Department of neurology uk 2 lf ale tomek december 2010
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Department of Neurology, UK 2. LF Aleš Tomek December 2010. stroke. Evidence b ased therapy of stroke. ČNS ČLS JEP – Czech guidelines www.cmp.cz ESO Guidelines ischemic 2009, ICH 2006 www.eso - stroke.org AHA-ASA Guidelines ischemic 2009, SAH 2009, ICH 2010 www.americanheart.org.

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Department of neurology uk 2 lf ale tomek december 2010

Department of Neurology, UK 2. LF

Aleš Tomek

December 2010

stroke


Evidence b ased therapy of stroke
Evidence basedtherapyofstroke

ČNS ČLS JEP – Czech guidelines

www.cmp.cz

ESO Guidelines

ischemic2009, ICH 2006

www.eso-stroke.org

AHA-ASA Guidelines

ischemic2009, SAH 2009, ICH 2010

www.americanheart.org


Reading
Reading

  • Tomek et al. Neurointenzivní péče 2012

  • Školoudík et al. Neurosonologie 2003

  • Uchino et al. Acute stroke care 2011

  • Mohr, Choi, Grotta et al. Stroke 2008

  • Caplan’s Stroke, 4th ed. 2009



Epidemiology in czech rep
Epidemiology in Czech Rep.

3rd most frequent cause of death

11 640 2007

11 685 2008

12 192 2009

11 567 2010

32 deaths per day

(Deaths – total in 2010 - 106 844 persons)

www.uzis.cz 9/2012


Hospitalizations
Hospitalizations

Hospitalisations I60-69

57 484 (2010)

853 078 days

www.uzis.cz


Hlavn p znaky fast face arm speech test 1x
Hlavní příznaky - FAST (Face Arm Speech Test) 1x


Clinical signs minor 2x
Clinicalsigns – minor (2x)

Acute

  • Coma

  • Hemihypesthesia

  • Dysarthria

  • Hemianopia

  • Diplopia

  • Headache

  • Meningealsigns

  • Vertigowithnausea


Clinical examination and signs
Clinical examination and signs

FAST

FaceArmSpeechTest

Internal

  • Esp. cardio-pulmonary

    Neurological

  • Consciousness

  • Speech, mnestic and cognitive, neglect

  • Cranial nerves

  • Motoric and sensory


Stroke scales
Stroke scales

  • COMA

    • GLASGOW COMA

    • FOUR SCORE

  • ACUTE ISCHEMIC

    • NIHSS

  • ICH

    • ICH SCORE

  • SAH

    • HUNT HESS

    • WFNS (WORLD FEDERATION OF NEUROSURGEONS)

  • OUTCOME

    • MODIFIED RANKIN SCALE


Prehospital care
Prehospital care

  • ABC

  • Correct diagnosis or suspicion of stroke (FAST)

  • Do not lower blood pressure (220/120)

  • Immediate transportation to stroke center


Situace u n s 2013
Situace u nás2013

  • Tvorba sítě iktových center (Věstník 2 a 8/2010 MZd ČR), start 1.1.2011

  • KCC (komplexní cerebrovaskulární centrum)

    • 10 center

  • IC (iktové centrum)

    • 1. vlna - 23 center

    • 2. vlna – 12 center


Komplexní cerebrovaskulární

a iktová centra

Kraj Praha

I. Nemocnice Na Homolce

I. ÚVN

II. FN Motol II. VFN

II. FNKV + FTNsP

Ústecký kraj

I. MNUL

II. Chomutov

II. Děčín

II. Teplice

Královéhradecký kraj

I. FN Hradec Králové

II. Obl.nem.Trutnov

Liberecký kraj

I. KN Liberec

II. Česká Lípa

Pardubický kraj

II. Pardubice

II. Litomyšl

Moravskoslezský kraj

I. FN OstravaII. MN Ostrava

II. Vítkovická nemocnice

II. Krnov

II. Třinec

II. Karviná

Olomoucký kraj

I. FN Olomouc

Karlovarský kraj

II. Nem. Sokolov

Středočeský kraj

II. Kolín

II. Kladno

Zlínský kraj

II. Krajská nem.

T. Bati Zlín

Plzeňský kraj

I. FN Plzeň

Kraj Vysočina

II. Nemocnice Jihlava

Jihomoravský kraj

I. FNUSA + FN Brno

II. Břeclav

II. Vyškov

Jihočeský kraj

I. Nemocnice Č. Budějovice

II. Nemocnice Písek

Soláň 13. - 14. 1. 2012


Komplexní cerebrovaskulární

a iktová centra

Ústecký kraj

Ústí n. Labem

Chomutov

Děčín

Teplice

Nem. Litoměřice

Hl. m. Praha

Nemocnice Na Homolce

ÚVN

FN Motol VFN

FNKV + FTNsP

Královéhradecký kraj

FN Hradec Králové

Obl.nem.Trutnov

Obl. Nem. Náchod

Liberecký kraj

KN Liberec

Česká Lípa

Pardubický kraj

Pardubice

Litomyšl

Moravskoslezský kraj

FN Ostrava MN Ostrava

Vítkovická nemocnice

Krnov

Třinec

Karviná

Olomoucký kraj

IFN Olomouc

Prostějov

Karlovarský kraj

Nem. Sokolov

Nem. Karlovy Vary

Středočeský kraj

Kolín

Kladno

Mladá Boleslav

Příbram

Zlínský kraj

Zlín (T. Bati)

Uh. Hradiště

Plzeňský kraj

I. FN Plzeň

Jihomoravský kraj

FNUSA + FN Brno

Břeclav

Znojmo

Vyškov

Kraj Vysočina

Jihlava

Nové Město na Moravě

Jihočeský kraj

I. Nemocnice Č. Budějovice

II. Nemocnice Písek

Soláň 13. - 14. 1. 2012


Tia x ischemic stroke
TIA x ischemic stroke

  • TIA x RIND x completed stroke

  • 35% of TIA’s have DWI MR lesions

  • Same mortality and morbidity as minor stroke

  • AHA-ASA 2009 new definition of TIA:

    = tissue definition

    • No signs of acute MR or CT lesion


Stroke imaging ct
Stroke imaging - CT

ischemie

hemorhagie

  • Gold standard

  • ischemic / hemorhagic

  • + availability, speed, senzitivity for hemorhagy,...

  • - negative first 3-6 hours, poor for brainstem


Early ct diagnostics of stroke
Early CT diagnostics of stroke

Native CT – markers of early ischaemia:

Early hypodenzity

Lower difference between gray x white matter

Lost gyrification (SA space)

Dense artery sign (MCA)


Mr diagnostics of stroke
MR diagnostics of stroke

  • More senzitive for smaller strokes and for brainstem

  • Early vs. Old ischemic stroke (DWI)

  • Availability and duration of exam

akutní ischemie

ischemie

ischemie


Penumbra concept
Penumbra concept

CBF < 10 ml/100g/min (< 20%)

Cytotoxic oedema + neuronal cell death

CBV, CMRO2decreased to zero

OEF 100%

Ischemic core

CBF 10-18 ml/100g/min

Cell death without reperfusion

Loss of function of neurons

OEF 100% can not stop declineCMRO2

Penumbra

Benign oligemia

CBF 20-50 ml/100g/min

Survives without reperfusion

Elevatedoxygen extraction fraction (OEF) Normal cerebralmetabolic rate of

oxygen (CMRO2)

Normal tissue

CBF 50-60 ml/100g/min

Functional for

CPP 60-130 mmH, changes CBV

Warach S. Stroke 2001;32:2460-2461.



Ct perfusion
CT Perfusion

24 hours later….






Strategy of ischemic stroke therapy
Strategy of ischemic stroke therapy

  • Recanalization

  • Neuroprotection

  • Therapy of complications (oedema, epilepsy, infection…)

  • Secondary prevention of recurrent stroke

  • Restoration of function (physiotherapy, occupational therapy


The only causal therapy recanalization
The only causal therapy - recanalization

  • Intravenous thrombolysis

  • Intraarterial thrombolysis

  • Mechanical recanalization

  • Sonothrombotripsy

Katzan et al, Arch Neurol 2004

Thomas et al, N Engl J Med 2006

  • 2 - 30% patients with stroke



Time is brain
“Time is brain”

  • Every 1 minute:

  • 1 900 000 neurons

  • 14 000 000 000 synapsis

  • 12 km of myelinated fibers

270 minutes

180 minutes

90 minutes

Saver JL. Stroke 2006;37(1):263-6.

Hacke W et al. NEJMN 2008;359:1317­29.


Rtpa a ctilyse
rtPA (Actilyse)

  • r-TPA (Actilyse)

    • 0,9mg/kg, max. 90 mg

    • t½= 3-8min


Ivt limitations
IVT limitations

CT or MR without blood

Max. 4,5 hours after beginning

Min. 30 min of duration

Serious disability NIHSS 4 – 25 (relative)

Age 18-80 (relative)


Rescue therapy after ivt
Rescue therapy after IVT

  • Assessment of efficiency

    • Examination in 60. minute

    • Recanalized only in 40-50% cases, early reocclusion, recanalisation does not mean clinical effect

  • Our goal: What happened during IVT?

    • TCCS or NIHSS (40% points down)

    • Ultimate DSA (after 30/60 minutes)

  • RESCUE = mechanical





E xperimental methods
Experimental methods

  • PTA balloon angioplasty and stenting +/- IAT

  • laser microcavitation: LaTIS, EPAR

  • Ultrasound cavitatione: Ekos, ACS

  • Thrombus aspiration: AngioJet, Oasis, Neurojet






Secondary prevention
Secondary prevention

  • Antithrombotic

    • Antiplatelet

    • Anticoagulation (VKA)

  • ACEI or AT1 blocker, diuretic

  • Statine


Toast subtypes

Other known

2,1/100 000

TOAST subtypes

Large vessel disease

15.3/100 000

Small vessel disease

25.8/100 000

Cardiogenic

30.2/100 000

Cryptogenic

39,3/100 000

TOAST, Adams et al, Stroke 1993

N = incidence for 100 000 persons, Kolominsky-Rabas et al, Stroke 2001



Therapy of cvt
Therapy of CVT

  • Anticoagulation (3, 6 months, chronic)

  • Lifestyle changes (smoking, hormonal, drinking)

  • Depends on etiology of thrombofilic state

    • Inborn (Leiden, homocysteine…)

    • Acquired (hormonal, posttraumatic, post infection, surgery…etc)


Intracerebral hemorrhage ich
Intracerebral hemorrhage (ICH)


Dynamics of ich
Dynamics of ICH

First 24 hrs– 20*-36%**volume progression

(majority first 3 hours)

*Brott et al. Stroke. 1997;28:1-5

**Kazui et al. Stroke. 1996;27:1783-1787.


Treatment options in ich

Bleeding

RHB

progression

24hrs

Brain oedema

3-5.day

Hydrocephalus

14 days

Treatment options in ICH

Diagnostics

CT

Angiography

MRI + MRA

Therapy

Stabilisation of hemostasis

Blood pressure correction

Surgery – treatment of mass effect and of source of bleeding

Antioedematous therapy, decompression

EVD, shunts

RHB


Hypertension
Hypertension

  • Goal – 140/90

  • Hypertonics

  • Aim 120 MAP (160/100), maximum 180/105, no more than than 20%

  • Normotonisi – aim 110 MAP (150/90), max.160/95

  • ABP monitoring , i.v. therapy (Urapidil, Esmolol, Enalapril, Nitroprusid)


Hemostasis
hemostasis

  • APTT, Quick, trombocytes

  • Trombocytes

    • treat <75 000, substitution in caso of antiplatelet medication

  • Warfarine

    • INR <8 FP 2-3 TU

    • INR >8 FP 6 TU

    • Better concentrated prothrombin complex (fa. II, VII, IX, X) Prothromplex Total TIM4

    • rFVIIa – best ever- 10 minutes (10-40 μg/kg)

    • Vitamin K - after 6-12 hoours

  • Heparine

    • protamine sulphate (1mg/100 IU, max. 50mg/10 min)


Surgery
Surgery

Craniectomy (mass + source)

Stereotactic – event. + rtPA

External ventricular drainage – event. + rtPA


Surgery yes
Surgery yes:

  • Cerebellar above 10ml (>3-4cm) + GCS =<13

  • Lobar superficial (temporal lobe) 10-40ml or with later clinical progression

  • Typical BG initialy 10-30ml with good clinical state and later worsening (first 24-48 hrs)

  • ICH score 3 and age under 50 years

  • Ultimum refugium in case of cranio-caudal deterioration


Secondary prevention of ich
Secondary prevention of ICH

PRIMARY 80% Recurrence/ year

Hypertensive microangiopathy 2%

Amyloid angiopathy 10,5%

AVM 18%

Cavernous angioma 4,5%

SECONDARY 20%

Tumors

Exclude the source of bleeding (if possible)

Hypertension

Correction of bleeding disorders and exclusion of anticoagulants

Lifestyle - smoking, alcohol


Subarachnoidal hemorrhage sah
Subarachnoidal hemorrhage (SAH)


Sah diagnostics
SAH diagnostics

  • Headache 97%

  • Meningeal syndrome (after 6-24 hrs)

  • Nausea, vomitting, loss of conscioussness + neurological deficite

  • Grading by Hunta and Hess HH 1-5 or WFNS

  • Diagnostic problems with HH1 – CSF exam.

  • In the first 24 hours DSA – to find and treat source of bleeding



Specific complications of sah
Specific complications of SAH

Rebleeding (7%)

- Majority in the first two weeks (4% first day, after that 1,5% daily for the first 2 weeks)

Hydrocephalus (20%)

- Obstruction type acute (EVD), hyporesorbtive type later (shunting)

Vasospasms (46%)

- Max. 5. – 12. day

- TCD daily


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