General measures of acute stroke management
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General measures of acute stroke management
Apostolos . HatzitoliosAssociate Professor of Internal Medicine1st Propedeutic Department of Internal MedicineDepartment of Vascular Diseases and HypertensionAristotle University of Thessaloniki, AHEPA HospitalThessaloniki, Central Macedonia, HELLAS
Emerging therapies for acute strokeMain target is the early intervention and preservation of penumbra within a short therapeutic interval before necrosis of ischemic area occurs. New drugs are tested on this direction. The development of specific therapeutic procedures is an important research priority.
Advances in this field aim mainly to enlarge the capability of thrombolysis use, despite limitations (since recovery may be achieved with a narrow time window of ~ 3-4.5 h).
Investigation interest is focusing on the: use of neuroprotective agents leading to expansion of the therapeutic window (over 3 h), immediate MRI with advanced sequences to refine the patient selection and reveal the exact size of infarct, use of next-generation thgrombolytics (plasminogen activators and glycoprotein IIb/ IIIa inhibitors), use of agents to avoid hemorrhagic transformation of large infarcts, endovascular approaches to thrombolysis and thrombectomy, and adjuvant use of ultrasound.
There is still also no proven therapy for intracerebral hemorrhage, although early results with recombinant activated factor VII look very promising.
Treatment strategies aiming mainly at stabilizing the critically ill patient in order to control systemic problems that may impair stroke recovery, become of the greatest clinical importance
Cardiac/respiratory careFluid and electrolyte balanceBlood pressure control Glucose metabolismBody temperatureDysphagia and nutritionGeneral measures of acute stroke management
Cardiac complications more frequent in ICH and SAH than in ischemic stroke
15-40% of stroke patients may experience - AMI - Congestive heart failure - Arrhythmias, particularly AF - Sudden death
There is a more significant correlation between cardiac complications and infarcts of the insular cortexCardiac care
Adequate oxygenation is important to preserve the penumbra.
Most common causes of hypoxia in stroke: - Preexisting pulmonary diseases - Airway obstruction due to cranial nerves paresis causing oropharyngeal muscular hypotonia or vomiting leading to aspiration (brainstem stroke, reduced vigilance) - Hypoventilation due to: Large hemispheric infarct or Brainstem infarct or hemorrhage Heart failure Pulmonary embolism Status epilepticusRespiratory care
Continuous cardiac monitoring in the first 48 hours Oxygenation monitoring and Oxygen administration in case of hypoxemia
Monitoring and correction of electrolyte and fluid disturbance
Hypotonic solutions are contraindicated due to the risk of brain oedema, caused by the reduced plasma osmolality
Cardiac / respiratory care & Electrolyte / fluid homeostasis
In hypertension, cerebral vessels adjust to elevated BP by wall thickening, increased resistance and shift of blood flow autoregulation at higher BP level. The problem is greater in older patients because of increased vascular resistance and decreased cerebral blood flow So, great and abrupt BP decrease results in blood flow disturbance, cerebral ischemia and cognitive function deterioration Management of Hypertension in stroke patients
Because of cerebral autoregulation abolishment in ischemic stroke area, blood flow is directly depended on systemic BP
406080100120140160180200220 transfer 2 hours later1st day2nd dayMean BP mm Hg Therefore, BP increases in acute stroke as response to stress due to increased levels of catecholamines and cortisol, in order to maintain blood flow in the critical ischemic penumbra, while
BP decreases automatically the next days
Target should be the progressively decrease of BP, < 15% /day, without orthostatic phenomena and hypotension, so that gradually more BP decrease becomes tolerable.
Routine BP lowering is not recommended, except for extremely elevated values which are lower for hemorrhagic strokes (>200-220 SBP or 120 DBP for ischemic, >180/105 for hemorrhagic stroke)
Immediate antihypertensive therapy for more moderate hypertension is recommended in heart failure, aortic dissection, acute MI or acute renal failure co-existence and in case of thrombolysis (avoid SBP above 180mmHg), but should also be applied cautiously.
Generally, recommended target BP in patients - with prior hypertension: 180/100-105mmHg - without prior hypertension: 160-180/100mmHg
4. Hypotension should be also avoided and treated (SBP < 120 mmHg) since hypovolemia could cause neurological deterioration
Blood pressure control & Management of hypotension
Narrow pathophysiological relationship between Hyperglycemia and Neuronal damage HyperglycemiaBrain ishemiaAnaerobic metabolism - glycolysisLactic production / lactic acidocis ( +) Free radicalsEndonucleasesGlutamicIntracellular Ca+2Mitochondrial damageintracellular oedemaIrreversible neuron cell damage
Hyperglycemia, but also hypoglycemia should be treated because they might worsen the ischemic damage and attenuate neuron metabolism and restoration respectively
Monitoring of serum glucose levels and treatment with insulin titration is recommended
Restoration to normal has to be gradual, especially in diabetics, in order to avoid intracellular neuron oedema
Immediate correction of hypoglycemia (i.v. dextrose) is also recommendedManagement of hyperglycemia & hypoglycemia
Experimentally fever increases infarct size
Body temperature increases in up to 50% of patients consequent to a severe brain infarct as an acute phase response High body temperature may favor stroke progression and long term bad outcome
Treatment of body temperature >37.5C and search of possible infection (site and etiology) is recommended
Dysphagia is present in up to 50% of patients
Predictor of poor prognosis enhancing the risk for aspiration and pneumonia, dehydration and malnutrition
Early commencement of nasogastric feeding, within 48 hours, is recommended in stroke patients with impaired swallowing while PEG (Percutaneous endoscopic gastrostomy) feeding after the first 2 weeks
TemperatureDysphagia & Feeding
Most frequent complications of acute stroke are - Bladder dysfunction and urinary tract infections - Bronchopneumonia - Decubital ulcers - Seizures - Deep vein thrombosis and pulmonary embolism
Low molecular weight heparin (or low dose subcutaneous heparin) should be considered for patients at high risk of DVT or PE. Anticoagulant therapy may add a further benefit during stroke in-evolution by preventing clot expansion.
Incidence of venous thromboembolism may be also reduced through early re-hydration and mobilization, as well as compression stockings
Regarding oxidative stress and its management, the favorable action of antioxidants like vitamin E, for the treatment of is controversial
Prevention of acute stroke complications
Prevention of stroke reccurenceSurgical or electrophysiological intervention& anticoagulation in patients with high embolic risk :
Atrial fibrillationValvular diseaseDilated cardiomyopathyPatent foramen ovale
Checking for stenosis in the carotids (common/internal) with Triplex Echo and CTA or MRA
Symptomatic carotid stenosis
> 70%:requires endarterectomy (at centers with perioperative mortality 60%,
Intervention is also discussed, since risk for stroke is also significant (annual 2%, expected reduction 1% )at centers with low perioperative mortality rate (
High co-existence percentage of CHD, CeVD & PADTotal risk management with common preventive measuresCoronary Heart diseasePeripheral arterydiseaseCerebrovascular disease15%33%14%12%5%13%8%Stroke = Clinical manifestation of Global Vascular DiseaseAtherothrombotic manifestation from a vascular area should alarm for the existence of vascular disease also in another area
Total Risk: Secondary Prevention ofCardio- Cerebro-Vascular & Renal DiseaseLifestyle Changes
Hypertension (< 130/80 mmHg)
Dyslipidemia (LDL< 100 mg/dl)
Diabetes ( HbA1c < 7%)
Antiplatelets/anticoagulantsAtherosclerosis progression as well as oxidative stress induction should be inhibited by use of agents exerting endothelium protection, inflammation decrease, stabilization of atherosclerotic plaque and - in case of stroke - possible neuroprotection from ischemia (RAS inhibitors, statins, vitamin E?)
International guidelines for stroke management& Secondary prevention after stroke/TIA
European Stroke Organization - ESO (formerly known as EUSI - European Stroke Initiative) Recommendations for stroke management