The modern management of
s-t-r-o-k-e
Tom Hughes
Royal Glam
May 2013
Acknowledgements
• Neuroradiology colleagues (Shawn Halpin,
Maggie Hourihan, Yogish Joshi)
• Neurology SpRs
• Neurology colleagues
• Radiographers and research pharmacists
• Dr Hamsaraj Shetty, Dr Shak Ahmad, Dr Susan
White
• Welsh Ambulance service
• Dr Suzanne Wyatt and Dr Jo Mower (EU)
• IST3 trial organisers
– Peter Sandercock, Karen Innes, Mat Williams
The lecture
• A review of thrombolysis
• A review of the relevant anatomy and
pathology
• I will try not to use the word S-T-R-O-K-E
Time to open up the dorma windows of the discussion
The ABCDE approach
Artery
Brain
Clinical Features
Disease
Evidence
Three types of artery to consider in
cerebrovascular disease
(small arrows)
Large artery
occlusions
Lenticulostriate perforators
Leptomeningeal perforators
The ABCDE approach: large artery
Artery
Brain
Clinical
features
Disease
Evidence
Large artery e.g.
MCA
Cortex
Cortical deficits
e.g. Dysphasia,
dyscalculia,
apraxia etc.
Embolic
Warfarin in AF
Endarterectomy
Antiplatelets
Statins
BP treatment
Cortex
Right and left cerebral cortex do different things
The ABCDE approach: large artery
Artery
Brain
Clinical
features
Disease
Evidence
Large artery e.g.
MCA
Cortex
Cortical deficits
e.g. Dysphasia,
dyscalculia,
apraxia etc.
Embolic
Warfarin in AF
Endarterectomy
Antiplatelets
Statins
BP treatment
CHADS2 Scoring Scheme
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C Congestive heart failure
H Hypertension
A Age > 75 years
D Diabetes Mellitus
S2 Prior Stroke or TIA
1
1
1
1
2
Annual Stroke Risk with Respect to CHADS 2
Score (1)
•
•
•
•
•
•
•
•
CHADS2
0
1
2
3
4
5
6
Stroke Risk %
1.9
2.8
4.0
5.9
8.5
12.5
18.2
95% CI
1.2-3.0
2.0-3.8
3.1-5.1
4.6-7.3
6.3-11.1
8.2-17.5
10.5-27.4
Anticoagulation based on CHADS2
score
Score
Risk
Anticoagulatio
n therapy
0
Low
Aspirin
1
Moderate
Aspirin or
Warfarin
2 or greater
Moderate or
High
Warfarin
CHA2DS2-VASc score
If 2 or above give warfarin, <2
think!
•
•
•
•
•
•
•
Feature
Score
Congestive Heart Failure
1
Hypertension
1
Age >75 years
2
Age between 65 and 74 years
1
Stroke/TIA/TE
2
Vascular disease (previous MI, peripheral
arterial disease or aortic plaque)
1
• Diabetes mellitus
1
• Female
1
The ABCDE approach:
lenticulostriate
Artery
Brain
Lenticulostriate Internal
capsule, basal
ganglia
Clinical
features
Disease
Evidence
Pure motor
and sensory
In-situ
obliteration
causing
lacunes
Traditional
secondary
prevention?
Involvement of internal capsule and basal
ganglia
The ABCDE approach:
lenticulostriate
Artery
Brain
Lenticulostriate Internal
capsule, basal
ganglia
Clinical
features
Disease
Evidence
Pure motor
and sensory
In-situ
obliteration
causing
lacunes
Traditional
secondary
prevention?
The ABCDE approach:
leptomeningeal perforators
Artery
Brain
Clinical
features
Disease
Evidence
Leptomeningeal
perforators
Perventricular
white matter
Gait apraxia
Preserved
“bed cycling”
Subcortical
dementia
Incontinence
Leukoaraiosis
Not clear
White matter tracts
Superior longitudinal fasciculus
Inferior longitudinal fasciculus
Arcuate fasciculus
Uncinate fasciculus
Things have changed!
89-year-old female
We are changing things!
What is all the fuss about?
Cochrane
Death, dependency and good outcome in
randomized trials of rt-PA given within
3 hours of acute ischaemic stroke
(3 trials, n=869)
NNT
Alive and
independent
100
80
44.3
30.2
Alive but
dependent
60
40
10
38.4
Dead
51.4
20
17.3
18.4
Thrombolysis
Control
0
Differences/1000: 141 extra alive and independent (P<0.01)
130 fewer dependent survivors (P<0.01)
12 fewer deaths (NS)
Cochrane Library 2003
4.5 hours....it is difficult
• A perfect perfect clinical storm
– A health service not used to dealing with stroke as an
emergency (3-6 hours)
– No pain or bleeding, no spots or screaming,
– Negative rather than positive signs
– Common condition
– Lots of mimics
– An evolving story
– Immature signs
– Shortage of time
– CT scan (plain) which is not always diagnostic (excludogram)
– Dangerous treatment
But it is happening........
Inclusion criteria
• Inclusion Criteria used in the SITS-MOST
study of relevance to the on-call general
physician
• Male or female aged 18-80 years old
• Clinical diagnosis of ischaemic s---e
• Onset of symptoms within three hours/4.5hours
of predicted initiation of thrombolysis
• S---e symptoms present for at least 30 minutes,
without significant improvement before
commencement of therapy
Exclusion criteria used in the SITS-MOST study of relevance to
the on-call general physician
• Evidence of intracranial haemorrhage
(ICH) on the CT scan
• Duration of symptoms >3 hours/4.5hours
from likely time of initiation of tPA infusion,
or time of symptom onset not known
• Minor neurological symptoms or
symptoms rapidly improving
• Severe s---e as assessed clinically or by
appropriate imaging techniques
Exclusion criteria used in the SITS-MOST study of relevance to the
on-call general physician
• Seizure onset at s---e onset
• Symptoms suggestive of subarachnoid
haemorrhage, even if the CT scan is
normal
• Administration of heparin within the
previous 48 hours and a thromboplastin
time exceeding the upper limit of normal
• Past history of s---e and concomitant
diabetes (controversial)
Exclusion criteria used in the SITS-MOST study of
relevance to the on-call general physician
• Previous s---e within last three months
• Known platelet count of <100,000/mm3
• Systolic blood pressure >185mmHg or
diastolic blood >110mmHg, or the need to
treat aggressively with IV medication to
achieve these levels.
• Blood glucose <50 or > 400mg/l
• Known haemorrhagic diathesis
Exclusion criteria used in the SITS-MOST study of
relevance to the on-call general physician
• Warfarin therapy (although it is considered
appropriate if INR<1.4)
• Recent or current bleeding
• Known history of or suspected intracranial
haemorrhage
• Presenting symptoms and signs, or disability,
likely to be due to recent or past subarachnoid
haemorrhage
• Known CNS disease e.g. neoplasm, aneurysm,
past intracranial or spinal surgery
• Haemorrhagic retinopathy
Stop tPA
Seek immediate medical advice
Administer oxygen if sats low
Anaphylaxis
Give Hydrocortisone 200mg and Chlorpheniramine 10mg IV
If circulatory collapse and IV access give 100micrograms (1ml) to
200micrograms (2ml) of 1 in 10,000 IV Epinephrine then review response
(NB no IM epinephrine)
Stop tPA
Seek immediate medical advice-recheck Bp in 5 mins if lowered –
recommence Tpa BP stable if still elevated commence treatment
If Systolic 185 mmHg or Diastolic  110mmHg
First Line:Labetalol 10mg IV over 2 minutes.
May repeat or double every 10 minutes to a total dose of 150mg
Or: give initial dose then infusion at 2mg/min, titrated to 8mg/min
as needed
Second line: Administer GTN 10micrograms/min & titrate
Hypertension
Suspected bleeding
– Stop tPA!
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Suspect if headache, nausea and vomiting, fall in GCS, new focal neurological
signs or acute hypertension
Check bloods for APPT, INR, FBC, group and save and clotting screen
Arrange urgent CT scan
If Intracerebral or life - threatening systemic bleeding give the following:
Administer Fibrinogen Concentrate
A standard dose of fibrinogen for an average size person would be about 4gm
and then check the fibrinogen straight after the infusion.
In addition if severe beleeding consider an anti-fibrinolytic ie tranexamic acid
500mg IV 6 hourly in the acute phase.
If platelets below 100 and life threatening bleed or ICH administer platelets
All available from Blood bank
NB fibrinogen concentrate is not licensed in the UK and so would be on a
named patient basis
But what are we dealing with?
• Justification for not using the s---e word
Conclusions
• Think anatomy first
• Then pathology
• Thank you