Acute Ischemic Stroke & Transient Ischemic Attack (TIA) Sumet Preechawuttidej, M.D.

โรคหลอดเลือดสมอง Cerebrovascular disease (CVD) CVA Stroke “Rapidly developed clinical signs of focal (global) disturbance of cerebral function lasting more than 24 hours or leading to death, with no apparent cause other than a vascular origin.”

ผลของโรคหลอดเลือดสมอง เสียชีวิต Stroke ความผิดปกติ muscle weakness, ataxia, loss of sensation, etc ปัจจัยเสี่ยง ความพิการ Inability to walk, feed, etc เกิดโรคซ้ำ (สมองเสื่อม vascular dementia)

อายุคาดเฉลี่ยคนไทย พ.ศ. 2546-2556

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โรคที่เป็นสาเหตุของความสูญเสียปีสุขภาวะประชากรไทย อัตราตายของประชากรไทย

Content Acute Ischemic Stroke & TIA Etiology Clinical manifestation Diagnosis Management Prevention

Approach to Cerebrovascular disease Definition conditions in which injury to the brain or spinal cord occurred from a vascular cause 2 main types: ischemic and hemorrhagic stroke

The perforators Charcot-Bouchard aneurysm Parent artery

Acute Ischemic Stroke & TIA

Etiology Ischemic Stroke Subtypes (TOAST classification) Large-artery atherosclerosis Cardioembolism Small-vessel occlusion (Lacunar infarction) Stroke of other determined etiology Hypercoagulable disorder Venous sinus thrombosis Vasculitis Stroke of undetermined etiology

เปลี่ยนแปลงไม่ได้ Non-modifiable Age, Gender, Race, Heredity Risk Factors เปลี่ยนแปลงไม่ได้ Non-modifiable Age, Gender, Race, Heredity เปลี่ยนแปลงได้ Modifiable Behaviors Cigarette smoking Alcohol abuse Physical inactivity Medical Conditions Hypertension Cardiac disease Atrial fibrillation Dyslipidemia Diabetes mellitus Carotid stenosis Prior TIA or stroke Elevated homocysteine Atherosclerosis of aorta Sacco RL, et al. Stroke 1997;28:1507-1517. Pancioli AM, et al. JAMA 1998;279:1288-1292.

Prevalence of Stroke by Age and Sex NHANES III: 1988-94 Risk Factors CDC/NCHS.

เปลี่ยนแปลงไม่ได้ Non-modifiable Age, Gender, Race, Heredity Risk Factors เปลี่ยนแปลงไม่ได้ Non-modifiable Age, Gender, Race, Heredity เปลี่ยนแปลงได้ Modifiable Behaviors Cigarette smoking Alcohol abuse Physical inactivity Medical Conditions Hypertension Cardiac disease Atrial fibrillation Dyslipidemia Diabetes mellitus Carotid stenosis Prior TIA or stroke Elevated homocysteine Atherosclerosis of aorta Sacco RL, et al. Stroke 1997;28:1507-1517. Pancioli AM, et al. JAMA 1998;279:1288-1292.

Risk Factors

อาการของโรคหลอดเลือดสมอง Clinical manifestation อาการของโรคหลอดเลือดสมอง รวดเร็วหรือทันทีทันใด!! อ่อนแรงของร่างกายครึ่งซีก ชาครึ่งซีก เวียนศีรษะ ร่วมกับเดินเซ ตามัว หรือ มองเห็นภาพซ้อน พูดไม่ชัด ลิ้นแข็ง ปวดศีรษะ อาเจียน ซึม ไม่รู้สึกตัว

Transient ischemic attacks (TIA) Duration is <24 hours, but most TIAs last <1-2 hours The risk of stroke after a TIA is ~10–15% in the first 3 months Most events occurring in the first 7 days ABCD2 score

MANAGEMENT

History and Physical examination Determining the exact time when symptoms began or the last time the patient was known to be well Concomitant medical illnesses Risk factors

History and Physical examination (cont.) Vital signs Cardiovascular systems General neurologic examination The National Institutes of Health Stroke Scale (NIHSS)

NIHSS 1. Level of consciousness Level of consciousness Question Command 2. Best gaze 3. Visual field 4. Facial palsy 5. Motor arm 6. Motor leg 7. Limb ataxia 8. Sensory 9. Best language 10. Dysarthria 11. Extinction and Inattention

SUDDEN ONSET OF FOCAL NEUROLOGICAL DEFICIT SUSPICIOUS STROKE <4.5 hr 4.5-72 hr Stroke fast track Emergency lab + CT brain NC Emergency lab + CT brain NC STROKE STROKE General Mx Hemorrhagic Ischemic Candidate for thrombolytic therapy? Consult neuroSx

Initial investigation and Workup Blood test FBS, CBC, Lipid profile, BUN/Cr, Electrolyte, PT, PTT, INR, UA Cardiac workup EKG 12 lead, CXR If suspect cardioembolism  TEE, Holter monitoring Pt. age <45 yr without evidence of cardioembolism/ atherosclerosis risk factor ESR, ANA, Anti HIV, VDRL, LFT, Thrombophilia lab Vascular workup Carotid duplex US, TCDUS MRA, CTA

Brain imaging CT brain non contrast DDx Ischemic or Hemorrhagic MRI brain (further investigation) Early signs in CT (MCA infarction) Loss of gray-white junction Insular ribbon sign Blurring of borders of basal ganglia Dense artery sign

Treatment IV thrombolytic treatment General management Antithrombotic treatment Stroke Unit and Rehabilitation

IV thrombolytic therapy Indication Clinical diagnosis of stroke Onset ≤ 4.5 hr Age > 18 yr CT brain  no hemorrhagic or edema of >1/3 of the MCA territory Consent by patient or surrogate

IV thrombolytic therapy (cont.) Contraindication (onset within 3 hour) Sustained BP ≥185/110 mmHg despite Tx Platelet < 100,000; Hct < 25%; Glucose < 50mg% or > 400 mg% Use heparin within 48 hr and prolonged PTT or elevated INR Rapidly improving symptom  NIHSS ≤ 4 Prior stroke or head injury within 3 months; prior intracranial hemorrhage Major surgery in preceding 14 days Minor stroke symptom Gastrointestinal bleeding in preceding 21 days Recent myocardial infarction Coma or stupor

IV thrombolytic therapy (cont.) Additional contraindication in patient (onset within 3 – 4.5 hour) History of warfarin use Age > 80 year Diabetic with prior ischemic stroke NIHSS > 25

IV thrombolytic therapy (cont.) Administration of rt-PA (Recombinant tissue-plasminogen activator) 0.9 mg/kg (maximum 90 mg) IV as 10% of total dose by bolus The followed by remainder 90% over 1 hour No other antithrombotic treatments for 24 hours For decline in neurologic status/uncontrolled BP  stop infusion and give cryoprecipitate and reimage brain immediately Avoid urethral catheterization

General management Keep SpO2 > 94% Antihypertensive drug SBP ≤220 mmHg or DBP ≤120 mmHg with CHF, Aortic dissection, Acute MI, Acute renal failure, Hypertensive encephalopathy If SBP >220 mmHg or DBP >120 mmHg Decrease blood pressure 10-15% Nicardipine 5 mg/hr IV Keep BP <180/105 mmHg in Pt. received thrombolysis

General management (cont.) IV hydration Isotonic solution (0.9%NaCl) NPO when Unconsciousness Suspected large infarction Tendency to surgery Infratentorial infarction

General management (cont.) Blood glucose controlled Keep 140-180 mg% Avoid high body temperature If patient seizure  Antiepileptic drug (no need prophylaxis) Tx co-morbidity; MI, electrolyte imbalance Early mobilization for prevention DVT Swallowing evaluation

Medical treatment Antiplatelets Aspirin 160 – 325 mg/day in first 24 – 48 hour No Aspirin within 24 hours after thrombolytic therapy Anticoagulants Others; Immunosuppressive drug in vasculitis

Tx Increase intracranial pressure Intubation if deteriorated consciousness Semifowler position (20 – 30 degrees) Hyperventilation  16-20/min keep pCO2 30-35 mmHg Osmotherapy 20% Mannitol 1g/kg IV in 20-30 min then 0.25-0.5g/kg IV in 10 min q 4-6 hour (max 2g/kg/day) for 24 – 48 hours Keep Serum Osmo <320 mmol/L Consult neurosurgeon for decompressive craniectomy

Stroke Unit Rehabilitation Swallowing evaluation

Stroke Unit (cont.)

Stroke Unit (cont.)

Rehabilitation Contraindication Body temperature >38 degrees celcius HR >100 or <60/min BP >180/110 or <90/60mmHg Cardiac condition: MI, arrhythmia Dyspnea Deteriorated consciousness Seizure

Secondary prevention Atherosclerosis risk factor BMI <23 kg/m2 DM HbA1C < 7% HT <140/90 mmHg in general patient <130/80 mmHg in DM patient Smoking  stop Abnormal blood cholesterol (low HDL, high LDL) Keep LDL < 100 mg/dL in general patient Keep LDL < 70 mg/dL in DM/heart disease patient Keep TG < 150 mg/dL, HDL >40 mg/dL (male), >50 mg/dL (female)

Secondary prevention (cont.) Antiplatelet agent Non-cardioembolic stroke ASA 50-325 mg/day Clopidogrel 75 mg/day ASA + dipyridamole 50/400 mg/day Cilostazol 200 mg/day

Secondary prevention (cont.) Anticoagulant Cardioembolic stroke Warfarin  keep INR 2.0-3.0 in patient with Persistent or paroxysmal AF Acute MI and LV thrombus Mechanical heart valve

Thank You For Your Attention