1. Professor Phyo Kyaw Myint Clinical Chair in Medicine (Old Age)
Stroke Management
Professor Phyo Kyaw Myint
Clinical Chair in Medicine (Old Age)

2. Outline Definition/classification Diagnosis Acute management
- Hyperacute stage
- Acute physiological monitoring and management
Complications of thrombolysis and management

3. Definition
Stroke is a clinical syndrome characterised by rapidly developing clinical symptoms and/or signs of focal neurological deficit lasting more than 24 hours and thought to be of vascular origin [Warlow et al, 1996].
This definition arbitrarily distinguishes stroke from a Transient Ischaemic Attack (TIA) where symptoms last less than 24 hours.
However, the distinction between them is controversial [Albers et al, 2002].

4. Classification Ischaemic Stroke Haemorrhagic stroke
Anatomical classification
Oxfordshire Community Stroke Project (OCSP) Classification
TACS – Total Anterior Circulation Stroke
PACS –Partial Anterior Circulation Stroke
LACS –Lacunar Stroke
POCS – Posterior Circulation Stroke
PICH- Primary Intracerebral Haemorrhage
Undetermined
Pathophysiological classification
Ischaemic Stroke
Haemorrhagic stroke

5. Haemorrhagic stroke (ICH)
Ischaemic stroke
Small deep infarcts (lacunar)
Cardio-embolic
Large artery infarcts
Artery-to-artery embolism
Extracranial occlusion
Intracranial atherosclerosis
Arterial dissection (carotids/vertebral)
Arteritis
Cryptogenic
Haemorrhagic stroke (ICH)
Primary
Amyloid angiopathic or hypertensive)
Secondary
- AVM
- Aneurysm
- Coagulopathy (warfarin)

6. Hyperacute phase (< 6hrs)
Need to be quick: “time is brain”
Need to triage in A&E as potential thrombolysis
NIHSS and OCSP classification if FAST positive

7. Face Arm Speech Test (FAST) screening for paramedics/nurses Harbison
Face Arm Speech Test (FAST) screening for paramedics/nurses Harbison. Stroke 2003;34;71-76.

8. Stroke mimics

9. Problems of clinical diagnosis
Note
Problems of clinical diagnosis
within 6 hours of onset
Approximately 75% of conditions mimicking stroke are neurological
How many of these can be identified by CT?
~15% of non-stroke disorders (e.g. SDH) diagnosed by CT
rest diagnosed clinically/with other tests
CT < 6hrs of ischaemic stroke often normal
If CT is normal
Often need stroke specialist or neurologist to confirm clinical
diagnosis of stroke before thrombolysis or thrombectomy:
Avoid thrombolysis for migraine, focal epilepsy, ‘functional
weakness’, ischaemic deficit after subarachnoid haemorrhage!

10. Clinical pointers for thrombolysis
Likely to be eligible
Known time of onset
Abnormal vascular signs (AF, PVD)
Unilateral neurological signs
Can assign an OCSP classification
Increasing NIH score
Likely to be not eligible
prior cognitive impairment
LOC early
Seizure
can walk now ( too mild)

11. Indications for urgent CT scan are
Suspected SAH or infective pathology e.g. meningitis/encephalitis
Patients on anticoagulation
Patients with deteriorating or fluctuating level of consciousness
When thrombolysis treatment is considered appropriate
History of or suspicious of head injury and/or sub/extradural haematoma

12. Thrombectomy in ischaemic stroke
As soon as possible after the onset of stroke symptoms
CT scan and a CT or MR angiogram to confirm the presence of a major vessel occlusion.
under sedation, but sometimes general anaesthesia is used.
A delivery catheter is inserted, usually through the femoral artery in the groin, and advanced into the occluded artery using X‑ray guidance.
A clot‑retrieval device attached to a guidewire is introduced through the delivery catheter to the site of the occlusion, to remove the clot and re‑establish blood flow to the affected part of the brain.
Many patients will also have had initial treatment with intravenous thrombolysis.
Analysis of the five trials and the Catalan population-based SONIIA registry revealed that the observed number needed to treat (NNT) of 5 to reach a modified Rankin scale (mRS) score of 0-2 only applies to approximately 1 % of all stroke patients. (Breuer et al. 2016)

13. Thrombolysis Symptoms and signs of clinically definite acute stroke.
Time of stroke onset is known and treatment can be started within 4.5 hours of onset
CT or MRI brain scan has reliably excluded both intracranial haemorrhage and structural brain lesions which can mimic stroke.
The patient was independent in activities of daily living before this stroke.
Major surgery, trauma (e.g. major fall at time of stroke) or gastrointestinal or urinary tract haemorrhage within the previous 3 weeks.
Arterial puncture at a non-compressible site within a week.
Current/recent oral anticoagulant therapy with INR > 1.4.
Current heparin therapy (including LMWH)
Known defect of clotting or platelet function or low platelet (<105/mm cu)
Pregnancy and/or breast feeding
Hypoglycaemia (blood glucose <2.7 mmol/L)- or hyperglycaemia (blood glucose > 22.1 mmol/L)
Patient has other life threatening illness with guarded prognosis
Severe stroke assessed by NIHSS score > 25
Epileptic seizure at the onset of stroke
Prior stroke within last 3 months
History of prior stroke and concomitant diabetes
Systolic blood pressure > 185 mmHg or diastolic blood pressure > 110 mmHg
Minor or rapidly improving neurological symptoms prior to treatment
Known or suspected history of intracranial structural pathology including SAH, sub/extradural haematoma or neoplasm
Haemorrhagic retinopathy
Systematic disease which potentially can lead to haemorrhage (e.g. acute pancreatitis, oesophageal varices, severe liver disease)

14. Rankin 0-1 at day 90 (adjusted OR with 95% CI) N =2776

15. NNT Lansberg et al, 2009, Stroke
Pooled data set of the first 6 major randomized acute stroke trials
3.6 for patients treated between 0 and 90 minutes,
4.3 with treatment between 91 and 180 minutes,
5.9 with treatment between 181 and 270 minutes, and
19.3 with treatment between 271 and 360 minutes.
The NNT for harm estimates for the corresponding time intervals are 65, 38, 30, and 14.

16. IST-3 Lancet Neurology 2013 FINDINGS (N=3035)
Mortality at 18 months, 34·9% Vs. 35·1% (p=0.85)
35·0% cf. 31·4% had an OHS score of 0-2 (p=0·024).
A favourable shift in the distribution of OHS grades (p=0·002).
Treatment was associated with significantly higher overall self-reported health (adjusted mean difference in EQ utility index 0·060; p=0·019).
IST-3 provides evidence that thrombolysis with intravenous alteplase for acute ischaemic stroke does not affect survival, but does lead to statistically significant, clinically relevant improvements in functional outcome and health-related quality of life that are sustained for at least 18 months.

17. Immediate management steps
General and Supportive measures
Establish correct diagnosis (as above)
Attend ABC (Airways, Breathing and Circulation) if appropriate
Monitor conscious level and neuro-observation
Normalise physiological parameters such as oxygenation, glycaemic control, temperature
Blood pressure (BP) monitoring
Swallowing assessment
Hydration
Prevention of complications e.g. DVT, bedsores, aspiration
Specific measures
Admit to an acute stroke unit
Thrombolysis should be considered in appropriate cases and offered if the service is available locally
Ischaemic stroke due to carotid or vertebral dissection need a special management
Anticoagulation is not recommended in newly diagnosed atrial fibrillation

18. Special circumstances
Carotid dissection
younger patients
without vascular risk factors
preceding episode of cervical strain or injury
Urgent carotid imaging is indicated
Anticoagulation should be considered and discussion should be made with a stroke consultant.

19. Special circumstances
Blood pressure monitoring in these patients is vital. Systolic blood pressure (SBP) should be kept at least below 180 mm Hg and mean arterial pressure (MAP) should be lower than 130 mmHg
Seizures should be treated after the first occurrence. Prophylactic anticonvulsant is not currently recommended in UK and European guidelines.
Neurosurgical opinion should be sought when appropriate especially if there is evidence of hydrocephalus or raised intracranial pressure. Main results of STICH trial showed no evidence of an overall benefit of early surgery when compared to initial conservative treatment [Mendelow et al, 2005].
For all secondary causes of ICH, the underlying aetiology should be addressed and treated if possible (e.g. aneurysm, anticoagulation).

20. Complications due to thrombolysis
Anaphylaxis
Haemorrhage
Intra-cerebral haemorrhage

21. Allergic reactions
Anaphylactoid reaction, laryngeal oedema, orolingual angioedema, rash, and urticaria
usually respond to conventional therapy
many of these patients received concomitant ACEI therapy
Most cases resolved with prompt treatment; there have been rare fatalities as a result of upper airway haemorrhage from intubation trauma
Other Adverse Reactions
-Nausea and/or vomiting, hypotension and fever

22. ICH Symptomatic ICH Non-symptomatic ICH
“contemporaneous neurological worsening” (Levy et al, 1994)
“ any CT-documented haemorrhage that was temporally related to deterioration in the patient’s clinical condition in the judgement of the clinical investigator” (NINDS, 1995)
“an increase of 4 or more points in the NIHSS score within 36 hours from treatment initiation associated with any intracranial blood on CT.” (PROACT II, 2001)
Non-symptomatic ICH

23. Risk factors for ICH post throbolysis
Stroke severity, cerebral oedema or mass effect on CT prior to Rx
ECASS 2- rtPA, h/o CHF, extent of parenchymal hypoattenuation on baseline CT, increasing age
PROACT II- baseline hyperglycaemia > 200mg/dL
Protocol violation! ?? Post thrombolytic unfractionated heparin use

24. Management of Bleeding Complications
Guided by
(1) the location and size of the hematoma
(2) the likelihood that the bleeding can be controlled mechanically
(3) the risk of neurological worsening or death
(4) the interval between administration of the drug and the onset of haemorrhage
If bleeding is suspected
For all potentially life-threatening haemorrhages, including suspected intracranial bleeding, ongoing infusion of a thrombolytic drug should be stopped immediately.
FBC, APTT, PT/INR, and fibrinogen.
Grouped and matched if transfusions are needed
(at least 4 U of packed red blood cells, 4 to 6 U of cryoprecipitate or fresh frozen plasma, and 1 U of single donor platelets).
These therapies should be made available for urgent administration.

25. Management of Bleeding Complications
Could it be controlled mechanically?
-Compression
Treat hypotension or hypovolemic shock
Urgent CT of the brain is needed if an intracranial haemorrhage is suspected; if bleeding is demonstrated  neurosurgical consultation
Surgery is delayed until the fibrinolytic state is corrected. For patients with severe non-neurological haemorrhage, emergency imaging studies should be performed before prescribing any surgical or medical therapy. Surgical interventions usually are delayed until the fibrinolytic state is corrected.

26. Surgical vs. medical therapy
Surgical removal
Superficial
Clot volume ml
Worsening neurological status
Relatively young
Midline shift/raised ICP
Cerebellar haematoma >3 cm/causing hydrocephalus
Medical therapy
Large haematoma with moribund patient (GCS<5)
Oriented patient with small haematoma

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28. ACTRA Aberdeen
The key objective of the ACTRA is to promote the health and independence of older people through research which:
increases knowledge about novel risk factors and prognostic markers for common conditions of older age
facilitates the interaction between clinical and experimental researchers and provides training for students and staff interested in ageing-related research
identifies personalised optimal treatment targets for relevant outcomes
develops and tests new therapies, and undertakes lifestyle, clinical and service interventions that aim to improve the health and healthcare of ageing populations

29. Thank you for your attention