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Treatment Of Acute Ischemic Strokes

Dr Sanjith Aaron

Dept. of Neurology

Christian Medical College,

Vellore

1. Pathophysiology

2. Assessment

3. Treatment

1. Pathophysiology

2. Assessment

3. Treatment

Stroke mechanisms:

1. Embolic

2. Atherosclerosis

3. Low-flow

4. Lacunar

Distant source – Cardiac

Artery to artery - Carotids

Embolic

Atrial Fibrillation

Rheumatic Heart Disease

Atherosclerosis

Thrombus developing

on an atherosclerotic

plaque – Plaque

rupture

Diabetes

Hypertension

Smoking

Low-flow /

Hemodynamic strokes

Sudden drop in blood

pressure

Watershead infarcts

•Cardiac arrhythmia

•Myocardial infarction

•B P medications

Lacunar

Penetrating vessels

Lipohyalinosis

Atheromatous

Diabetes

Hypertension

• Progression of a large Ischemic stroke

CORE

Penumbra Large Infarct

Within 4 - 6 hours

30000 brain cells die

per second

1. Pathophysiology

2. Assessment -

3. Treatment

Clinical / Imaging

• Level of consciousness

• Orientation

• Comprehension

• Gaze

• Visual fields

• Facial motor function

• Limbs motor function (R and L scored independently )

• Limb ataxia (cannot be tested in presence of paresis)

• Sensory function

• Language

• Articulation

• Extinction or inattention (neglect)

Clinical

NIH Stroke Scale (NIHSS)

Composed of 11 items adding up

to a total score of 0 to 42

The higher the score – the more severe

NIH Score Good Outcome at 3 Months

The higher the stroke

severity - as measured by

the NIH Score –

The worse the outcome

Especially in the elderly

Imaging assessment

3 P s

CORE

Penumbra

Which vessel is

occluded (Pipe)

How much brain is already

Infarcted (Parenchyma)

Is there any more tissue

at risk (Penumbra)

CORE

How much brain is already

Infarcted (Parenchyma)

CT vs MRI

CT Scan – Fast

Easily available

Differentiate hemorrhage better

MRI Scan – Pick up early Ischemia (15 mts)

Posterior circulation pick up better

60 Minutes into stroke – CT Vs MRI

Diffusion restriction

Seen within 15 minutes DWI ADC

Loss of the insular ribbon sign refers to a loss

of definition of the gray-white interface in the

lateral margin of the insular cortex ("insular

ribbon")

Dense MCA sign

Plain CT Scan – Hyperacute phase

Sulci and gyri ironed out

2 slices:

Basal ganglia

Supra ganglionic level

ASPECTS score

0 - 5 Large Infarct Core

6 – 7 Moderate infarct Core

8- 10 Small Infarct core

ASPECTS score = < 7 predicts

1. Worse functional outcome at 3 months

2. Increased chance of symptomatic

haemorrhage.

ASPECTS score of 10 is Normal

Lower the ASPECTS – The more area damaged

CT - Established infarct

CORE

Which vessel is

occluded (Pipe)

How much brain is already

Infarcted (Parenchyma)

For successful treatment Vessel

imaging is essential

CORE

Penumbra

Which vessel is

occluded (Pipe)

How much brain is already

Infarcted (Parenchyma)

Is there any more tissue

at risk (Penumbra)

MR Perfusion Study

Cerebral Blood Volume

MTT

53 yrs Male –with R

Hemiplegia - 5 hours

25yrs Smoker

Wake-up stroke

Right hemiplegia

R - Neglect

Global aphasia

Large

penumbra

1. Pathophysiology

2. Assessment

3. Treatment

Treatments available for acute

ischemic stroke

CORE

Penumbra

Recanalization and

restoration of cerebral

blood flow

Acute stDefinitive therapy - Reperfusion

CORE

Penumbra

Recanalization and

restoration of cerebral

blood flow

Intra-venous thrombolysis

rtPA (Tissue Plasminogen

activator)

Acute stDefinitive therapy - reperfusion

Intravenous Thrombolysis

rtPA (Tissue Plasminogen activator)

Which patient can benefit form this

therapy?

Onset of symptoms <4.5 hours before

beginning treatment

Exclusion criteria

Significant stroke / head trauma < three months

Previous intracranial hemorrhage / Symptoms

suggestive of subarachnoid hemorrhage

Intracranial neoplasm

Active internal bleeding / Acute bleeding diathesis

Anticoagulant use with an INR >1.7

Heparin within 48 hours with elevated aPTT

Current stroke already involving >33 % MCA

Relative exclusion criteria

Major surgery or trauma in the previous 14 days

Gastrointestinal or urinary tract bleeding in the

previous 21 days

Pregnancy / Recent MI (<3 Months) Complicated by

pericardititis

Consider IA / Mechanical devices if available

0

1

2

3

4

5

6

7

8

50 60 70 80 90 100 110 120 130 140 150 160 170 180

Minutes from Stroke Onset to Start of Treatment

Od

ds R

ati

o f

or

Fa

vo

rab

le

Ou

tco

me a

t 3 M

on

ths

Relationship of Time to Thrombolyse and

Odds Ratio of Favorable Outcome

Benefit for rt-PA

No Benefit for rt-PA

Tpa can be given up to 4.5 hours

Needle Time NNT

(In minutes)

0 to 90 4.5

91 to 180 9

181 to 270 14

271 to 360 21.4

Lancet. 2010;375(9727):1695

Sonothrombolysis

Ultrasound enhanced

thrombolysis

(Sonothrombolysis )

Sonothrombolysis – 42 Male .Needle time 4 Hours

Drawbacks of IV thrombolysis

73%

30 - 40% 14%

Stroke. 1995;26(4):581.

Recanalization rates

at 8 and 24 hours after

thrombolysis

Site of occlusion

Contraindications for IV Tpa

• Patient on anticoagulation

• Pregnancy

• Post surgery

• Patient presenting beyond window period

of 4.5 hours – having a salvageable

penumbra

31 year old lady

8 months pregant

Known Rheumatic heart disease

Mitral Stenosis – on Warfarin

L Hemiplegia –

Time of onset -- 4 hours( not very certain)

Potential

infarct area

• Pregnancy

Tpa -relatively contraindicated

• Patient on warfarin

INR awaited

• Time of onset not very clear

IV Tpa window 4.5 hrs

• Proximal M1occlusion

IV Tpa 15 – 20% chance

Mechanical thrombectomy

--- The PENUMBRA Suction device

Angio –

MCA (M1) Cut off PENUMBRA suction

device catheter

Mechanical thrombectomy

Pre Post

Other Mechanical thrombectomy devices

Solitaire device

Merci

Solitaire™ FR Revascularization Device

Five multicenter open-label randomized controlled trials

•MR CLEAN

•ESCAPE

•SWIFT PRIME

•EXTEND-IA

•REVASCAT

Second-generation mechanical thrombectomy devices is superior to standard IV Tpa. – in strokes caused by a proven large artery occlusion in the proximal anterior circulation

2015 American Heart Association/American

Stroke Association Focused Update of the 2013

Guidelines for the Early Management of Patients

With Acute Ischemic Stroke -- Regarding

Endovascular Treatment

CORE

Penumbra

Recanalization and

restoration of cerebral

blood flow

Collateral flow –Maintain/

Augmentation

For thrombolysis

Systolic < 185 mmHg

Diastolic < 110 mmHg

If no thrombolysis

Diastolic <120mmHg

Systolic < 220mmHg

Never

reduce BP

abruptly

60 yr male –

Chronic smoker /diabetic

Newly diagnosed

hypertension – treated by a

GP - Ampodipine 5mg BD

R – Hemiparesis.

Recovered

Made to walk on 3rd day

Recurrence of weakness

CORE

Penumbra

Recanalization and

restoration of cerebral

blood flow

Collateral flow –Maintain/

Augmentation

Neuroprotection

Citicoline

Cytidyl diphosphocholine

Edaravone

Free Radical Scavenger

Cerebrolysin® peptide that stimulates

neurotrophic regulation

Surgical intervention

16h

Can treat with 3% Saline / Mannitol

Keep the neurosurgeon informed

No Aspirin / Clopodigrel / Warfarin / Heparin

16h 24h

48h:

hemicraniectomy

16h 24h

48h:

hemicraniectomy

16h

Cranioplasty after 4

months

24h

Early secondary preventive measures

Antiplatlet agents

Single antiplatlet Double antiplatlet

agents Aspirin

Clopidogrel

Cilazitazole

Dipyridamole

Anticoagulants : Warafarin /Acitrom

Newer oral anticoagulants ?

Cardiac Emboli

Carotid atherothrombus

Intracranial thrombus

Carotid disease Symptomatic Stenosis - 70 to 99 %

1. Recent

2. Nondisabling ischemic stroke

3. Life expectancy of at least five

years

Carotidendarterectomy (CEA)

Preferred over stenting)

Medical Rx High dose statins

Double antiplatlets

>70% stenosis Maximum benefit if CEA done < 2 weeks

50 -69% stenosis : benefit only if CEA done < 2 weeks

Acute Stroke

Important medical emergency

Brain Stroke = Brain Attack (Heart Attack)

??

Thank You

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