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MANAGEMENT OF

ACUTE ISCHEMIC
STROKE
Internal Medicine
Mini Lecture
June 2016
Objectives
• Establish the components in diagnosing a stroke
• Learn which initial imaging is available in acute stroke
• Know the management of acute ischemic strokes
Causes
• Ischemic stroke (85% of all strokes)
• Atherosclerotic disease
• Cardioembolic
• Other (cervical artery dissection, endocarditis, vasculitis,
hypercoagulable state, herniation)
• Hemorrhagic stroke (15% of all strokes)
• Intracerebral hemorrhage (ICH)
• Subarachnoid hemorrhage (SAH)
CODE STROKE
• Focused history and physical
• Including contraindications to thrombolytic therapy
• Neurologic assessment
• facial paresis, arm drift/weakness, and abnormal speech indicate
high positive predictive value for stroke
• Vitals, glucose
• Noncontrast CT Head STAT
• To distinguish intracranial hemorrhage from ischemic stroke
National Institutes of Health Stroke Scale
(NIHSS)
• Provides a structured, quantifiable neurologic examination
• NIHSS has 11 parts similar to our neurologic exam
• Score between 0 and 42
• NIHSS scores ≥20 indicate a severe stroke
• NIHSS score on admission has been correlated to stroke
outcome

• http://www.mdcalc.com/nih-stroke-scale-score-nihss/
Time is Brain
• Time of ischemic stroke symptom onset is critical
• If unknown, then time the patient was last awake and free
of stroke symptoms
Initial Imaging
• Noncontrast CT
• CT Angiography
• visualizes great vessels, occlusion, and can reconstruct circle of
Willis and extracranial cerebral arteries
• CT Perfusion
• areas of hypoattenuation correlates with ischemic brain regions

• Use of all 3 combined shows improved detection of acute


infarction when compared with noncontrast CT alone
Acute treatment
• Medically: TPA (intravenous tissue plasminogen activator)
• FDA: Within 3 hours
• AHA/ASA: Within 4.5 hours
• the earlier tPA is administered, the higher the likelihood of a
positive neurologic outcome

• Endovascular: Intra-arterial mechanical thrombectomy


• For proximal large vessel occlusion of anterior circulation
(intracranial internal carotid, middle cerebral, anterior cerebral)
• Within 6 hours of last-seen normal
• Can follow TPA administration
Main things to remember for TPA:
• Inclusion: within 4.5 hours since onset of symptoms or
last known normal

• Absolute Exclusion:
• Head trauma or stroke in last 3 months
• Previous ICH, Intracranial tumor, AVM, or aneurysm
• Recent intracranial or intraspinal surgery
• Active internal bleeding
• Bleeding diatheses (plt<100, heparin in last 48h ie abnormal PTT,
current anticoagulant use ie INR>1.7)
• More exclusion criteria
Blood pressure in ischemic stroke
• If receiving lytic therapy
• Prior to: Recommend SBP ≤185 mmHg and DBP ≤110 mmHg
• Afterwards: stabilize and maintain BP <180/105 mmHg for at least
24 hours after thrombolytic treatment.

• No thrombolytic therapy
• BP should not be treated acutely unless hypertension is extreme
SBP>220 mmHg or DBP>120 mmHg or other acute issues exist*
• When treatment is indicated, cautious lowering of blood pressure
by approximately 15% during the first 24h
Additional Medical Management
• Antithrombotic treatment
• Aspirin 160 to 325 mg within 48 hours
• High dose statin
• Atorvastatin 80mg
• Anticoagulation: only in cardioembolic stroke
• IV not recommended during first 48h after acute ischemic stroke
• Warfarin can be started for small or moderate-sized infarct after 24
hours
Neurologic symptoms
suggestive of acute
stroke

CT Head noncontrast CT Head noncontrast


shows hemorrhage no hemorrhage

Outside therapeutic
within 4.5 hours Within 6 hours
Admit to ICU, reverse window
coagulopathy,
manage BP, call
Neurosurgery

No h/o ICH, recent Refer for


Optimize secondary
stroke, head trauma, endovascular
prevention
intracranial surgery, or intervention
bleeding diatheses,
and BP<185/110

IV TPA
BP in stroke

Ischemic
stroke

TPA No TPA

BP<185/110 Permissive
prior to HTN to
giving 220/120

BP<180/105
for 24h
afterwards
Case Vignette
• A 57-year-old man is evaluated in the emergency
department 45 minutes after developing acute-onset left
arm weakness. He has a 50-pack-year smoking history.
He has no history of stroke, trauma, bleeding, cardiac
disease, or surgery. His only medications is atorvastatin.
• On physical examination, blood pressure is 168/98 mm
Hg and pulse rate is 86/min and irregular. Neurologic
examination reveals left hemineglect, an inferior left visual
field deficit, left facial weakness, mild dysarthria, and left
arm and leg drift. He scores 6 on the National Institutes of
Health Stroke Scale, indicating a moderate stroke.
Case Vignette
What is the next step?
Case Vignette
What is the next step?

Answer: CT Head without contrast


Case Vignette
Laboratory study findings shows complete blood count, a
comprehensive metabolic profile, and coagulation studies
are normal. A noncontrast CT scan of the head shows no
acute hemorrhage.

Which of the following is the most appropriate next step in


treatment?
A. High-dose aspirin
B. Insulin
C. Intravenous heparin
D. Intravenous recombinant tissue plasminogen activator
Case Vignette
Laboratory study findings shows complete blood count, a
comprehensive metabolic profile, and coagulation studies
are normal. A noncontrast CT scan of the head shows no
acute hemorrhage.

Which of the following is the most appropriate next step in


treatment?
A. High-dose aspirin
B. Insulin
C. Intravenous heparin
D. Intravenous recombinant tissue plasminogen activator
Case Vignette
An electrocardiogram (ECG) shows atrial fibrillation; an ECG obtained
1 year ago was normal. An echocardiogram shows a left ventricular
ejection fraction of 50% without valvular disease or wall motion
abnormalities. A chest radiograph and a carotid ultrasound show
normal findings.
MRI of the head shows an acute infarction in the right parietal and
frontal lobes involving half of the hemisphere.
Which of the following is the most appropriate next step in treatment?
A. Aspirin
B. Dabigatran
C. Intravenous heparin
D. Warfarin
Case Vignette
An electrocardiogram (ECG) shows atrial fibrillation; an ECG obtained
1 year ago was normal. An echocardiogram shows a left ventricular
ejection fraction of 50% without valvular disease or wall motion
abnormalities. A chest radiograph and a carotid ultrasound show
normal findings.
MRI of the head shows an acute infarction in the right parietal and
frontal lobes involving half of the hemisphere.
Which of the following is the most appropriate next step in treatment?
A. Aspirin
B. Dabigatran
C. Intravenous heparin
D. Warfarin
Summary
• Diagnosis of stroke involves focused history and physical,
NIHSS, and CT head noncontrast
• CT noncon, CTA and CT perfusion combined improves
the detection of an acute stroke
• TPA within 4.5 hours, thrombectomy within 6 hours
• Aspirin should be given within 48 hours
• Permissive hypertension to 220/120 is indicated in non-
TPA ischemic strokes only
References
• Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A
Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association. Jauch et al., on behalf of the American
Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on
Peripheral Vascular Disease, and Council on Clinical Cardiology Stroke.
2013;44:870-947
• 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early
Management of Patients With Acute Ischemic Stroke Regarding Endovascular
Treatment: A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association. Powers et al. on behalf of the American
Heart Association Stroke Council Stroke. 2015
• Collaborative meta-analysis of randomised trials of antiplatelet therapy for
prevention of death, myocardial infarction, and stroke in high risk patients.
Antithrombotic Trialists' Collaboration. BMJ. 2002 January 12; 324(7329): 71–86.
• Uptodate:
• Initial assessment and management of acute stroke (http://www.uptodate.com/contents/initial-
assessment-and-management-of-acute-stroke)
• Neuroimaging of acute ischemic stroke (http://www.uptodate.com/contents/neuroimaging-of-
acute-ischemic-stroke)
• Antithrombotic treatment of acute ischemic stroke and transient ischemic attack
(http://www.uptodate.com/contents/antithrombotic-treatment-of-acute-ischemic-stroke-and-
transient-ischemic-attack)