RECOMMENDATIONS FOR STROKE MANAGEMENT
BRAIN ATTACK
•Acute stroke = „brain attack” •Every minute matters: „time is brain” •Combat therapeutic nihilism
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Optimal stroke care: principles
Acute stroke = medical emergency All patients should have: hospital evaluation and treatment, preferably within 3 hours rapid access to specialised stroke units or stroke teams Single hospital or department responsible for stroke services Co-ordination for each geographical area/population
PRIMARY PREVENTION
Primary Prevention
•Conditions and lifestyle factors identified as a risk for stroke: –arterial hypertension –myocardial infarction –atrial fibrillation –diabetes mellitus –elevated cholesterol levels –carotid artery disease –smoking –alcohol use –physical activity
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Primary Prevention
EUSI-recommendations 1.BP measurement should be an essential component of regular health care visits; BP should be lowered to normal (120/80mmHg) values by means of life-style and/or pharmacological treatment(Level I) 2.Blood glucose should be checked regularly. In diabetic patients high blood pressure should be managed intensively aiming for levels below 130/80 mmHg (angiotensin converting inhibitor or angiotensin receptor agonist.
•EUSI-recommendations
Primary Prevention
3. Blood cholesterol should be checked regularly. It is recommended that high blood cholesterol (LDL > 150 mg/dl) should be managed with lifestyle modification and a statin.
4. Cigarette smoking should be discouraged(Level II)
Primary Prevention
•EUSI-recommendations 5. Heavy use of alcohol should be avoided, while moderate consumption may be permitted(Level II)
6. Regular physical activity is recommended(Level II)
7. A diet low in salt and saturated fat,high in fruit and vegetables and rich in fibre is recommended (Level B)
Primary Prevention
•EUSI-recommendations 8. Subjects with an elevated body mass index are recommended to take a weight-reducing diet (Level B)
9. Antioxidant vitamins supplements are not recommended (Level A)
10. Hormone replacement therapy is not recommended for the primary prevention of stroke
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Primary Prevention
Antithrombotic therapy 1. Low-dose aspirin is recommended in women aged 45 years or more who are not at increased risk for intrecerebral haemorrhage and who have good gastrointestinal tolerance; however, its effect is very small (Level I) 2. It is recommended thart low-dose aspirin may be considered in men for the primary prevention of myocardial infarction; however, its does not reduce the risk of ischaemic stroke (Level I) 3. Low dose aspirin is recommended forpatients with asymptomatic internal carotid artery (ICA) stenosis >50% to reduce their risk of vascular events (Level II)
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Primary Prevention
Atrial fibrillation: EUSI-recommendations 1.Long-term oral anticoagulation therapy (target INR 2.5; range 2.0 -3.0) should be considered for all AF patients who are at high risk for stroke(Level I) 2. Patients aged less than 65 years with no cardiovascular disease or patients who are unable to receive anticoagulants should be offered aspirin (Level I) 3. Patients who are aged 65-75 years,without risk factors could be offered both AC and aspirin(Level I)
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Primary Prevention
Atrial fibrillation: EUSI-recommendations 4. Oral anticoagulation (INR 2.0-3.0) is recommended for patients with non-valvular AF who are aged >75, or who are younger but have risk factors such as high blood pressure, left ventricular dysfuntion or diabetes mellitus (Level I) 5. It is recommended that patients with AF who have mechanical prosthetic heart valves should receive long-term anticoagulation with targed INR based on the prosthetic type, but not less than INR 2-3 (Level II)
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Primary Prevention
Asymptomatic carotid artery stenosis Carotid surgery is not recommended for asymptomatic individuals with significant carotid stenosis (NASCET 60-99%), except in those at high risk of stroke (Class I, Level C) Carotid angioplasty, with or without stenting, is not recommended for patients with asymptomatic carotid stenosis (Class IV, GCP) It is recommended that patients should take aspirin before and after surgery (Class I, Level A)
ACUTE STROKE MANAGEMENT
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Acute Stroke Care-Emergency Diagnostic Tests
Differentiation between different types of stroke Ruling out other brain diseases Assessing the underlying cause of brain ischemia Providing a basis for physiological monitoring of the stroke patient Identifying concurrent diseases or complications associated with stroke
Emergency Diagnostic Tests
•Cranial computed tomography (CCT) –distinguishes reliably between hemorrhagic and ischemic stroke –early signs of ischemia detected as early as 2 h after stroke onset –identifies hemorrhages almost immediately –detects SAH in the majority of cases –helps to identify other neurological diseases (e.g. neoplasms)
Emergency Diagnostic Tests
•Magnetic resonance imaging (MRI) –only helpful in centres using modern MRI techniques –diffusion-and perfusion-weighted MRI may help to differentiate between infarcted tissue and tissue at risk
Emergency Diagnostic Tests
•Electrocardiogram –high incidence of heart involvement in stroke patients –coincidence of stroke and myocardial infarction –ischemic stroke may cause arrhythmias –detection of atrial fibrillation as a possible cause of embolic stroke
Emergency Diagnostic Tests
•Ultrasound studies –cw/pw-Doppler and/or duplex sonography of the extracranial cervical and the basal intracranial arteries •identification of vessel stenosis, occlusion, state of collaterals, or recanalisation –transesophageal echocardiography to screen for cardiogenic emboli (not in the ER but recommended within the first 24 h after stroke onset)
•Laboratory tests –hematology –clotting parameters –electrolytes –renal and hepatic chemistry –cardiac enzymes –basic parameters of infection
Emergency Diagnostic Tests
Acute Stroke Care-General Management
•EUSI-recommendations include –Pulmonary and airway care –Blood pressure –Body temperature –Glucose metabolism –Fluid and electrolyte management
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Thrombolytic Therapy
EUSI Recommendations (for centers offering thrombolysis)
Intravenous rtPA (0.9 mg/kg body weight, maximum 90 mg), with 10% of the dose given as a bolus followed by a 60-minute infusion, is recommended within 4.5 hours of onset of ischaemic stroke(Class I, Level A), although treatment between 3 and 4.5 h is currently not included in the European labelling (modified January 2009).
Thrombolytic Therapy
•EUSI Recommendations •The use of multimodal imaging criteria may be useful for patient selection for thrombolysis but is not recommended for routine clinical practice (Class III, Level C) •It is recommended that blood pressures of 185/110 mmHg or higher is lowered before thrombolysis (Class IV, GCP) •It is recommended that intravenous rtPA may be used in patients with seizures at stroke onset, if the neurological deficit is related to acute cerebral ischaemia (Class IV, GCP)
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Thrombolytic Therapy
EUSI Recommendations The use of multimodal imaging criteria may be useful for patient selection for It is recommended that intravenous rtPA may also be administered in selected patients under 18 years and over 80 years of age, although this is outside the current European labelling (Class III, Level C) Intra-arterial treatment of acute MCA occlusion within a 6-hour time window is recommended as an option (Class II, Level B) Intra-arterial thrombolysis is recommended for acute basilar occlusion in selected patients (Class III, Level B). Intravenous thrombolysis for basilar occlusion is an acceptable alternative even after 3 hours (Class III, Level B)
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Thrombolytic Therapy
EUSI Recommendation It is recommended that aspirin (160–325 mg loading dose) be given within 48 hours after ischaemic stroke (Class I, Level A) It is recommended that if thrombolytic therapy is planned or given, aspirin or other antithrombotic therapy should not be initiated within 24 hours (Class IV, GCP) The use of other antiplatelet agents (single or combined) is not recommended in the setting of acute ischaemic stroke (Class III, Level C)
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Thrombolytic Therapy
EUSI Recommendation The administration of glycoprotein-IIb-IIIa inhibitors is not recommended (Class I, Level A) Early administration of unfractionated heparin, low molecular weight heparin or heparinoids is not recommended for the treatment of patients with acute ischaemic stroke (Class I, Level A) Currently, there is no recommendation to treat ischaemic stroke patients with neuroprotective substances (Class I, Level A)
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General stroke treatment
EUSI-recommendation Intermittent monitoring of neurological status, pulse, blood pressure, temperature and oxygen saturation is recommended for 72 hours in patients with significant persisting neurological deficits (Class IV, GCP) It is recommended that oxygen should be administered if the oxygen saturation falls below 95% (Class IV, GCP) Regular monitoring of fluid balance and electrolytes is recommended in patients with severe stroke or swallowing problems (Class IV, GCP)
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General stroke treatment
EUSI-recommendation Normal saline (0.9%) is recommended for fluid replacement during the first 24 hours after stroke (Class IV, GCP) Routine blood pressure lowering is not recommended following acute stroke (Class IV, GCP) Cautious blood pressure lowering is recommended in patients with extremely high blood pressures (>220/120 mmHg) on repeated measurements, or with severe cardiac failure, aortic dissection, or hypertensive encephalopathy (Class IV, GCP) It is recommended that abrupt blood pressure lowering be avoided (Class II, Level C)
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General stroke treatment
EUSI-recommendation It is recommended that low blood pressure secondary to hypovolaemia or associated with neurological deterioration in acute stroke should be treated with volume expanders (Class IV GCP) Monitoring serum glucose levels is recommended (Class IV, GCP) Treatment of serum glucose levels >180 mg/dl (>10 mmol/l) with insulin titration is recommended (Class IV, GCP) It is recommended that severe hypoglycaemia (<50 mg/dl [<2.8 mmol/l]) should be treated with intravenous dextrose or infusion of 10–20% glucose (Class IV, GCP points) • • • • General stroke treatment EUSI-recommendation It is recommended that the presence of pyrexia (temperature >37.5°C) should prompt a search for concurrent infection (Class IV, GCP) Treatment of pyrexia (temperature >37.5°C) with paracetamol and fanning is recommended (Class III, Level C) Antibiotic prophylaxis is not recommended in immunocompetent patients (Class II, Level B)
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Elevated Intracranial Pressure and Brain Edema Treatment
EUSI-recommendation Surgical decompressive therapy within 48 hours after symptom onset is recommended in patients up to 60 years of age with evolving malignant MCA infarcts (Class I, Level A) It is recommended that osmotherapy can be used to treat elevated intracranial pressure prior to surgery if this is considered (Class III, Level C)
Elevated Intracranial Pressure and Brain Edema Treatment
•EUSI-recommendations •No recommendation can be given regarding hypothermic therapy in patients with space-occupying infarctions (Class IV, GCP) •It is recommended that ventriculostomy or surgical decompression be considered for treatment of large cerebellar infarctions that compress the brainstem (Class III, Level C)
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Rehabilitation
EUSI Recommendations Admission to a stroke unit is recommended for acute stroke patients to receive coordinated multidisciplinary rehabilitation (Class I, Level A) Early initiation of rehabilitationis recommended (Class III, Level C) It is recommended that early discharge from stroke unit care is possible in medically stable patients with mild or moderate impairment providing that rehabilitation is delivered in the community by a multidisciplinary team with stroke expertise (Class I, Level A) It is recommended to continue rehabilitation after discharge during the first year after stroke (Class II, Level A) Itis recommended to increase the duration and intensity of rehabilitation (Class II, Level B)
SECONDARY PREVENTION
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Secondary Prevention
EUSI-recommendations It is recommended that blood pressure be checked regularly. Blood pressure lowering is recommended after the acute phase, including in patients with normal blood pressure (Class I, Level A) It is recommended that blood glucose should be checked regularly. It is recommended that diabetes should be managed with lifestyle modification and individualized pharmacological therapy (Class IV, GCP) In patients with type 2 diabetes who do not need insulin, treatment with pioglitazone is recommended after stroke (Class III, Level B)
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Secondary Prevention
EUSI-recommendations Statin therapy is recommended in subjects with non-cardioembolic stroke (Class I, Level A) ?It is recommended that cigarette smoking be discouraged (Class III, Level C) It is recommended that heavy use of alcohol be discouraged (Class IV, GCP) Regular physical activity is recommended (Class IV, GCP) A diet low in salt and saturated fat, high in fruit and vegetables, and rich in fibre is recommended (Class IV, GCP)
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Secondary Prevention
EUSI-recommendations Subjects with an elevated body mass index are recommended to adopt a weight-reducing diet (Class IV, Level C) Antioxidant vitamin supplements are not recommended (Class I, Level A) Hormone replacement therapy is not recommended for the secondary prevention of stroke (Class I, Level A)
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Secondary Prevention
EUSI-recommendations Sleep-disordered breathing such as obstructive sleep apnoea is recommended to be treated with continuous positive airway pressure breathing (Class III, Level GCP) It is recommended that endovascular closure of PFO be considered in patients with cryptogenic stroke and high risk PFO (Class IV, GCP)
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Secondary Prevention
EUSI-recommendation It is recommended that patients not requiring anticoagulation should receive antiplatelet therapy(Class I, Level A). Where possible, combined aspirin and dipyridamole, or clopidogrel alone, should be given. Alternatively, aspirin alone, or triflusal alone, may be used (Class I) The combination of aspirin and clopidogrelis not recommendedin patients with recent ischaemic stroke, except in patients with specific indications (e.g. unstable angina or non-Q-wave MI, or recent stenting); treatment should be given for up to 9 months after the event (Class I) It is recommended that patients who have a stroke on antiplatelet therapy should be re-evaluated for pathophysiology and risk factors (Class IV)
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Secondary Prevention
EUSI-recommendation Oral anticoagulation(INR 2.0–3.0) is recommended after ischaemic stroke associated with AF(Class I, Level A). Oral anticoagulation is not recommended in patients with co-morbid conditions such as falls, poor compliance, uncontrolled epilepsy, or gastrointestinal bleeding (Class III, Level C). Increasing age alone is not a contraindication to oral anticoagulation (Class I, Level A) It is recommended that patients with cardioembolic strokeunrelated to AF should receive anticoagulants (INR 2.0-3.0) if the risk of recurrence is high(Class III, Level C)
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Secondary Prevention
EUSI-recommendation It is recommended that anticoagulation should not be used after non-cardio-embolic ischaemic stroke, except in some specific situations, such as aortic atheromas, fusiform aneurysms of the basilar artery, cervical artery dissection, or patent foramen ovale in the presence of proven deep vein thrombosis (DVT) or atrial septal aneurysm(Class IV, GCP) It is recommended that combined low dose aspirin and dipyridamole should be given if oral anticoagulation is contraindicated (Class IV, GCP)
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Secondary Prevention
Carotid Endarterectomy (CEA) CEA is recommended for patients with 70–99% stenosis (Class I, Level A). CEA should only be performed in centres with a perioperative complication rate (all strokes and death) of less than 6% (Class I, Level A) It is recommended that CEA be performed as soon as possible after the last ischaemic event, ideally within 2 weeks (Class II, Level B)
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Secondary Prevention
Carotid Endarterectomy (CEA) It is recommended that CEA may be indicated for certain patients with stenosis of 50–69%;maleswith very recent hemispheric symptoms are most likely to benefit (Class III, Level C). CEA for stenosis of 50–69% should only be performed in centres with a perioperative complication rate(all stroke and death) of less than 3%(Class I, Level A) CEA is not recommendedfor patients with stenosis of less than 50% (Class I, Level A) It is recommended that patients remain on antiplatelet therapy both before and after surgery (Class I, Level A)
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Secondary Prevention
Percutaneous Transluminal Angioplasty (PTA) Carotid percutaneous transluminal angioplasty and/or stenting (CAS) is only recommended in selected patients(Class I, Level A). It should be restricted to the following subgroups of patients with severe symptomatic carotid artery stenosis: those with contra-indications to CEA, stenosis at a surgically inaccessible site, re-stenosis after earlier CEA, and post-radiation stenosis(Class IV, GCP). Patients should receive a combination of clopidogrel and aspirin immediately before and for at least 1 month after stenting (Class IV, GCP) It is recommended that endovascular treatment may be considered in patients with symptomatic intracranial stenosis (Class IV, GP