascular diseaseMalignant neoplasms
InjuriesRespiratory infections
COPD and asthmaHIV/AIDS
Perinatal conditionsDigestive diseases
Diarrhoeal diseasesTuberculosis
Childhood diseasesMalaria
Diabetes
10% of All Deaths Worldwide 10% of All Deaths Worldwide Are Due to StrokeAre Due to Stroke
HIV/AIDS=human immunodeficiency virus/acquired immunodeficiency syndrome.Adapted from World Health Organization. Global Burden of Stroke. 2005. Available at: www.cvd_atlas_16_death_from_stroke.pdf.
Other 27%
Cancer 12%
Stroke10%
Injury9%
Respiratory tractinfection 7%
HIV/AIDS 5%
Chronic obstructive pulmonary disease 5%
Perinatal causes
Diarrheal diseaseTuberculosis
3%3%4%
2%
Malaria
Coronary heart disease 13%
Stroke-Related Mortality Is Expected to Stroke-Related Mortality Is Expected to Continue to Increase Slightly Over TimeContinue to Increase Slightly Over Time
0
2
4
6
8
10
12
14
2010 2020 2030
All
Dea
ths
(%)
Men
Women
Adapted from Reinhardt E. The Atlas of Heart Disease and Stroke. UN Chronicle Online Edition. 2005. Available at: http://www.looksmarttrends.com/p/articles/mi_m1309/is_1_42/ai_n14695955.
Year
WORLD HEALTH ORGANIZATION
The WHO Stroke Surveillance System
Facts:• Stroke is to a large extent preventable, but
prevention relies on good epidemiologic data• Two-thirds of all stroke deaths occur among people
in developing countries • Stroke will be among the five most important
causes of disability in both developing and developed countries
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Burden of stroke in Thailand
STROKE: Epidemiology, Burden of disease
อั�ตราตายอั�ตราตาย/ / แสนประชากรด้�วยโรคหลอัด้เล�อัด้สมอังแสนประชากรด้�วยโรคหลอัด้เล�อัด้สมอัง ((I60- I60- I69)I69) ป�ป� - 2537 254- 2537 25477
9.64 9.85 8.98 8.516.26
1012.42
17.3219.85
29.0631.09
0
5
10
15
20
25
30
35
40
2537 2538 2539 2540 2541 2542 2543 2544 2545 2546 2547
ส�าน�กระบาด้ว�ทยา กรมควบค มโรคส�าน�กระบาด้ว�ทยา กรมควบค มโรค, http://epid.moph.go.th/, http://epid.moph.go.th/
Proportion of ill-define deathsProportion of ill-define deaths
0 0.1 0.2 0.3 0.4 0.5 0.6
Thailand
El savador
Egyp
Ecuador
Guatamala
Portugal
France
World Health Organization. the WHO Mortality Database 1999 Geneva, 1999
The top ten killers in Thailand 1999 (Males)The top ten killers in Thailand 1999 (Males)
Diseases Deaths %
1. HIV/AIDS 40,064 18
2. Traffic accidents 21,901 10
3. Stroke 18,286 8
4. Liver cancer 13,774 6
5. COPD 10,977 5
6. Ischemic heart disease 9,734 4
7. Homicide/violence 6,786 3
8. Suicides 6,671 3
9. Lung cancer 6,461 3
10. Diabetes 6,223 3
Burden of disease and injuries in Thailand: Ministry of Public Health Nov 2002 (http://203.157.19.191/index-burden.htm)
The top ten killers in Thailand 1999 (FemalesThe top ten killers in Thailand 1999 (Females))
Diseases Deaths %
1. Stroke 23,433 14
2. HIV/AIDS 16,443 10
3. Diabetes 12,235 7
4. Ischemic heart disease 8,089 5
5. Liver cancer 7,938 5
6. Lower respiratory tract infection 5,521 3
7. Traffic accident 5,330 3
8. COPD 5,132 3
9. Tuberculosis 4,413 3
10. Nephritis&Nephrosis 4,123 2
Burden of disease and injuries in Thailand: Minstry of Public Health Nov 2002 (http://203.157.19.191/index-burden.htm)
Top ten cause of disease burden (DALYS) in Thailand 1999 (male)Top ten cause of disease burden (DALYS) in Thailand 1999 (male)
Disease DALYs %
1. HIV/ AIDS 960,086 172. Traffic accident 510,909 93. Stroke 271,009 54. Liver cancer 248,083
45. Diabetes 168,594 36. Ischemic heart disease 159,188 37. COPD 156,861 38. Homocide/ violence 156,853 39. Suisides 147,988 310. Drug dependency 137,703 2 Burden of disease and injuries in Thailand:
Minstry of Public Health Nov 2002 (http://203.157.19.191/index-burden.htm)
Disease DALYs %
1. HIV/ AIDS 372,956 102. Stroke 282,509 73. Diabetes 267,155 74. Depression 145,336 45. Liver cancer 118,384
36. Osteoarthritis 117,994
37. Anemia 112,990 38. Traffic accident 108,449 39. Ischemic heart disease 102,863 310. Cataracts 96,091 2 Burden of disease and injuries in Thailand:
Minstry of Public Health Nov 2002 (http://203.157.19.191/index-burden.htm)
Top ten cause of disease burden (DALYS) in Thailand 1999 (female)Top ten cause of disease burden (DALYS) in Thailand 1999 (female)
Preliminary data from TES studyPreliminary data from TES study
• Crude prevalence (age 45- 80 years) ~ 1.9 %
• Crude incidence (age 45- 80 years) ~ not less than 261/ 100,000/ year
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Mortality 25% within a year, 15-30% permanently disable. (The most common cause of long-term disability in the elderly.)
DISEASE BURDEN
THAILAND USA WORLD
1 POPULATION 65 M. 250 M. 6,500 M.
2 NEW CASES/YEAR 100,000 – 150,000
600,000 –
750,000
20 M.
3 HEMORRHAGE 30% 15% 25%
4 ISCHEMIC STROKE
65 – 75% 85% 75%
5 MORTALITY 40,000 150,000 5.5
16
IN THAILAND
- 150,000 NEW CASES/YEAR
COST OF CARE
- 2,500 - 25,000 USD/CASE
(NOT INCLUDE THE INCOME LOSS)
SOCIAL IMPACT
50,000-80,000 PEOPLE CAN BE
SAVE(COST 125 - 200 MILLION USD/YEAR)
THE CONTINUUM OF STROKE CARE
PRIMARY PREVENTION
Stroke Unit. & Acute care
Investigation
Rehabilitation and
recovery
TIME
ACUTE STROKE
Secondary prevention
Stroke free population DEATH
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Management of Ischemic Stroke
Management of Ischemic Stroke
Management Management iischemic strokeschemic stroke• Diagnosis & differential diagnosis
• General supportive care
• Acute treatment
• Treatment of neurological complication
• Secondary prevention
Management Management iischemic strokeschemic stroke• Diagnosis & differential diagnosis
• General supportive care
• Acute treatment
• Treatment of neurological complication
• Secondary prevention
Ischemic strokeIschemic strokeDiagnosis & differential diagnosis
• Sudden onset, focal deficit, risk factors
• Brain imaging
• Cardiac test
• Blood tests ( blood sugar, BUN, Cr, electrolytes, etc.)
Brain imaging • CT should be done in all case• May be except in lacunar syndromes
- Pure motor hemiparesis- Pure sensory stroke- Motor sensory stroke- Ataxic hemiparesis- Dysarthria clumsy hand syndrome
Ischemic strokeIschemic stroke
Ischemic strokeIschemic strokeGeneral supportive care
• Airway, Breathing, Circulation
• Fever
• Hypertension
• IV fluid
• Treatment of underlying diseases
HypertensionHypertension• DBP > 140 mmHg X 2 5 min apart
Sodium nitroprusside 0.25-10 µg/ kg/ min IV
Nitroglycerine 5 mg IV and 1-4 mg/ h
• SBP > 220 mmHg, DBP 120-140 mmHg X 2 20 min apart Captopril 6.25-12.5 mg oralNitroglycerine patchHydralazine 5-10mg IV
• Do not use Nifedipine sublingual
HypertensionHypertension• SBP 185-220 mmHg or DBP 105-120 mmHg
Do not use antihypertensive drug except
- Left ventricular failure- Aortic dissection- Acute myocardial infarction- Acute renal failure- Hypertensive
encephalopathy
Management Management iischemic strokeschemic stroke• Diagnosis & differential diagnosis
• General supportive care
• Acute treatment• Treatment of neurological complication
• Secondary prevention
Ischemic strokeIschemic strokeAcute treatment • Recanalization
IV rt-PA (Intravenous thrombolysis )
IA r-proUK (FDA?)• Neuroprotective treatment• Aspirin in first 48 hours• Anticoagulant• Hemodilution• Therapeutic hypothermia• Stroke unit
Intravenous Intravenous thrombolysisthrombolysis• FDA approved 1996 based on NINDS rt- PA Stroke
Study• Treatment within 3 hours of symptom onset• Complete neurological improvement or
improvement >= 4 points on NIHSS at 24 hours
• Complete or nearly complete recovery at 3 months• Symptomatic brain hemorrhage is major risk (6.4%
VS 0.6%)• But mortality rate was similar
3 months (17% VS 20%)1 year (24% VS 28%)
Intravenous Intravenous thrombolysisthrombolysis
• Presence of brain edema, mass effect associated with hemorrhage
• NIHSS < 20, age < 75 years had greatest possibility for good outcome
• NIHSS >22 had very poor prognosis whether or not rt-PA
• Low attenuation > 1/ 3 of MCA territory less likely to had good outcome
• Good response were highest among patients with NIHSS <10normal baseline CT
Patients with ischemic stroke who Patients with ischemic stroke who could be treated with rt-PAcould be treated with rt-PA
1. Measurable neurological deficit
2. Signs should not be clearing spontaneously
3. Signs should not be minor and isolated
4. Caution should be exercised with patient with major deficits
5. Symptoms should not be suggestive of SAH
6. Onset of symptoms < 3 hours before start of treatment
Patients with ischemic stroke who Patients with ischemic stroke who could be treated with rt-PAcould be treated with rt-PA
7. No head trauma or prior stroke in previous 3 months
8. No MI in previous 3 months
9. No GI or urinary tract hemorrhage in previous 21 days
10.No major surgery in previous 14 days
11.No arterial puncture at non compressible site previous 7 days
12.No history of intracranial hemorrhage
Patients with ischemic stroke who Patients with ischemic stroke who could be treated with rt-PAcould be treated with rt-PA
13.BP not elevated (systolic < 185 and diastolic <110)
14.No evidence of active bleeding or acute trauma on examination
15.Not taking anticoagulant, or INR <= 1.5
16. If received heparin in previous 48 hours, aPTT must be normal
17.Platelet >= 100,000/ mm3
18.Blood glucose >= 50 mg%, <= 400 mg%
Patients with ischemic stroke who Patients with ischemic stroke who could be treated with rt-PAcould be treated with rt-PA
19.No seizure with postictal deficit
20.CT dose not show a multilobar infarction( hypodensity > 1/ 3 cerebral hemisphere )
21.Patient or family understand the potential risks and benefits of treatment
Regimens for iv rt-PA Regimens for iv rt-PA treatmenttreatment• Infusion 0.9 mg/ kg (max 90 mg) over 1 hour,
10 % bolus dose over 1 minute
• Admit to ICU or stroke unit
• Neurological assessments every 15 minutesduring infusion
every 30 minutes next 6 hours
every hours until 24 hours
• If severe headache, acute hypertension, nausea, vomiting, discontinue infusion, and emergency CT brain
Regimens for iv rt-PA Regimens for iv rt-PA treatmenttreatment• Measure BP every 15 minutes for first 2 hours
every 30 minutes for next 6 hoursevery 1 hours until 24 hours
• If systolic BP >=180 mmHg or diastolic BP >=105 mmHg,
increase frequency of BP measurement, administer antihypertensive drug to maintain BP at or below this levels
• If diastolic BP >140 mmHg, sodium nitroprusside 0.5mg/ kg/ min
Regimens for iv rt-PA Regimens for iv rt-PA treatmenttreatment• Delayed placement of NG tube, bladder
catheters, intra- arterial catheters
• Anticoagulants and antiplatelet agents should be delayed for 24 hours after treatment
• Staffs, CT, Neurosurgeon, Laboratory test available 24 hours
• Cryoprecipitate or fresh frozen plasma, platelet concentration
Ischemic strokeIschemic stroke
Aspirin (mg)Aspirin (mg)
EUSI * ASA † RCOP (London) ‡
Acute treatment 100-300 160-300 300
2nd prevention 50-325 50-300
* European Stroke Initiative Executive Committee( EUSI ). 2003 † American Stroke Association ( ASA ). 2003‡ Royal College of Physician of London. 2004
Stroke unitStroke unit• Stroke patient should be treated in
stroke unit (level I)• Reduced mortality and handicap
17% reduction in death7% increase in being able to
live at home8% reduction in length of stay
• Provide a co-ordinate multidisciplinary approach to treatment and care
Stroke unitStroke unit• Consists of a hospital unit or a part of
hospital unit • Provide a co-ordinate multidisciplinary care• Team should have specialist interest in
stroke management, work in co-ordinate way (through regular meeting)
• Admission, discharge criteria, care protocol, outcome data should be provided
• Programme of regular staff education and training should be provided
Stroke unitStroke unitTypical components of care• Assessment
• Early management (early mobilization, prevention of complications, treatment of metabolic derangement)
• Rehabilitation
Stroke unitStroke unit• Various forms of stroke unit exist
1. Acute stroke unit ( continuing treatment < 1 wk )
2. Comprehensive stroke unit
3. Rehabilitation stroke unit (after delay of 1-2 wks)
4. A mobile stroke team• Optimal size of stroke unit is not known• Small hospital comprehensive unit
Large hospital acute + rehabilitation
Stroke unitStroke unit• Well defined geographic area
• Multidisciplinary team approach with regular meeting
• Treatment protocol: CPG, care map, clinical pathway
• Evaluation
Ischemic strokeIschemic strokeTreatment
Effects measured in trials
IV r-tPA 10 63 ASA 3 12Stroke unit 9 56
#avoiding#avoidingdeath ordeath or
dependency/dependency/10001000
relative risk relative risk reduction (%)reduction (%)
Hankey G, Warlow C. Lancet 1999; 354: 1457- 63
AnticoagulantAnticoagulant• Routine anticoagulant is not
recommended in acute ischemic stroke (A)
• Not recommend in moderate- severe stroke (A)
• Not recommend within 24 h. in patient with r-tPA
• Used only hemorrhage has been excluded by imaging
American stroke association 2003
AnticoagulantAnticoagulantPossible remaining indications for heparin
treatment after stroke• Cardioembolic with high risk of re-embolism
(artificial valve, AF,MI with mural thrombi, left atrial thrombosis )
• Symptomatic dissection of extracranial arteries• Symptomatic extracranial and intracranial stenoses
a. Symptomatic ICS prior to operationb. Crescendo TIAs or stroke in progression
• Sinus- venous thrombosis• Coagulopathy such as protein C and S deficiency
European Stroke Initiative Executive Committee and the EUSI Writing committee 2003
AnticoagulantAnticoagulantContraindications• Large infarction• Uncontrollable arterial
hypertension• Advanced microvascular
changes in the brain
*European Stroke Initiative Executive Committee and the EUSI Writing committee 2003
Management Management iischemic strokeschemic stroke• Diagnosis & differential diagnosis
• General supportive care
• Acute treatment
• Treatment of neurological complication• Secondary prevention
Treatment of Treatment of neurological neurological complicationcomplication• Cerebral edema and increased
intracranial pressure
• Seizures
• Hemorrhagic transformation
Cerebral edema and Cerebral edema and increased intracranial increased intracranial pressurepressure• Elevated head of the bed 20- 30 degrees• Avoid “Jugular vein” compression• Consider osmotherapy
20% Mannital 0.25-0.5 g / Kg IV in 20 mins 4-6 times / dayor 10% Glycerol 250 ml IV in 30-60mins 4 time / dayor 50% Glycerol50 ml oral 4 time / dayand / or
Furosemide 1 mg / Kg IV
Cerebral edema and Cerebral edema and increased intracranial increased intracranial pressurepressure• Avoid hypotonic solution
• Avoid hypoxia, consider intubation
• Hyperventilationkeep pCO2 30-35 mmHg
• Avoid steroid
Treatment of Treatment of neurological neurological complicationcomplication• Cerebral edema and increased
intracranial pressure
• Seizures
• Hemorrhagic transformation
Management Management iischemic strokeschemic stroke• Diagnosis & differential diagnosis
• General supportive care
• Acute treatment
• Treatment of neurological complication
• Secondary prevention
Risk of Recurrent Cardiovascular Risk of Recurrent Cardiovascular Events Is HighEvents Is High
0
5
10
15
20
30 Days 1 Year 5 Years
Recurrent stroke
MI = myocardial infarction.
Adapted from Dhamoon MS et al. Presented at the 57th Annual Meeting of the American Academy of Neurology; Miami Beach, FL. April 9-16, 2005. S38.005.
MI or fatal cardiac event
Follow-up Timepoint
Pat
ien
ts W
ith
Eve
nt
(%)
(n=655)
Secondary preventionSecondary preventionAntiplatelet• There are 3 treatment options
Aspirin 50-325 mg OD
Clopidogrel 75 mg OD
Aspirin 50 mg + dipyridamole 200 mg twice daily
Secondary preventionSecondary preventionAnticoagulant• Cardioembolic stroke
INR 2-3• Should not be used in non cardioembolic
stroke
Control risk factors• HT, DM, Smoking, Hyperlipidemia, Life
style, Stress, Obesity
Secondary preventionSecondary preventionCarotid endarterectomy• CEA is indicated for patient with stenosis 70-99 %
valid only for center with perioperative complication < 6 % (level I)
• CEA may be indicated for patient with stenosis 50-69 %valid only for center with perioperative complication < 6 % (level III)
• CEA is not recommended for patient with stenosis < 50 %
Secondary preventionSecondary prevention
Extracranial-Intracranial Anastomosis• Is not benificial in preventing stroke in patient
with MCA or ICA stenosis or occlusion
Carotid Angioplasty and stenting• May be indicated for patient with
contraindication to CEA or with stenosis at surgical inaccessible sites
• May be indicated for patient with re-stenosis after CEA orstenosis following radiation
Management Management iischemic strokeschemic stroke• Diagnosis & differential diagnosis
• General supportive care
• Acute treatment
• Treatment of neurological complication
• Secondary prevention
http://www.pni.go.th
ConclusionsConclusions
• Stroke is a major health problem in Thailand
• Stroke unit, r-tPA are the major advances
• To improve the quality of care :Multidisciplinary/ network
approach CQI activities are very importance