AN UPDATE MANAGEMENT

OF ACUTE ISCHEMIC STROKE

Suroto
Blood flow in the critical penumbra passively
dependent on the mean arterial pressure
 Six mainstays
to the management of acute ischemic stroke
1) Diagnosis procedures to confirm diagnosis and provide the opportunity
to make therapeutic decision
2) Treatment and stabilisation of general conditions
3) Specific therapy, either recanalisation of a vessel occlusion or
prevention of mechanisms leading to neuronal death in the ischemic
brain (neuroprotection).
4) Prophylaxis and treatment of complications such as secondary
haemorrhage, space-occupying oedema or seizures, aspiration,
infections, decubital ulcers, deep venous thrombosis, or pulmonary
embolism.
5) Early secondary prevention (to avoid early stroke recurrence)
6) Early rehabilitation
Stroke Mimickers
 Ancillary Diagnostic Tests
• In all patients
– Brain Imaging: CT or MRI
– ECG
– Laboratory Tests
• Complete blood count and platelet count,
prothrombin time or INR, PTT
• Serum electrolytes, blood glucose
• CRP or sedimentation rate
• Hepatic and renal chemical analysis

ESO 2008
 Ancillary Diagnostic Tests
• In selected patients
– Duplex / Doppler ultrasound
– MRA or CTA
– Diffusion and perfusion MR or perfusion CT
– Echocardiography, Chest X-ray
– Pulse oximetry and arterial blood gas analysis
– Lumbar puncture
– EEG
– Toxicology screen

ESO 2008
• Supplemental oxygen should be provided to
maintain oxygen saturation >94% (Class I;
Level of Evidence C). (Revised from the
previous guideline)

• Supplemental oxygen is not recommended in

nonhypoxic patients with acute ischemic
stroke (Class III; Level of Evidence B).
(Unchanged from the previous guideline)

ASA 2013
• Airway support and ventilatory assistance are
recommended for the treatment of patients
with acute stroke who have decreased
consciousness or who have bulbar
dysfunction that causes compromise of the
airway (Class I; Level of Evidence C).
(Unchanged from the previous guideline)

ASA 2013
 Cardiac monitoring

• Cardiac monitoring is recommended to

screen for atrial fibrillation and other
potentially serious cardiac arrhythmias that
would necessitate emergency cardiac
interventions. Cardiac monitoring should be
performed for at least the first 24 hours
(Class I; Level of Evidence B). (Revised from
the previous guideline)
ASA 2013
 Acute/Subacute
Complications of Stroke

Medical
Urinary tract infection
Pneumonia
Airway obstruction Cardiac arrhythmias

Hypertension Decubitus ulcers

Dehydration Joint problems

Electrolyte disturbances Stress hyperglycemia

Pulmonary embolism Stress ulcers (gastrointestinal)

Deep venous thrombosis

 Acute/Subacute
Complications of Stroke
Neurological

Elevated intracranial pressure Herniation

Hemorrhagic transformation Seizures

Cerebral edema

Hydrocephalus

Recurrent stroke
 Hypertension During Acute Stroke

• Systolic BP > 160mmHg is seen in over 60% stroke patients

(Robinson et al, Cerebrovasc Dis., 1997)
• BP declines within first hours after stroke without medical
treatment
• Occurs in previously normotensive and hypertensive
patients
• Elevated BP: stress, full bladder, pain, preexisting HT,
physiological response to hypoxia, increased ICP.
 Antihypertensive Tx for AIS Nonthrombolytic candidates

• Blood Pressure Treatment

1. DBP >140 mm Hg Sodium nitroprusside (0.5 g/kg per

minute). Aim for 10% to 15% reduction in
DBP.

2. SBP >220, DBP 121 to 10 to 20 mg labetalol IV push over 1 to 2

140, or MAP >130 mm Hg minutes. May repeat or double labetalol
every 20 minutes to a maximum dose of 300
mg.
Or Nicardipine 5 mg/hr IV infusion as initial
dose; titrate to desired effect by increasing
2.5 mg/hr every 5 min to maximum of 15
mg/hr
Aim for a 10% to 15% reduction of blood
pressure
3. SBP <220, DBP <120, or Emergency antihypertensive therapy is
MAP <130 mm Hg deferred in the absence of aortic dissection,
acute myocardial infarction, severe congestive
heart failure, or hypertensive encephalopathy.
 Selecting Anti Hypertension

Recommendations:
• Select antihypertensive agents considering other co-existing
medical conditions
Example: asthma - do NOT use ß-blockers
HR < 60bpm - Do NOT use ß-blockers
• Do not use sublingual Nifedipine:
Has a prolonged effect and precipitous decline in BP

Source: 2008 APSS Recommendations

(Albeta Provincial Stroke Strategy)
 Glucose
• Worse outcome after stroke:
– diabetics
– acute hyperglycemia at time of infarct
• Mechanism uncertain
– increase in lactate in area of ischemia
– gene induction,
– increased number of spreading depolarizations
• Insulin is a neuroprotective
 Glucose
• Avoid any IV fluids with D5
– instruct prehospital personnel not to give D5 as
part of the “coma cocktail” to acute stroke
patients
• Check a finger stick ASAP
– treat only if low (< 50)
• Use insulin to establish euglycemia
• Evidence indicates that persistent in-hospital
hyperglycemia during the first 24 hours after stroke is
associated with worse outcomes than
normoglycemia, and thus, it is reasonable to treat
hyperglycemia to achieve blood glucose levels in a
range of 140 to 180 mg/dL and to closely monitor to
prevent hypoglycemia in patients with acute
ischemic stroke (Class IIa; Level of Evidence C).
(Revised from the previous guideline)

AHA/ASA 2013
• Hypoglycemia (blood glucose <60 mg/dL) should be
treated in patients with acute ischemic stroke (Class
I; Level of Evidence C). The goal is to achieve
normoglycemia. (Revised from the previous
guideline)

ASA 2013
 Statin
• Background
– Atorvastatin (80mg) reduces stroke recurrence by
16%
– Simvastatin (40mg) reduces risk of vascular events
in patients with prior stroke, and of stroke in
patients with other vascular disease (RR 0.76)
– ARR for statin treatment is low (NNT 112-143 for 1
year)
– Statin withdrawal at the acute stage of stroke may
be harmful
1:
ESO 2008
 Statin

• Among patients already taking statins at the time of

onset of ischemic stroke, continuation of statin
therapy during the acute period is reasonable (Class
IIa; Level of Evidence B). (New recommendation)

AHA/ASA 2013
 Aspiration and Pneumonia
• Aspiration and pneumonia
– Bacterial pneumonia is one of the most important
complications in stroke patients
– Preventive strategies
• Withhold oral feeding until demonstration of intact swallowing,
preferable using a standardized test
• Nasogastric (NG) or percutaneous enteral gastrostomy (PEG)
• Frequent changes of the patient’s position in bed and pulmonary
physical therapy
– Prophylactic administration of levofloxacin is not
superior to optimal care

1: ESO 2008
 Dysphagia

• Dysphagia and feeding

– Dysphagia occurs in up to 50% of patients with
unilateral hemiplegic stroke and is an independent
risk-factor for poor outcome
– For patients with continuing dysphagia, options for
enteral nutrition include NG or PEG feeding
– PEG does not provide better nutritional status or
improved clinical outcome, compared to NG2,3

1:
ESO 2008
 Urinary Tract Infections

– Most hospital-acquired urinary tract infections are

associated with the use of indwelling catheters
– Intermittent catheterization does not reduce the risk
of infection
– If urinary infection is diagnosed, appropriate
antibiotics should be chosen following basic medical
principles

ESO 2008
 Fever
• Fever worsens outcome: for every 1°C rise in temp, risk of
poor outcome doubles
• Greatest effect in the first 24 hours
• Sources of hyperthermia (temperature >38°C) should be
identified and treated, and antipyretic medications should be
administered to lower temperature in hyperthermic patients
with stroke (Class I; Level of Evidence C). (Unchanged from
the previous guideline)
• Treat aggressively with acetaminophen, ibuprofen, or both
• The utility of induced hypothermia for the treatment of
patients with ischemic stroke is not well established, and
further trials are recommended (Class IIb; Level of Evidence
B). (Revised from the previous guideline)
AHA/ASA 2013
 Deep Vein Thrombosis
and Pulmonal Embolism
and pulmonary embolism
• DVT and PE
– Risk might be reduced by good hydration and early
mobilization
– Low-dose LMWH reduces the incidence of both
DVT (OR 0.34) and pulmonary embolism (OR 0.36),
without a significantly increased risk of
intracerebral (OR 1.39) or extracerebral
haemorrhage (OR 1.44)
1 ESO 2008
 Elevated Intracranial Pressure
• Basic management
– Head elevation up to 30°
– Pain relief and sedation
– Osmotic agents (glycerol, mannitol, hypertonic
saline)
– Ventilatory support
– Barbiturates, hyperventilation, or THAM-buffer
– Achieve normothermia

ESO 2008
 Cerebral Edema
 Factors heralding onset of cerebral edema / mass effect :
Drowsiness ( earliest )
Progressive decline in level of consciouness
Worsening neurological deficit
Headache
Nausea & Vomiting

 Life threatening cerebral edema associated with massive

MCA infarction becomes evident b/w 2 and 5 days after
stroke onset
 Medical Tx for Cerebral Edema

• IV Mannitol : 1 g/kg intial bolus

maintainence : 0.25 – 0.5 g/kg every 4-6 hrs
target s.osmolality : 310-320 mosm/L
• Hypertonic Saline : 3 % NaCl
target : S.Na+ : 145 mmol/L
• Barbiturates
• Hyperventilation : target Pa Co2 : 30 mm Hg
• Elevated Head Position : head of bed kept at 30 degrees
 Seizures
• Occur in 5% of acute strokes
• Usually generalized tonic-clonic
• Possible causes:
severe strokes
cortical involvement
unstable tissue at risk
spreading depolarizations
hx of seizure disorder
 Seizures
• Protect patient from injury during ictus
• Maintain airway
• Benzodiazepines:
– lorazepam (1-2 mg IV)
– diazepam (5-10 mg IV)
• Phenytoin:
– 18 mg/kg loading dose, at 25-50 mg/min infusion
with cardiac monitor
• Prophylactic anticonvulsive treatment is not
beneficial
• Agitation
– Causal treatment must precede any type of
sedation or antipsychotic treatment
 Antiplatelet

• Oral administration of aspirin (initial dose is 325 mg)

within 24 to 48 hours after stroke onset is
recommended for treatment of most patients (Class
I; Level of Evidence A). (Unchanged from the previous
guideline)

AHA/ASA 2013
• The usefulness of clopidogrel for the treatment of
acute ischemic stroke is not well established (Class
IIb; Level of Evidence C). Further research testing the
usefulness of the emergency administration of
clopidogrel in the treatment of patients with acute
stroke is required. (Revised from the previous
guideline)

AHA/ASA 2013
 Anticoagulation
• Unfractionated heparin
– No formal trial available testing standard i.v. heparin
– IST showed no net benefit for s.c. heparin treated
patients because of increased risk of ICH
• Low molecular weight heparin
– No benefit on stroke outcome for low molecular
heparin (nadroparin, certoparin, tinzaparin, dalteparin)
• Heparinoid (orgaran)
– TOAST trial neutral

1. ESO 2008
 Neuroprotective agent

• At present, no pharmacological agents with putative

neuroprotective actions have demonstrated efficacy
in improving outcomes after ischemic stroke, and
therefore, other neuroprotective agents are not
recommended (Class III; Level of Evidence A).
(Revised from the previous guideline)

AHA/ASA 2013
 Summary
• Maintaining mileu of penumbra is the principal one in
acute ischemic stroke.
• Six mainstays to the management of ischemic stroke
• Guidedlines is very important to obtain optimum
outcomes in stroke pts.
• The most followed guidelines for stroke are AHA/ASA and
ESO, both which is updated every several years
• Revised recommendations in 2013 guidelines include:
oxygen saturation target, cardiac monitoring, glucose
level, statin using, antiplatelet choosing.
Questions and Comments