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Project: Ghana Emergency Medicine Collaborative
Document Title: The Management of Acute Ischemic Stroke & TIA
Author(s): Rashmi U. Kothari, M.D. (KCMS/MSU), 2012
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The Management of Acute Ischemic Stroke & TIA
Rashmi U. Kothari, M.D.Borgess Research InstituteDepartment of Emergency
MedicineKCMS/MSU
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65 y.o. Fire Chief w/ Lt arm numbness & weakness X 15 minutes
Has 15 minutes of symptoms now normal
Wife takes him to ED Now refuses to be
evaluatedNaval History and Heritage Command, flickr
4
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70 y.o male “found down” while cutting lawn
Last seen 1hr to 911 Rt arm/leg weakness Hx of HTN, DM,
resolved old stroke
cduruk, flickr
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41y.o male w/ Lt eye deviation & drooling. RN notes initial BP= 200/110
Brought to ED 5 hrs. after onset
Lt. Eye deviation, drooling, slurred speech
RN notes elevated BP=200/110
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The Management of Acute Ischemic Stroke & TIA
Rashmi U. Kothari, M.D.Borgess Research InstituteDepartment of Emergency
MedicineKCMS/MSU
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Stroke Chain of Survival & Recovery
Detection Dispatch/Decision Delivery
Door/TriageDecision DataDrug
Elsie esq., flickr Seattle Municipal Archive, Wikimedia Commons
Reytan, Wikimedia Commons
Paramedics Worldwide, Wikimedia Commons
8
Andrew Ciscal, Wikimedia Commons
?Valerie Everett, flickr
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Goals
Stroke definitions Management of TIA Management of Ischemic
Stroke– management of hyper-acute
stroke
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Definition of Stroke
Any disease process that decreases vascular blood flow to a certain region of the brain
causing neuronal cell death.
10Source undetermined Source undetermined
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Stroke Subtypes
Ischemic85%
Hemorrhagic 15%
Thrombotic Embolic Subarachnoid Hemorrhage
Intracerebral Hemorrhage 11
Sources of images undetermined
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Stroke Vocabulary
TIA : Symptoms <24 hrs Lacunar: Small infarcts “Mini-Strokes”: TIA
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Current Management of TIA
13
U.S. Navy, Wikimedia Commons Mvhayes, Wikimedia Commons
Novic84, Wikimedia Commons
Source undetermined
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Current Management of TIA
All new onset TIAs should be admitted!!!
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Short-term Prognosis after ED Diagnosis of TIA
Cohort study 1707 patients w/
TIAs Followed for 90 days 3/97-2/98 16 EDs
10.5% stroked 1/2 w/in 2 days 25% had:
– Stroke/TIA– Cardiac
hospitalization– Death
Johnson et al: JAMA 2000;28415
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Independent Risk Factor of Stroke within 90-days of a TIA
Odds Ratio
P value
Age>60 1.8 .01
Diabetes 2.0 <.001
>10 min duration
2.3 <.005
Weakness 1.9 <.001
Speech 1.5 .01
Johnson et al: JAMA 2000;28416
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90-day Stroke Risk by Number of Risk Factors
# RisksFactors
PatientsN=
Stroke w/in
90 days
0 22 0%
1 179 3%
2 509 7%
3 584 11%
4 337 15%
5 76 34% 17
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Medical Interventions in Patients with TIAs
Atrial fibrillation
Warfarin, Aspirin
Carotid stenosis
Heparin, Endarterecto
my, Cardiovascul
ar eventr/o MI
Stroke in-evolution
Thrombolysis, Heparin,
Endarterectomy
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Exceptions to the Rule PMH of Stroke/TIA
– Negative ED CT– recent negative stroke w/u– Close Follow-up
Minimal symptoms of short duration
– w/ negative ED w/u– Negative doppler or MRA– +Echo– Antiplatelet agent– Close Follow-up 19
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Current Management of TIA
All new onset TIA’s should be admitted!!!
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65 y.o. Fire Chief w/ Lt arm numbness & weakness X 15 minutes
Has 15 minutes of symptoms now normal
Wife takes him to ED Now refuses to be
evaluated
Naval History and Heritage Command, flickr
21
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Management of Ischemic Stroke
Diagnostic tests Anticoagulation BP management
22Source undetermined
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Diagnostic Tests
Priority studies Recommended studies
Elective studies
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Priority Studies
24Novic84, Wikimedia Commons
dextrostick
Source undetermined
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44 y.o male “found down” while cutting lawn
Last seen 1hr to 911 Rt arm/leg weakness Hx of HTN, DM, old
resolved stroke
cduruk, flickr
25
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Recommended Studies
CBC with platelets Basic Metabolic Panel
PT & INR CXR U/A
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Individualized Tests
Cardiac enzymes VDRL Antithrombin III antibodies Protein C & S deficiency Antiphospholipid antibodies
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Anticoagulation
Heparin, aspirin, ticlopidine, clopdiogrel, dipyridamole, warfarin
Commonly used Unproven efficacy in acute
stroke 28
and parsecs to go, flickr
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Antiplatelet Agents(aspirin, ticlopidine, clopdiogrel, dipyridamole)
Long-term reduction in stroke
Long-term reduction in cardiovascular events
Not proven in acute stroke
29and parsecs to go, flickr
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Antiplatelet Agents(aspirin, ticlopidine, dipyridamole, clopdiogrel*)
Event Risk ReductionNon-fatal
Stroke25%
Non-fatal MI 35%Vascular death 15%
Death any cause
15%30
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Heparin
Commonly used in acute setting
No data supporting it’s use
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International Stroke Trial (IST) 467 Hospitals 19,435 Patients
Factorial Design– Heparin 5,000/12,500
IU – Avoid Heparin
– Aspirin– No Aspirin
Treatment– w/in 48 hrs– for 14 days
Lancet 1997:34932
Heparin
Jcb10, Wikimedia Commons
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International Stroke Trial: ResultsHepari
n(N=9717
)
No Heparin(N=9718)
Events preventab
le per 1000
Ischemic Stroke
(recurrent)2.9% 3.8% 9*
Hemorrhagic Stroke 1.2% 0.4% -8*
Death or Non-fatal
Stroke11.7% 12% 4
Dead or Dependent 62.9% 62.9% 0
Transfused or fatal
hemorrhage1.3% 0.4% -9*
* 2p<0.05 Lancet 1997:34933
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1989 Survey of Neurologist Regarding Heparin Use
82% might decrease recurrent emboli
70% might be indicated in progressing stroke
6% thought proven useful
16% thought proven ineffective
Marsh et al: Neurology 198934
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High Risk Stroke/TIA Patients
Crescendo TIAs Vertebrobasilar TIA High grade carotid stenosis Carotid / verterbral
dissection Small cardioembolic stroke
35
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HEPARIN
36
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Thrombolytic Candidates
Can treat patients who are on aspirin
Avoid antiplatelet & anticoagulants X 24 hrs following thrombolysis
37
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Blood Pressure Management
Non-Thrombolytic Candidates
Thrombolytic Candidates– pre-treatment
Thrombolysied Patients– during & post-treatment
38
Mvhayes, Wikimedia Commons
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Blood PressureManagement In Stroke
39
Guidelines in old ACLS (Advanced Cardiac Life Support) Handbook
In ACLS cards that come with new handbook
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BP Management for Non-Thrombolytic Candidates
Recheck blood pressure
DON’T TREAT acutely!
40
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cc/min/gm 120/60 (MAP=80)
41
Source undetermined
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Current Guidelines Recheck BP Treat:
–Systolic BP >220-230–Diastolic BP >120-130
Reduce gradually42
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BP Management for Thrombolytic Candidates
Pre-Treatment– Be gentle
»Systolic 185>»Diastolic110>
During/Post-Tx– Be aggressive
»Systolic 185>»Diastolic105>
43
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BP Management
Non-Thrombolytic Candidate–Don’t Treat!!!
Pre-Thrombolysis–Be Gentle!!!
During & Post-Thrombolysis–Be Aggressive!!!
44
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41y.o male w/ Lt eye deviation & drooling. RN notes initial BP= 200/110
Brought to ED 5 hrs. after onset
Lt. Eye deviation, drooling, slurred speech
RN notes elevated BP=200/110
45
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Key Points
Admit all new onset TIAs Avoid heparin use Treat only extreme HTN
46
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70 y.o. female w/ Rt. sided weakness. RN notes initial BP= 200/110
Last seen normal 5 hrs. PTA
Slurred speech, Rt arm & leg weakness
RN notes elevated BP
47
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Effectiveness of Heparin In Progressive
Phase 1:–Late 1970’s–310 patients–↓speech/motor between 2 exams
–No Heparin
Phase 2:–Late 1980’s–907 patients–2 pt. ↓in SSS–Heparin infusion»No bolus»aPTT=50-80Journal Internal Med 2000:248
48
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41y.o male w/ Lt eye deviation & drooling. RN notes initial BP= 200/110
Brought to ED 5 hrs. after onset
Lt. Eye deviation, drooling, slurred speech
RN notes elevated BP=200/110
49