** นพ.สมชาย โตวณะบุตร **
แพทย์ ทรงคุณวุฒิทางอายุรกรรมสาขาประสาทวิทยา สถาบันประสาทวิทยา
ปรึกษาผู้อานวยการด้ านถ่ ายทอดฯ, หัวหน้ าศูนย์ ข้อมูลข่ าวสารระบบประสาท
อาจารย์ พเิ ศษของมหาวิทยาลัยต่ างๆ ม.จุฬาลงกรณ์ , ม.มหิดล,
ม.ธรรมศาสตร์ , ม.ศรีนครินทร์ วโิ รจน์ ประสานมิตร
นายกสมาคมโรคลมชักแห่ งประเทศไทย
อุปนายกสมาคมประสาทวิทยาแห่ งประเทศไทย
Somchai Towanabut M.D.
Neurology, Prasat Neurological Institute
,Department of medical services,MOPH,
Bangkok, Thailand
Stroke definition :WHO 2521
“ Rapidlly developed clinical signs of focal or global
disturbance of cerebral function :lasting more than 24
hours or leading to death,with no apparent cause other
than a
vascular origin .”
How to diagnose Stroke ?
• Clinical
–Acute onset ( mins to days)
–Neuro. Deficit
Brain + vascular
• R/O other causes: Hypoglycemia,
SDH
Stroke type ?
West
East
IS 50-70 %
IS 70-80 %
HS 30-50%
HS 20-30%
IS=ISCHEMIC STROKE,HS=HEMORRHAGIC
STROKE,ICH =INTRACEREBRAL
H,SAH=SUBARRACHNOID H,
Transient Ischemic Attack
• Episodes of temporary and
focal cerebral dysfunction of
vascular (occlusive) origin.
• Lasting < 24 hours
Continuum of disease
Natural history of
Transient Ischemic Attack
Annual risk of stroke or death
10% (2-62%)
Cardiac death 4% per year
High risk in first 3 years
Etiology of Ischemic Stroke
• Large vessel atherosclerosis
– Carotid siphon, MCA,
Basilar artery, Vertebral artery, etc.
• Embolic stroke
– Cardiac, Carotid, Ascending aorta, Unknown
• Small vessel disease
• Others:
– Hemodynamic, Dissection, vasculitis, FMD,
Polycythemia, etc.
Risk factors of atherosclerosis
•
•
•
•
•
•
Advanced age
Hypertension
Diabetes
Smoking
Alcoholic drinking
Dyslipidemia ?
Acute Stroke Syndrome?
• Real “ STROKE” ?
CT scan
• Ischemic or Hemorrhagic ?
Stroke emergency evaluation
• Clinical ( onset )
• Lab
• CT brain
Brain CT scan in Stroke !
Normal
Abnormal
Hypodense
Ischemic
stroke
Hyperdense
Hemorrhagic
stroke
Acute Management
• General management
• Specific treatment
• Treatment of complications
Acute management of
Ischemic Stroke
• General management
– Airway, Breathing, Circulation
No sublingual Nifedipine
– IV fluid if dehydrated
– Absolute bed rest if BP>180/100mmHg
– Avoid anti-hypertensives drugs
– Treatment of fever
– Plasma glucose control
Except:
End-organ failure : CHF, RF, HT
encephalopathy
Aortic dissection
Severe HT >220/120
use Nitroprusside
Ischemic stroke
Penumbra zone
Ischemic core
Large infarct
with midline shift or herniation
 Avoid anticoagulant
 Medical treatment for brain edema
 Hyperventilation reduce PCO2 25-30
 Reduction of IV fluid
 Osmotic agent : Mannitol, Glycerol
 Diuretics
 Steriod is not useful (Grade A)
 Surgical treatment ( Emergency)
 Cerebellar infarct
 MCA infarct
(Grade B)
Ischemic stroke: Reactive HT
Penumbra zone
Ischemic core
Ischemic stroke: Reactive HT
Penumbra zone
Ischemic core
Ischemic stroke: Hypotension
Penumbra zone
Ischemic core
Ischemic stroke: Hypotension
Penumbra zone
Ischemic core
Acute stroke treatment
Treatment
RRR%
Numbers
avoiding death or
dependency per
1000 Rx
% can be
Rx
Indication
Stroke
Unit
9
56
80%
Routine
ASA
3
13
80%
Routine for
ischemic
IV rt-PA
10
63
5%
Very
selective
Warlow CP. Lancet 2003 :362
FAST
• F=face
• A=arm
• S=speech
• T=time
Thrombolytic therapy for
acute ischemic stroke
< 4.5 Hr
Hyper acute stroke
Consider IV rt-PA
Stroke care in the Future
More Tertiary
Center
Advanced Rx
Public education
Stroke awareness
EMS
1669
rtPA,stroke unit
Patient education
Stroke alert
More Stroke
Centers
Stroke unit care in different
European countries
•
Sweden
75.9% of all patients
2003
•
Norway
at almost all hospitals
2003
•
UK
at 73% of hospitals, but only
27% of all stroke patients
2002
•
Scotland
50-60% of patients
2002
•
Germany
at 30% of hospitals
2002
•
Poland
at 20% of hospitals
2002
•
Italy
at 7% of hospitals
2002
•
Portugal
at 20% of hospitals
2002
•
Austria
35% of patients
2002
Norrving 2005, www.riks-stroke.org, www.rcplondon.ac.uk/pubs/strokeaudit01-02,
and Cerebrovasc dis suppl1, 2003
What exactly is a stroke unit?
• Stroke unit provides multidisciplinary specialized
care for acute stroke patients.
• The team consists of nurses, pharmacists, social
workers, medical staff, and occupational, physical
and speech therapists.
Stroke Unit
• Immediate medical (and surgical) treatment
• Close monitoring for deterioration and
acute complications
• Investigations
• Early rehabilitation
• Psychosocial support and patient education
The Stroke Unit Trialists’ Collaboration
O.R. 95 % C.I.
Men
0.66 (0.51-0.85)
Women
0.77 (0.60-0.98)
< 75 years
0.77 (0.63-0.94)
 75 years
0.69 (0.56-0.85)
Mild stroke
0.95 (0.66-1.36)
Moderate stroke
0.70 (0.58-0.84)
Severe stroke
0.55 (0.38-0.81)
0.5
0.7
1.0
Stroke Unit better
Stroke Unit Trialist‘s Collaboration. Cochrane Database Syst Rev 2000; 2
Stroke Unit worse
Aspirin (Grade A evidence)
Tested in large RCT in acute (< 48 hours) stroke
Significant reduction in death and dependency (NNT 70) and
recurrence of stroke (NNT 140)
In a combined analysis of IST and CAST, the reduction in death and
dependency during the first 2 weeks was 1 % (NNT 100)
International Stroke Trial Investigators. Lancet 1997; 349 (9065): 1569-158.
Chinese Acute Stroke Trial Investigators. Lancet 1997; 349 (9066): 1641-1649.
ASA in acute ischemic stroke
ASA 160-300 mg/day should be given with ischaemic
stroke within 48 hours after stroke onset (Grade A)
EUSI Recommendations
Treatment of complications
Neurological complications
•Brain edema with herniation
•Hemorrhagic transformation
Life-threatening: Large infarct
with herniation
• Malignant MCA infarct
• Cerebellar infarct
Wide craniectomy
in 48 Hr.