1. Update on Acute Ischemic
Stroke Management
1/15/2014
Amy Lynn Teleron, MD
Assistant Professor, Internal Medicine
UVM College of Medicine
PCIM Hospitalist
2. Review management of acute ischemic stroke
Discuss updates from the 2013 Stroke Guidelines
by the American Stroke Association (ASA) /
American Heart Association( AHA)
Case presentation
Importance
◦ Availability of neurologists/stroke code teams
◦ Responsibility of primary care physicians/hospitalists
◦ Boards
3. Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013
4. 65yo female arrives at ED 12:20pm
CC: Vaginal bleeding worsening x 3 days
HPI:
◦ Never established with physician until last month
◦ Fist-size clots x 2 months
◦ No pelvic exam > 30 years
◦ + fatigue
5. New dx of HTN at first PCP visit 1 month prior
Patient wanted to try diet first as treatment
◦ SBP at home 140-150 per patient
In triage
◦ BP 227/110, Hb 10.2 (baseline 11)
◦ Clonidine 0.2mg PO x 1 given at 15:08
In ER waiting room
◦ N/V and syncopal episode - given Zofran 15:50
6.
Patient transferred urgently to ER bed
◦ SBP verbally reported as decreased to 80/40
Given NS 1L bolus 17:00
◦ New symptoms after syncope & decreased BP included
Right facial droop
Right upper and lower extremity weakness
◦ Examination done by ED physician
7.
V/S from time of triage
◦ T 36.9, P 98, R 18, BP 227/110, O2 Sat 99%RA,
◦ BMI 28.9
V/S on M/S exam
◦ T 36, P 61 (NSR), R 15, BP 142/55, O2 Sat 99% RA
Gen: AAOx3, NAD
Neuro: Droop on right side of mouth only
◦ Slow to respond but appropriate and following commands
◦ CN 2-12 otherwise grossly intact
◦ Neuro exam:
5/5 strength, 2+ DTR throughout, downgoing plantar B/L
8.
Transfer to step-down unit at 02:00
◦ Patient is AAO x 3 throughout early am
◦ Completely resolved right sided weakness <1.5 hrs
Initial bedside swallow evaluation failed in ER
Repeated on floor after clinical improvement – passed
Patient refusing aspirin PR and PO
◦ Neuro checks q2 hours
◦ Pelvic/Transvaginal US for vaginal bleed put on hold
13.
Past: Neurological dysfunction up to 24 hours with
complete clinical reversal of symptoms.
Arbitrary time threshold too broad
30-50% of classically defined TIA had brain injury on MRI
DWI
Impossible to define a time cutoff to distinguish if a
sx ischemic event will result in brain injury
◦ However, typical duration is <1 or 2 hours
Easton et al. Definition and Evaluation of Transient Ischemic Attack.
Stroke, 2009;40:2276-2293.
14.
ASA/AHA 2009– endorsed revised definition
◦ A transient episode of neurological dysfunction
◦ Caused by focal brain, spinal cord or retinal ischemia
◦ Without acute infarction
◦
Definition is now tissue based, like diagnoses of
cancer & MI
Like MI, dx is inferred from clinical, laboratory and
imaging data
Can sometimes be clinical Dx because it may not
be identifiable on imaging
◦ Ie. Small lateral medullary infarcts
Easton et al. Definition and Evaluation of Transient Ischemic Attack.
Stroke, 2009;40:2276-2293.
15. Sacco, RL et al. An updated definition of stroke
for the 21st century. Stroke.2013; 44: 2064-2089
16. Sacco, RL et al. An updated definition of stroke
for the 21st century. Stroke.2013; 44: 2064-2089
17.
Patients with transient ischemic neurological symptoms
should undergo neuro-imaging evaluation within 24
hours of symptom onset or as soon as possible in
patients with delayed presentations. MRI, including DWI,
is the preferred brain diagnostic imaging modality. If MRI
is not available, head CT should be performed
(Class I; Level of Evidence B).
(Unchanged from the 2009 TIA scientific statement6)
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
18.
Noninvasive imaging of the cervical vessels should be performed
routinely as part of the evaluation of patients with suspected TIAs
◦ (Class I; Level of Evidence A).
◦ (Unchanged from the 2009 TIA scientific statement)
Noninvasive imaging by means of CTA or MRA of the intracranial
vasculature is recommended to exclude the presence of proximal
intracranial stenosis and/or occlusion and should be obtained when
knowledge of intracranial steno-occlusive disease will alter
management.
◦ (Class I; Level of Evidence A)
◦ (Revised from the 2009 TIA scientific statement6)
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013
20.
Johnston et al. Lancet 2007
◦ Scoring system to help physicians make the decision to
admit patient, ie. Treat a TIA as an emergency
In order to optimize stroke prevention
◦ Modified two scoring systems into new unified system
California and ABCD scores
Incorporates elements of both
21. Feature
Points
Age >/= 60 years
+1
BP >/= 140/90
+1
Clinical Features
Unilateral weakness
Speech impairment without weakness
Duration
>/= 60 minutes
10-59 minutes
Diabetes Mellitus
+2
+1
+2
+1
+1
Johnston et al. Lancet 2007
22. Risk
of stroke at 2 days
◦ Low (0 – 3 points) = 1%
◦ Moderate (4 – 5 points) = 4.1%
◦ High (6 – 7 points) = 8.1%
23. Feature
Points
Age >/= 60 years
+1
BP >/= 140/90
+1
Clinical Features
Unilateral weakness
Speech impairment without weakness
Duration
>/= 60 minutes
10-59 minutes
Diabetes Mellitus
+2
+1
+2
+1
+1
Johnston et al. Lancet 2007
24. Risk
of stroke at 2 days
◦ Low (0 – 3 points) = 1%
◦ Moderate (4 – 5 points) = 4.1%
◦ High (6 – 7 points) = 8.1%
25.
At 10:00 patient given labetalol 10mg IV for BP 215/98
Order written PRN for SBP > 190
At 12:30, M/S resident called d/t patient confusion &
R-sided weakness
◦
◦
◦
◦
BP documented as 106/53 at that time, Patient in Afib rate 80’s
Labetalol order d/c’d
Patient refusing more medications
Neuro exam documented but no NIHSS documented
SBP rises to 180-190’s and remains stable
Stat CT head without contrast ordered
26.
27.
28.
Should you give rtPA to the patient?
How do you manage the blood pressure in acute
stroke?
Should you start a heparin gtt for new atrial
fibrillation?
29. Should
this patient receive IV rtPA??
rtPA = recombinant tissue plasminogen activator
30. Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
31. Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
32. Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
33.
Frank hypodensity on NECT may increase the risk
of hemorrhage with fibrinolysis and should be
considered in treatment decisions.
If frank hypodensity involves more than one third
of the MCA territory, intravenous rtPA treatment
should be withheld
◦ (Class III; Level of Evidence A).
◦ (Revised from the 2009 imaging scientific statement 9)
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
34.
This patient had witnessed onset of:
◦ Right facial droop
◦ Right sided weakness
◦ (Within the window for administration)
However:
◦ Hypodensity on CT head involved more than one third of
the MCA territory
◦ Uncontrolled BP (patient refusing meds)
Therefore, patient NOT a candidate for rtPA
35.
Recommendations to lower BP in candidates for acute
reperfusion therapy (Updated AHA/ASA 2013)
If SBP >185 or DBP >110
◦ Labetalol 10 to 20 mg IV over 1 to 2 minutes
May repeat x 1
◦ OR Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5- to
15-minute intervals, maximum dose 15 mg/h; when desired blood
pressure attained, adjust to maintain BP goals
◦ Other agents (hydralazine, enalaprilat, etc) may be considered
If BP is not maintained at or below 185/110 mm Hg, do not
administer rtPA
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
36.
If medications are given to lower blood pressure,
the clinician should be sure that the blood
pressure is stabilized at the lower level before
treating with IV rtPA and maintained below
180/105 mm Hg for at least the first 24 hours after
IV rtPA treatment.
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
37.
Maintain BP at or below 180/105 mm Hg:
◦ Monitor BP q15 minutes x 2 hrs from the start of rtPA
therapy, then q30 minutes x 6 hrs, then q1 hr x 16 hrs
If systolic BP >180–230 mm Hg or diastolic BP
>105–120 mm Hg:
◦ Labetalol 10 mg IV followed by continuous IV infusion 2–
8 mg/min; or
◦ Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5
mg/h every 5–15 minutes, maximum 15 mg/h
If BP not controlled or diastolic BP >140 mm Hg,
consider IV sodium nitroprusside
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
38. Symptomatic Intracerebral Bleeding
Systemic bleeding
Myocardial rupture if fibrinolytics are given within a
few days of acute myocardial infarction,
Reactions such as anaphylaxis or angioedema
(1.3-5.1%)
39.
40.
If hypotension present, correct to limit further
cellular damage
◦ Hypotension = Blood pressure that is lower during acute
ischemic stroke than the premorbid pressure
Appropriate tx in acute stroke is still CONTROVERSIAL
◦ Ongoing study: CHHIPS in J Hypertens
Controlling Hypertension and Hypotension Immediately Post-Stroke
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013
41.
AHA/ASA Guidelines 2013
◦ “Reasonable goal”
Lower BP by 15% on the first day (Class I)
(changed from 15-25% from 2007 Guidelines)
◦ Consensus is to treat only if SBP >220 or DBP >120
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013
42.
Data inconclusive and conflicting
◦ An ideal blood pressure range has not yet been
scientifically determined.
Initiating antihypertensive therapy within 24 hours
is relatively safe
Reasonable to restart BP meds after 24 hours
Both Class IIa indications (new in 2013)
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013
43.
44.
Schrader et al. in Stroke 2003 (noted in 2007 ASA/AHA Guidelines)
◦ Day 2: Medications increased if SBP > 160 or DBP > 100
◦ Day 7: Added antihypertensives if persistent high BP’s
For every 10mmHg increase > SBP 180,
◦ Risk of neuro deterioration increases by 40%
◦ Risk of poor outcome increases by 23%
45.
Should you start a heparin gtt on this patient since
she now has new Afib (rate of 80’s) in the setting
of acute stroke?
46.
What about stroke in Atrial Fibrillation?
Urgent anticoagulation, with the goal of preventing early
recurrent stroke, halting neurological worsening, or
improving outcomes after acute ischemic stroke, is not
recommended for treatment of patients with acute
ischemic stroke
(Class III; Level of Evidence A).
(Unchanged from the previous guideline13)
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
47. Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013
49. Absence of normal flow to a large part of the L
frontal and frontoparietal lobe and left temporal
lobe due to what appears to be an occlusion of the
L-ICA
There is very little cross filling from an ACOM
The Left Anterior communicating artery does not
appear to provide cross filling from the left A2
segment but I do not see strong A1 segment or
enough A1 segment to replace the left MCA.
Basilar system in tact.
50.
51.
52.
65 yo WF presented with vaginal bleeding and
hypertensive urgency SBP 220’s
◦ Likely acute carotid occlusion causing increased BP
BP acutely dropped TIA
◦ Syncope and R-sided facial droop & weakness
Symptoms resolved within 2 hours
BP decreased in hospital Acute ischemic stroke
◦ Combined L-ICA occlusion & incomplete Circle of Willis
53.
The usefulness of emergent or urgent CEA when clinical indicators
or brain imaging suggests a small infarct core with large territory at
risk (eg, penumbra), compromised by inadequate flow from a critical carotid stenosis or occlusion, or in the case of acute neurological
deficit after CEA, in which acute thrombosis of the surgical site is
suspected, is not well established
(Class IIb; Level of Evidence B).
(New recommendation)
In patients with unstable neurological status (either stroke-inevolution or crescendo TIA), the efficacy of emergent or urgent CEA
is not well established
(Class IIb; Level of Evidence B).
(New recommendation)
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
54.
BP control within 24 hours of acute ischemic
stroke
◦ Decrease BP 15% only
◦ PRN BP med only if SBP >220 or DBP > 120
NIH Stroke Scale (NIHSS)
◦ Ensures that the major components of a neurological
examination are performed in a timely and uniform
fashion.
◦ Helps select patients for various interventions
◦ Facilitates communication
55.
56.
Other admission orders
◦ Aspirin (initial dose 325mg) within 24 – 48 hours
Not recommended within 24 hours of IV fibrinolysis
Data do not provide solid evidence about the utility of other
antiplatelet agents (ASA/AHA 2013 Stroke Guidelines)
? Dipyramidole + aspirin superior to aspirin alone (Lancet 2006)
? Plavix (NEJM 2008)
New studies with antiplatelets cont to be underway
◦ Telemetry for minimum 24 hours (Class I)
◦ Keep 02 Sats >94% (Class I)
◦ Goal blood glucose 140-180 (Class IIa)
57.
What about stroke in Atrial Fibrillation?
Urgent anticoagulation, with the goal of preventing early
recurrent stroke, halting neurological worsening, or
improving outcomes after acute ischemic stroke, is not
recommended for treatment of patients with acute
ischemic stroke
(Class III; Level of Evidence A).
(Unchanged from the previous guideline13)
Jauch, EC et al. Guidelines for the Early Management
of Patients With Acute Ischemic Stroke. Stroke 2013.
58.
Highlights on IV rtPA administration
◦ Window: 3 to 4.5 hours
◦ Recall indications/contraindications (see tables prior)
Intra-arterial rtPA administration
◦ Can be given in major ischemic strokes <6 hours caused
by occlusions of MCA
59. ◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
tPA considered*
Screen for dysphagia
Deep vein thrombosis prophylaxis*
Lipid profile within 48 hrs of hospitalization
Smoking cessation
Education about stroke*
Plan for rehabilitation considered*
Antithrombotic medications started within 48 hours*
Antithrombotic medications prescribed at discharge*
Anticoagulants prescribed to patients with A fib*
Discharged on statin medication*
(Or documentation why meds not prescribed)
*Those included in “Stroke Core Measure Set”
http://www.jointcommission.org/assets/1/6/Stroke.pdf
60.
Large vessel occlusion accounted for 46% of acute
stroke
Presence of large vessel occlusion was associated with
a 4.5-fold increased odds of death
Angiographic status of vessels is informative at the time
of hospital presentation.
◦ Wide variation in NIHSS scale scores despite identical
vascular segment occlusion
◦ May improve decision-making , ie. endovascular
intervention
Smith et al. Stroke and TIA Significance of Large Vessel Intracranial
Occlusion Causing Acute Ischemic. Stroke 2009.
STOP Stroke Study
61.
Future possibilities – studies underway
◦ Emergent CEA
Various studies: 21-42% mortality
◦ Emergent endovascular interventions
◦ Urgent open embolectomy for cardioembolic occlusion
Ie. in patients with atrial fibrillation
