stroke

1. Department of Neurology, UK 2. LF Aleš Tomek December 2010 stroke

2. 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

3. 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

4. Stroke types

5. 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

6. Hospitalizations Hospitalisations I60-69 57 484 (2010) 853 078 days www.uzis.cz

7. Hlavní příznaky - FAST (Face Arm Speech Test) 1x

8. Clinicalsigns – minor (2x) Acute • Coma • Hemihypesthesia • Dysarthria • Hemianopia • Diplopia • Headache • Meningealsigns • Vertigowithnausea

9. Clinical examination and signs FAST FaceArmSpeechTest Internal • Esp. cardio-pulmonary Neurological • Consciousness • Speech, mnestic and cognitive, neglect • Cranial nerves • Motoric and sensory

10. 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

11. Prehospital care • ABC • Correct diagnosis or suspicion of stroke (FAST) • Do not lower blood pressure (220/120) • Immediate transportation to stroke center

12. 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

13. 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

14. 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

15. 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

16. Stroke imaging - CT ischemie hemorhagie • Gold standard • ischemic / hemorhagic • + availability, speed, senzitivity for hemorhagy,... • - negative first 3-6 hours, poor for brainstem

17. 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)

18. 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

19. 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.

20. DWI PWI mismatch

21. CT Perfusion 24 hours later….

22. CT angiography

23. Ultrasound (TCD and carotid)

24. MR angiography

25. DSA – digital subtraction angiography

26. Strategy of ischemic stroke therapy • Recanalization • Neuroprotection • Therapy of complications (oedema, epilepsy, infection…) • Secondary prevention of recurrent stroke • Restoration of function (physiotherapy, occupational therapy

27. 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

28. IVT

29. “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.

30. rtPA (Actilyse) • r-TPA (Actilyse) • 0,9mg/kg, max. 90 mg • t½= 3-8min

31. 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)

32. 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

33. Intraarterial thrombolysis – IATCombined IVT + IAT

34. Sonothrombotripsy

35. Mechanical recanalization MERCI

36. Experimental methods • PTA balloon angioplasty and stenting +/- IAT • laser microcavitation: LaTIS, EPAR • Ultrasound cavitatione: Ekos, ACS • Thrombus aspiration: AngioJet, Oasis, Neurojet

37. Solitaire FR

38. Solitaire FR

39. Solitaire FR

44. Timetable of stroke th.

45. Secondary prevention • Antithrombotic • Antiplatelet • Anticoagulation (VKA) • ACEI or AT1 blocker, diuretic • Statine

46. 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

47. Cerebral veins (sinuses) thrombosis = CVT

48. 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)

49. Intracerebral hemorrhage (ICH)

50. 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.