acute stroke therapy n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Acute Stroke Therapy PowerPoint Presentation
Download Presentation
Acute Stroke Therapy

Loading in 2 Seconds...

play fullscreen
1 / 32

Acute Stroke Therapy - PowerPoint PPT Presentation


  • 159 Views
  • Uploaded on

Acute Stroke Therapy. Andrew Slivka, MD Associate Professor of Neurology Cerebrovascular Diseases and Stroke The Ohio State University Medical Center. General Early Supportive Care. 1. Early mobilization and measures to prevent aspiration

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Acute Stroke Therapy' - glenys


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
acute stroke therapy

Acute Stroke Therapy

Andrew Slivka, MD

Associate Professor of Neurology

Cerebrovascular Diseases and Stroke

The Ohio State University Medical Center

general early supportive care
General Early Supportive Care

1. Early mobilization and measures to prevent aspiration

*2. Heparin for DVT prophylaxis in immobilized patients, pneumatic compression devices in patients who cannot receive heparin

treatment of cerebral edema
Treatment of Cerebral Edema

*1. Steroids not recommended

2. Osmotherapy, hyperventilation for patients deteriorating due to increased intracranial pressure or with herniation syndromes

3. Surgical decompression, ventricular shunt for large cerebellar infarcts compressing brain stem

4. Surgical decompression for large hemispheric infarct may be life-saving, but may have severe residual neurological deficits

acute treatment antithrombotic therapy
Acute Treatment Antithrombotic Therapy

1. Heparin or LMW heparin when used within 48 hours of acute ischemic stroke do not reduce morbidity, mortality, or rate of stroke reoccurrence, but do increase systemic and CNS bleeding risk independent of stroke subtype

2. Aspirin (160-325mg) within 48 hours

acute stroke treatment strategies
Acute Stroke Treatment Strategies
  • Recanalization
  • Neuroprotection
recanalization strategies
Recanalization Strategies
  • Delivery (iv, ia, iv-ia)
  • Drugs (UK, t-PA, Pro-UK, retaplase, desmoteplase)
  • Mechanical (wire, balloon, snare, angiojet, MERCI)
thrombolytic therapy iv t pa
Thrombolytic Therapy - iv t-PA

NINDS t-PA Stroke Trial

  • Inclusion Criteria
    • Age > 18 years
    • Clearly defined time of onset < 3 hours
    • Clinical diagnosis of ischemic stroke
thrombolytic therapy iv t pa1
Thrombolytic Therapy - iv t-PA
  • Exclusion Criteria
    • Suspicion of SAH
    • Recent intracranial surgery, serious head trauma, recent previous stroke (within 3 months)
    • History of ICH
    • Uncontrolled HPT (> 185 mmHg systolic, > 110 mgHg diastolic
    • Seizure at onset
    • active internal bleeding
    • Intracranial neoplasm, AVM, or aneurysm
thrombolytic therapy iv t pa2
Thrombolytic Therapy - iv t-PA
  • Exclusion Criteria - continued
    • Bleeding diathesis: PT > 15 sec (or INR > 1.7 ) - heparin treatment with elevated PTT, platelet <100,000/mm3
    • Major surgery, serious trauma < 2 weeks GI or GU hemorrhage < 3 weeks
    • Arterial puncture at noncompressable site or LP < 1 week
thrombolytic therapy iv t pa3
Thrombolytic Therapy - iv t-PA
  • Exclusion Criteria - continued
    • Pregnant
    • Rapidly improving neurological signs
    • Isolated mild neurological deficits
    • Glucose < 50 mg/dl or > 400 mg/dl
ninds t pa stroke trial design
NINDS t-PA Stroke Trial: Design
  • Part I (n=291): half treated within 90 minutes
    • Primary outcome – complete resolution or > 4 point improvement in NIHSS at 24 hours.
    • Secondary outcome – minimal or no disability at 3 months
  • Part II (n= 333): half treated within 90 minutes
    • Primary outcome – minimal or no disability at 3 months
  • Dose: 0.9 mg/kg (maximum 90 mg); 10% bolus, remainder infused over 1 hour
predictors of outcome with t pa
Predictors of Outcome with t-PA
  • Age, deficit severity, diabetes, admission blood pressure, early CT changes, influence outcome, but do not alter likelihood of responding favorably to t-PA
  • NIHSS > 20: Rankin 0-1(at 3 months) 10% with t-PA, 4% placebo; Rankin 4,5 or 6 is 70%, independent of treatment
  • Brain edema/mass effect on CT: Rankin 0-1 (at 3 months) 25% with t-PA, 16% placebo; Rankin 4,5 or 6 is 55%, independent of treatment
  • Time to treatment correlates with outcome
symptomatic intracerebral hemorrhage with t pa treatment
Symptomatic Intracerebral Hemorrhage with t-PA Treatment
  • NINDS Trial (n=312) 6%
  • STARS Study (n=389) 3%
  • CASES Study (n=450) 4%
  • Average Phase IV Studies 5% (16%)
    • n=>1400
risks for symptomatic intracerebral hemorrhage
Risks for Symptomatic Intracerebral Hemorrhage
  • Hospital size (experience)
  • Protocol violations
  • Severity of neurological deficit
  • Brain edema or mass effect on CT
iv t pa use after 3 hours
IV t-PA Use After 3 Hours
  • Atlantis: 613 patients, 3-5 hours after stroke, NIH > 3
  • ECASS II: 800 patients < 6 hours after stroke
  • 90 day Outcome: Placebo t-PA
intra arterial thrombolysis
Intra-arterial Thrombolysis
  • Series with t-PA, UK
  • Pro-urokinase (PROACT II)
    • 180 patients with proximal MCA occlusion within 6 hours
    • Recanalization: 66% treated group, 19% control
    • Good outcome: 40% treated group, 25% control
    • Symptomatic ICH: 10% treated group, 2% control
    • Mortality: 25% treated group, 27% control
intra arterial thrombolysis at osu
Intra-arterial Thrombolysis at OSU
  • 81 patients treated from May 1995 to July 2003
  • 52% male, 16% African American, 1% Asian American, Mean age 72 years
  • 26% with good clinical outcome (mRS < 2)
  • 70% with recanalization (33% complete)
  • 7% with symptomatic ICH
predictors of clinical outcome
Predictors of Clinical Outcome
  • No occlusion
    • 38% with good outcome vs. 26% with occlusion, Rx
  • Age > 80 years
    • 0/14 with good outcomes (57% recanalize, 29% complete)
  • Admission NIHSS
    • Good outcome 11/16 (69%) 4-10

9/48 (19%) 11-20

1/18 (6%) >20

predictors of clinical outcome1
Predictors of Clinical Outcome

Time to Treat

  • < 5 hours – good outcome 15/47 (32%)
    • Recanalization 77% (41% complete)
  • > 5 hours – good outcome 6/34 (18%)
    • Recanalization 62% (24% complete)
predictors of clinical outcome2
Predictors of Clinical Outcome

Recanalization

  • Complete recanalization-13/27 (48%) good outcome
  • Partial recanalization 7/30 (23%) good outcome
  • No recanalization 1/24 (4%) good outcome
predictors of outcome
Predictors of Outcome

Collateral Circulation

  • When complete recanalization – linear relationship between clinical outcome and infarct size and collateral grade
  • When partial/no recanalization – no correlation with clinical outcome, excellent collateral have smaller infarcts than other collateral grades
intravenous intra arterial
Intravenous – Intra arterial
  • IMS (Stroke, 2004) 80 Patients within 3 hours
  • 6 mg/kg (max 60 mg) t-PA iv over 30 minutes up to 22 mg t-PA ia over 2 hours if occlusion seen by angiography
  • Good outcome 30% (32% iv t-PA, 18% control
  • Symptomatic ICH 6.3% (6.6% iv t-PA, 1% control
  • Mortality 16% (21% iv t-PA, 24% control)
mechanical disruption
Mechanical Disruption
  • Anecdotal: snare, balloon, angio jet
  • MERCI (Stroke, 2005)
    • 141 patients with intracranial large vessel occlusion treated within 8 hours
    • Recanalization: 48% (19% PROACT control)
    • Complications: 7% (emboli, dissection, SAH)
    • Good outcome: 28% (46% recanalized, 10% occluded)
    • Mortality: 43% (32 recanalized, 54% occluded)
desmoteplase
Desmoteplase
  • 45-60 patients within 9 hours, DWI/PI mismatch
  • DIAS – Europe, DEDAS – USA, Germany
  • Dose response found
  • Reperfusion: 50-70% (vs 20-37% control)
  • Good outcome: 66% (vs 22-25% control)
  • No symptomatic ICH
treatment algorithms
Treatment Algorithms
  • Less than 3 hours
    • NIHSS <10 iv t-PA
    • NIHSS 10 or greater iv/ia t-PA
  • 3-6 hours
    • DIAS-II
    • NIHSS < 10 or lacunar infarct: MR then ia t-PA (? Iv t-PA)
  • Greater than 6 hours
    • NIHSS 10 or greater: MR then MERCI
treatment special populations
Treatment: Special Populations
  • Post catheterization
  • Post operative
  • Children/adolescents