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Management of stroke
- 1. Management of STROKE Kalkidan Gulilat , Sujin Kim (MMC 2nd yr) 1
- 2. Outline • Objective • Introduction and prevalence of stroke • Types and Risk factors of stroke • Primary and secondary prevention • Management and Rehabilitation • Summary • References 2
- 3. Objective • know the different types of stroke • Identify the signs and symptoms of stroke • Describe the pathophysiology of both types of stroke • Describe the primary and secondary prevention methods • Identify the acute management of stroke 3
- 4. Introduction – Stroke • apoplexy, cerebrovascular accident (CVA) • is a sudden interruption of the blood supply to the brain. • a medical emergency 4
- 5. The Global burden of stroke Source: http://www.world-stroke.org/advocacy/world-stroke- campaign - 2016 STROKE 15 million have a sroke 5th cause of death in 15- 59years old 2ND leading cause of death >60 years old six million die • Every 53 sec some one will have a stroke •Every 3.3 min someone will die of stroke 5
- 6. Source: World Health Statistics 2007 Trends in Global Deaths 2002-30 6
- 8. Time lost is brain lost!! 8
- 10. Embolic - cardiogenic sources such as atrial fibrillation Thrombotic - associated with atherosclerotic plaque Ischemic Stroke 10
- 12. • ‘‘mini-strokes’’ • symptoms resolve completely (<24hr) and the person returns to normal Transient Ischemic Attack (TIA) 12
- 13. Risk Factors for IS 13
- 15. Hemorrhagic Stroke • weakened regions of blood vessels rupture as a result of increased pressure • HTN, cocaine,Amphetamine 15
- 16. Risk Factor of HS Brain Aneurism Arteriovenous malformation 16
- 17. Type of Hemmorhagic stroke 17
- 18. SSx of HS •depressed level of consciousness, •higher initial blood pressure, • or worsening of symptoms after onset favor Hs“Worst headache of my life” 18
- 19. Remember • determine cause of stroke before you start treatment • emergency head CT scan • No reliable clinical findings separate ischemia from hemorrhage 19
- 20. Management of a Stroke 20
- 21. General Picture of Tx 21
- 22. Primary and secondary prevention • A- antiplatelet and anti coagulants • B- blood pressure lowering medication • C- cholesterol lowering, cessation of smoking • D- diet • E- exercise 22
- 23. Asprin • Antiplatelet agent, irreversible COX inhibitor • Prevent adhesion and aggregation of platelets • dose of 81 mg enteric-coated aspirin is usually started 23
- 24. Platelet aggregation inhibitors • Abiciximab • Clopidogrel, Ticlopidine • Dipyridamole 24
- 25. Warfarin • Oral anticoagulant • Slow onset • Narrow therapeutic index, teratogenic • Drug- drug interaction – Inducers - phenytoin, rifampin, barbiturates – Inhibitors – amiodarone,SSRI, cimetidine 25
- 26. Lipid lowering drugs • ↓LDL • Atorvastatin, Cholestyramine, Ezetimibe 26
- 27. Antihypertensive dugs • Diuretics- thiazide • ACE inhibitors – Enalapril • CCB, beta blockers 27
- 28. 28
- 29. Acute management Harrison 19th ed. 2015 pg. 2560 29
- 30. Treatment fall into 6 categories (1) Medical support (2) Intravenous thrombolysis (3) Endovascular techniques (4) Antithrombotic treatment (5) Neuroprotection (6) Stroke centers and rehabilitation Acute management for IS 30
- 31. (1) Medical support •ABC •IV fluid •Cardiac monitoring & treat arrhythmia •Antipyretics 31
- 32. • Should be normoglycemia (90-140 mg/dL) : Treat hypoglycemia(D50) & hyperglycemia(insuline) • Candidates for IV fibrinolytic treatment Plus BP >185 /110 mmHg First, labetalol, nitroglycerin paste, or IV nicardipine 32
- 33. (2)Intravenous thrombolysis • Restore blood flow to ischemic regions of the brain • “< 3H” : prevent neurologic deficits tPA – the major tx of IS 33
- 34. Exclusion Criteria for tPA Use 34
- 35. (3) Endovascular techniques Occlusions of large arteries(MCA, ICA, BA) involve a large clot volume failure to open with IV tPA alone. thrombolytics via an intra-arterial route • concentration of drug at the clot site • systemic bleeding complications 35
- 36. (4) Antithrombotic treatment Asprin • Only antiplatelet agent effective for the acute treatment of IS • Use within 48 h of stroke onset : recurrence risk and mortality Rivaroxaban • Selective inhibitor of factor Xa • “bridging anticoagulation” Abiciximab, Ancrod (clinical trials) 36
- 37. (5) Neuroprotection •NMDA receptor antagonist Dextrorphan •GABA agonist Clomethiazole •Free radical scavenger tirilazad •Hypothermia, calcium channel blockers 37
- 38. Treatment of Hemorrhagic stroke Supportive therapy (no direct therapy) 38
- 39. •Stablize vital signs •Intubation and hyperventilation •Stop any medication that could increase bleeding (e.g. warfarin, aspirin). •Evacuate the hematoma •Measure and control the pressure within the brain 39
- 40. Cont… • ICP osmotic diuretics – mannitol Loop diuretics – furosumide • Anti hypertensive : Beta blocker • Vitamin K, Fresh frozen plasma • Acetaminophen : to reduce fever and headache • Antiemetic agents : Promethazine • Anti acids : for stress ulcers 40
- 41. Rehabilitation • Mobility • Activity of daily living • Communication • Swallowing Focuses on improving • Shoulder pain • Spasticity 41
- 42. Medical Interventions • Skeletal muscle relaxants – Botulinum Toxin – regional nerve block – Diazepam, Baclofen, Dantrolene – systemic • Anti depressant 42
- 43. 43
- 44. Tx of Stroke in Ethiopia • ABC, non contrast and contrast CT then • For IS: • No rtPA (But it is on the Ethiopian Treatment Guideline) • Asprin (80mg or 300 mg) • Heparin (first loading dose 10,000 IU and then maintenance 5,000 IU) • Warfarin • For HS: • Treat the HTN • No surgery unless the hemorrhage is massive – blood enter in to the ventricles • For SAH = Nimodipine injection 1 mg/5ml Source: - Standard Treatment Guideline For General Hospitals, 2010 - MCM physicians 44
- 45. Summary • There are two types of stroke: Ischemic and Hemorragic. • The most common cause of – ischemic stroke (IS) is cerebral infraction caused by thrombi or emboli. – hemorrhagic stroke (HS) is hypertension. • The treatment goal is to restore cerebral perfusion (IS) and to decrease the hypertension (HS) • The primary and secondary preventions aimed at decreasing the risk factors. 45
- 46. Reference • Harrisons principles of internal medicine, 19th edition, 2015 • Applied Therapeutics: The Clinical Use of Drugs, 9th edition • Standard Treatment Guideline For General Hospitals, 2010 • Pharmacology: Examination & Board Review, 10th edition • Lippincott illustrative Review of pharmacology; 6th ed., 2015 • http://emedicine.medscape.com/ • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585721/1/ • http://www.medicaldaily.com/birthcontrolpillsincreaseriskischemicstr okeonlycertainwomenstudy353634 • http://www.world-stroke.org/advocacy/world-stroke-campaign 46
- 47. THANK YOU! 47
Editor's Notes
- Cerebrovascular diseases include some of the most common and devastating disorders: ischemic stroke and hemorrhagic stroke. Stroke is the second leading cause of death worldwide, causing 6.2 million deaths in 2011, and is double the rate of heart disease in China. Strokes cause ~200,000 deaths each year in the United States and are a major cause of disability. The incidence of cerebrovascular diseases increases with age, and the number of strokes is projected to increase as the elderly population grows, with a doubling in stroke deaths in the United States by 2030. A stroke, or cerebrovascular accident, is defined as an abrupt onset of a neurologic deficit that is attributable to a focal vascular cause. Thus, the definition of stroke is clinical, and laboratory studies including brain imaging are used to support the diagnosis. The clinical manifestations of stroke are highly variable
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- What is a stroke? Ischemic stroke is accountable for 80% of all strokes. During an ischemic stroke the supply of blood and oxygen to the brain is blocked. This usually happens because of blood clots in an artery to the brain or a narrowing of the arteries (carotid stenosis) blocking or impeding the blood flow. In a hemorrhagic stroke, an artery in the brain bursts. There are two main types of hemorrhagic stroke. An intracerebral hemorrhage happens when a blood vessel in the brain leaks blood into the brain. A subarachnoid hemorrhage happens when there is bleeding under the outer membranes of the brain and into the thin fluid–filled space that surrounds the brain. This type of hemorrhage can cause extensive damage to the brain and is the most lethal of all strokes
- TIAs should not be ignored - they are an important warning sign.
- 2 types of weakened regions blood vessels usually cause HS
- although depressed level of consciousness, higher initial blood pressure, or worsening of symptoms after onset favor hemorrhage, and a deficit that remits suggests ischemia
- Arrhythmia : bb (short ancting, emergency t/t) Antipyretic : hyperthermia poor prognosis after stroke increase metabolic demand of brain ->oral or rectal acetoaminophen
- hyperglycemia results in poor outcomes and increased mortality to keep the serum glucose concentration < 140 mg/dL labetalol, nitroglycerin paste, or intravenous nicardipine should be used to reduce the blood pressure below 180/105 mmHg prior to starting tPA. In other patients, the only consensus on blood pressure control is that treatment is required when pressures exceed 220/120 mmHg. hypertension is greater risk for cerebral hemorrhage, especially if a thrombolytic agent is used.
- B/C risk of bleeding
- several antiplatelet agents proven for the secondary prevention of stroke Directly inhibit free Fxa & prothrombinase activity Indirectly inhibits platelet aggregation induced by thrombin Direct : it doesn’t need a cofactor(anti-thrombin3) for activity
- Hypothermia attenuates the toxicity produced by the initial injury that would normally produce reactive oxygen species, neurotransmitters, inflammatory mediators, and apoptosis. Tetracycline antibiotics To reduce irreversible damage of neurons of ischemic
- Symptomatic
- Supportive therapy to maximize neurological func., prevention of further hemorrhagic events, complications. -> BP, pulmonary fung, fluid, elecrolytes, stop drugs inhibiting coagulation. *no direct therapy
- Neuropsychiatric compication of strke