Department of Neurology, UK 2. LF
Aleš Tomek
December 2010
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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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
TIA
Ischemic
RIND
ICH
Completed
stroke
STROKE
SAH
Venous
thrombosis
3rd most frequent cause of death
11 640
11 685
12 192
11 567
2007
2008
2009
2010
32 deaths per day
(Deaths – total in 2010 - 106 844 persons)
www.uzis.cz 9/2012
Hospitalisations I60-69
57 484 (2010)
853 078 days
www.uzis.cz
Acute
• Coma
• Hemihypesthesia
• Dysarthria
• Hemianopia
• Diplopia
• Headache
• Meningeal signs
• Vertigo with nausea
FAST
Face
Arm
Speech
Test
Internal
 Esp. cardio-pulmonary
Neurological
 Consciousness
 Speech, mnestic and
cognitive, neglect
 Cranial nerves
 Motoric and sensory
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COMA
 GLASGOW COMA
 FOUR SCORE
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ACUTE ISCHEMIC
 NIHSS
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ICH
 ICH SCORE
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SAH
 HUNT HESS
 WFNS (WORLD FEDERATION OF NEUROSURGEONS)
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OUTCOME
 MODIFIED RANKIN SCALE
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ABC
Correct diagnosis or suspicion of stroke
(FAST)
Do not lower blood pressure (220/120)
Immediate transportation to stroke center
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Tvorba sítě iktových center (Věstník 2 a
8/2010 MZd ČR), start 1.1.2011
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KCC (komplexní cerebrovaskulární centrum)
 10 center
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IC (iktové centrum)
 1. vlna - 23 center
 2. vlna – 12 center
Kraj Praha
Ústecký kraj
Královéhradecký kraj
I. Nemocnice Na
Homolce
I. MNUL
I. FN Hradec Králové
II. Chomutov
II. Obl.nem.Trutnov
I. ÚVN
II. Děčín
II. FN Motol
II. VFN
II. Teplice
II. FNKV + FTNsP
Komplexní
cerebrovaskulární
a iktová centra
Liberecký kraj
Pardubický kraj
I. KN Liberec
II. Pardubice
II. Česká Lípa
II. Litomyšl
Moravskoslezský kraj
I. FN Ostrava
II. MN Ostrava
Olomoucký kraj
II. Vítkovická nemocnice
I. FN Olomouc
II. Krnov
II. Třinec
Karlovarský kraj
II. Karviná
II. Nem. Sokolov
Středočeský kraj
II. Kolín
II. Kladno
Zlínský kraj
Plzeňský kraj
II. Krajská nem.
I. FN Plzeň
T. Bati Zlín
Kraj Vysočina
Jihočeský kraj
II. Nemocnice Jihlava
Jihomoravský kraj
I. FNUSA + FN Brno
I. Nemocnice Č. Budějovice
II. Břeclav
II. Nemocnice Písek
II. Vyškov
Soláň 13. - 14. 1. 2012
Hl. m. Praha
Nemocnice Na Homolce
Ústecký kraj
Ústí n. Labem
FN Hradec Králové
Chomutov
ÚVN
Obl.nem.Trutnov
Děčín
FN Motol
VFN
FNKV + FTNsP
Komplexní
cerebrovaskulární
a iktová centra
Královéhradecký kraj
Obl. Nem. Náchod
Teplice
Liberecký kraj
Pardubický kraj
Nem. Litoměřice
KN Liberec
Pardubice
Česká Lípa
Litomyšl
Moravskoslezský kraj
Olomoucký kraj
FN Ostrava
MN Ostrava
IFN Olomouc
Vítkovická nemocnice
Prostějov
Krnov
Třinec
Karlovarský kraj
Karviná
Nem. Sokolov
Nem. Karlovy Vary
Středočeský kraj
Kolín
Kladno
Mladá Boleslav
Zlínský kraj
Příbram
Zlín (T. Bati)
Uh. Hradiště
Plzeňský kraj
Jihomoravský kraj
I. FN Plzeň
Jihočeský kraj
I. Nemocnice Č. Budějovice
II. Nemocnice Písek
Soláň 13. - 14. 1. 2012
Kraj Vysočina
FNUSA + FN Brno
Břeclav
Jihlava
Nové Město na Moravě
Znojmo
Vyškov
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
ischemie
hemorhagie
• Gold standard
• ischemic / hemorhagic
+ availability, speed, senzitivity for hemorhagy,...
- negative first 3-6 hours, poor for brainstem
Native CT – markers of early ischaemia:
Early hypodenzity
Lower difference between gray x white matter
Lost gyrification (SA space)
Dense artery sign (MCA)
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More senzitive for smaller strokes and for
brainstem
Early vs. Old ischemic stroke (DWI)
Availability and duration of exam
akutní ischemie
ischemie
ischemie
Ischemic core
Penumbra
CBF < 10 ml/100g/min (< 20%)
Cytotoxic oedema + neuronal cell
death
CBV, CMRO2 decreased to zero
OEF 100%
CBF 10-18 ml/100g/min
Cell death without reperfusion
Loss of function of neurons
OEF 100% can not stop decline CMRO2
Benign oligemia
Normal tissue
CBF 50-60 ml/100g/min
Functional for
CPP 60-130 mmH,
changes CBV
CBF 20-50 ml/100g/min
Survives without reperfusion
Elevated oxygen extraction fraction (OEF)
Normal cerebral metabolic rate of
oxygen (CMRO2)
Warach S. Stroke 2001;32:2460-2461.
24 hours later….
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Recanalization
Neuroprotection
Therapy of complications (oedema, epilepsy,
infection…)
Secondary prevention of recurrent stroke
Restoration of function (physiotherapy,
occupational therapy
Intravenous
thrombolysis
Intraarterial
thrombolysis
Mechanical
recanalization
Sonothrombotripsy
2 - 30% patients with stroke
Katzan et al, Arch Neurol 2004
Thomas et al, N Engl J Med 2006
Every 1 minute:
•1 900 000 neurons
•14 000 000 000 synapsis
•12 km of myelinated fibers
270 minutes
180 minutes
90 minutes
NNT 14
NNT 7
(3,1)
NNT 2
Saver JL. Stroke 2006;37(1):263-6.
Hacke W et al. NEJMN 2008;359:131729.
 r-TPA (Actilyse)
 0,9mg/kg, max. 90 mg
 t½= 3-8min
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)
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Assessment of efficiency
 Examination in 60. minute
 Recanalized only in 40-50% cases, early
reocclusion, recanalisation does not mean clinical
effect
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Our goal: What happened during IVT?
 TCCS or NIHSS (40% points down)
 Ultimate DSA (after 30/60 minutes)
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RESCUE = mechanical
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PTA balloon angioplasty and stenting +/- IAT
laser microcavitation: LaTIS, EPAR
Ultrasound cavitatione: Ekos, ACS
Thrombus aspiration: AngioJet, Oasis, Neurojet
Timetable of stroke th.
Ischemic
Before 4,5
hours
IVT
4,5 – 8 h
w. penumbra
85%
4,5-6 IA
4,5-8
IA, mech,
Stroke
diagnosis
TT
After 4,5 hrs.
Wo. penumbra
ICH 12-15%
SAK 1%
Correction of
hemostasis and
oedema

Antithrombotic
 Antiplatelet
 Anticoagulation (VKA)
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ACEI or AT1 blocker, diuretic

Statine
Other known
2,1/100 000
Large vessel disease
15.3/100 000
Small vessel
disease
25.8/100 000
Cardiogenic
Cryptogenic
39,3/100 000
30.2/100 000
TOAST, Adams et al, Stroke 1993
N = incidence for 100 000 persons, Kolominsky-Rabas et al, Stroke 2001
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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)
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.
Diagnostics
CT
Angiography
MRI + MRA
Bleeding
progression
24hrs
Brain
oedema
3-5.day
RHB
Hydrocephalus
14 days
RHB
Therapy
Stabilisation of hemostasis
Blood pressure correction
Surgery – treatment of
mass effect and of
source of bleeding
Antioedematous therapy,
decompression
EVD, shunts
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Goal – 140/90
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Hypertonics
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Aim 120 MAP (160/100), maximum 180/105, no more than than 20%
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Normotonisi – aim 110 MAP (150/90), max.160/95
ABP monitoring , i.v. therapy (Urapidil, Esmolol, Enalapril,
Nitroprusid)
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APTT, Quick, trombocytes
Trombocytes
 treat <75 000, substitution in caso of antiplatelet medication
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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
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Heparine
 protamine sulphate (1mg/100 IU, max. 50mg/10 min)
Craniectomy (mass + source)
Stereotactic – event. + rtPA
External ventricular drainage – event. +
rtPA
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
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PRIMARY 80%
Hypertensive microangiopathy
Amyloid angiopathy
AVM
Cavernous angioma
Recurrence/ year
2%
10,5%
18%
4,5%
SECONDARY 20%
Tumors
Exclude the source of bleeding (if possible)
Hypertension
Correction of bleeding disorders and exclusion of anticoagulants
Lifestyle - smoking, alcohol
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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
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