Acute Ischemic Stroke First Eight Hours Dr. Mohammed Ateequr Rahman MD, DNB(Neuro), FINS. Interventional Neurologist. Care Hospital Nampally.

Acute Ischemic Stroke – The Burden Third leading cause of death Leading cause of disability Permanent disability 15-30% Stroke Burden – India Prevalence 203 per 100,000 (Anand et al 2001) Incidence 105 per 100,000 (Benerjee et al 2001)

Case 1 A 55 yrs male presented to the emergency with acute onset of left side weakness of 80 minutes duration. He was hypertensive. No history of headache, vomiting, and seizures. Exam: BP: 190/110, Pulse: 78/min and regular, Temp: 980F, Left motor hemiparesis, left homonimous hemianopia, brisk left sided reflexes and left plantar up going (NIHSS: 18) Blood sugar: 120 mg/dL Platelets: 1.5 lakhs, PT: 14 sec

Loss of Insular with obliteration of sulcal and gyral spaces Case 1 Loss of Insular with obliteration of sulcal and gyral spaces

Time is Brain

Therapeutic Strategies in Acute Ischemic Stroke Reperfusion - Recanalization. Neuroprotection – No effective drug. Avert clot propagation – Efficacy of anticoagulants is still controversial. Prevent complications.

Acute ischemic stroke – Reperfusion Strategies. Recanalization or antegrade reperfusion approaches Intravenous and or Intra arterial Thrombolysis. Thrombolytic agents Plasminogen activators, direct fibrinolytics, fibrinogenolytic agents. Adjunctive therapy: heparin, direct thrombin inhibitors, GP IIb/IIIa antagonist Endovascular thrombectomy Distal devices: Merci, Phenox, Solitaire, Trevo, Neuronet, Catch, Attracter-18. Proximal devices: Alligator, In-time retriever, Snares. Endovascular thromboaspiration Pneumbra, Possis AngioJet, F.A.S.T. Funnel Catheter. Mechanical thrombus disruption Microguidewire, Snares, Balloon angioplasty, Omni Wave. Endovascular thrombus entrapment. Self expanding and balloon expandable stents. Temporary endovascular bypass Resheathable (closed-cell) stents, Solitaire, Trevo, Re Vasc. Alternate Reperfusion Approaches Global reperfusion ( flow augmentation or transarterial retrograde reperfusion) Pharmacological: Vasopressors Mechanical: NeuroFlo Transvenous retrograde reperfusion (flow reversal) Partial: Retrograde transvenous neuroperfusion Complete: ReviveFlow

Acute Ischemic Stroke: Intravenous tPA Treatment Window period < 4.5 hrs Normal CT or infarct less than 1/3 rd of MCA territory Moderate stroke (NIHSSS 4-20)

Ischemic Stroke – Intravenous tPA 1 in 10 more will be independent 1 in 14 will suffer symptomatic hemorrhage 1 in 100 fewer may die as a result of the treatment The success rates of the IV rt-PA treatment, based on anatomical location, are: Saqqur M et al. Clinical detrioration after intravenous rt-PA treatment, Stroke 2007;38 Alexandrov AV . Current and future recanalisation strategies for acute ischemic stroke. J. Intern. Med. 267, 209-219. Artery % Recanalisation Basilar 30 Terminal part of ICA 6 M1 part of MCA M2 part of MCA 44 Tandem ICA and MCA 27

Earlier The Treatment: Better The Outcome Time of Onset NNT <60mnts 1:2 60-90 1:4 90-180 1:9 180-270 1:21 Will likely become symptom free or have minimal residual symptoms if treated with IV Thrombolysis. Marler JR et al: Early stroke treatment associated with better outcome: NINDS rt-PA stroke study. Neurology 55, 1649-1655.

Intravenous tPA – Outcome: CARE Experience H S

Acute Ischemic Stroke – Thrombolysis Intra-arterial Thrombolysis Window periods: 4.5-8 hrs Stroke severity: NIHSS > 10 Vessel occluded: Mid to large size

Intra-arterial Thrombolysis

Intra-arterial Thromobolysis

Stroke Subtypes – Anticoagulation

Acute Ischemic Stroke: Antiplatelet Therapy IST and CAST - Aspirin Reduction in recurrent stroke: 7 per 1000 (p <0.000001) Reduction of death or dependency: 12 per 1000 (p<0.01) (Chen et al 2000)

Acute Ischemic Stroke: First Eight Hours Take Home Message Time window determines appropriate treatment and outcomes. Intravenous tPA is the treatment of choice in patients with onset <4.5hrs, moderate stroke (NIHSSS 4-20) and normal CT or infarct less than 1/3 rd of MCA territory. Intra-arterial therapy is feasible in appropriate condition and in failure of IV tPA cases. Judicious management of BP & blood sugar is of great importance during acute phase. Control of elevated temperature is essential as it is detrimental to injured brain. Care in the stroke unit is associated with better outcomes.

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