Prevention Strategies and Ischemic Stroke Management

Webinar
Webinar
15
15 Agustus
Agustus 2021
2021
PREVENTION
STRATEGIES AND
ISCHEMIC STROKE
MANAGEMENT
Aldy Safruddin Rambe
Fakultas
Fakultas Kedokteran
Kedokteran
Universitas
Universitas Sumatera
Sumatera Utara
Utara 1
Outline
1 Introduction
2 Diagnostic Approach in Acute Ischemic Stroke
3 Role of Primary and Secondary Ischemic Stroke Prevention

in Primary Care
4 Principles of Acute Ischemic Stroke Care
5 Acute Reperfusion Treatments : Intravenous Thrombolysis
Webinar | Prevention Strategies and Ischemic Stroke Management 2

Introduction
Therapeutic
Therapeuticapproach
approachto
toacute
acuteischemic
ischemicstroke
stroke
Over
Overpast
past22decades
decades has
hasbeen
beendeeply
deeplytransformed
transformed
Adoption
AdoptionofofIVIV That
Thatbegan
began25
25years
yearsago
ago
trombolysis
trombolysis
Acute Additional
Additionaltreatment
treatmentw/
w/
Acute
reperfusion mechanical
mechanicalthrombectomy
thrombectomy
reperfusion
The Severe
Severeneurologic
neurologicdeficit
deficitfrom
Themost
mosteffective
effective from
treatment aaproximal
proximalintracranial
intracranialvessel
treatmentfor
foracute
acute vessel
ischemic occlusion
ischemicstroke
stroke occlusion
Rabinstein AA. Update on Treatment of Acute Ischemic Stroke. Contin Lifelong Learn Neurol. 2020;268–86.

Definisi Stroke
Stroke adalah tanda-tanda klinis Stroke : is an episode of acute
yang berkembang cepat akibat neurological dysfunctions
gangguan fungsi otak fokal (atau presumed to be caused by
global), dengan gejala-gejala yang ischemia or hemorrhage,
berlangsung ≥ 24 jam atau persisting ≥24 hours or until
menyebabkan kematian, tanpa death, but without sufficient
adanya penyebab lain yang jelas evidence to be classified
selain vaskuler. (Sacco, et al, 2013)
(WHO, 1986)

Epidemiology

Epidemiology

Stroke incidence and prevalence, now and in the
future
Patel A, Berdunov V, King D, Quayyum Z, Wittenberg R, Knapp M. Current , future and avoidable costs of stroke in the UK.

Yew KS, Cheng EM.
Diagnosis of acute stroke.
Am Fam Physician.
2015;91(8):528–36.

The ED algorithm for early
diagnosis and emergent
intervention
Patel P, Yavagal D, Khandelwal P. Hyperacute
Management of Ischemic Strokes: JACC Focus
Seminar. J Am Coll Cardiol. 2020;75(15):1844–56.

Suggested imaging protocols for patients presenting with acute stroke symptoms based
on the clinical scenario and the therapeutic options considered and available
Wintermark M, Sanelli PC, Albers GW, Bello JA, Derdeyn CP, Hetts SW, et al. Imaging Recommendations for Acute Stroke and Transient Ischemic Attack
Patients. J Am Coll Radiol. 2013;10(11):828–32.

Levels of stroke
prevention in a population
Boehme AK, Esenwa C, Elkind MSV. Stroke Risk Factors,
Genetics, and Prevention. Circ Res. 2017;120(3):472–95.
Webinar | Prevention
Overview ofStrategies
Diagnosticand
Approach
Ischemicand Management
Stroke in Ischemic Stroke
Management 11
AHA’s My Life Check –
Life’s Simple 7.
Seven approaches to
staying heart healthy
Virani SS, Alonso A, Benjamin EJ, Bittencourt MS,
Callaway CW, Carson AP, et al. Heart disease and stroke
statistics—2020 update: A report from the American
Heart Association. Circulation. 2020. 139–596 p.

Healthy lifestyle-related practices for improved cardiovascular health
Boehme AK, Esenwa C, Elkind MSV. Stroke Risk Factors, Genetics, and Prevention. Circ Res. 2017;120(3):472–95.

The ED algorithm for early
diagnosis and emergent
intervention
Patel P, Yavagal D, Khandelwal P. Hyperacute
Management of Ischemic Strokes: JACC Focus
Seminar. J Am Coll Cardiol. 2020;75(15):1844–56.

ACUTE
ISCHEMIC
STROKE
15
TIME IS BRAIN, SAVE THE PENUMBRA
• The penumbra is the zone of reversible ischemia around the core of

irreversible infarction.
• The brain tissue in the penumbra is particularly succeptible to

hypoperfusion, hyperglycemia, fever and seizures.
• It is salvageable in the first few hours after ischemic stroke onset
16
Outline
Principles of Acute Stroke
Three
Threemain
mainprinciples
principles
Recanalization
Recanalizationand
and Opening
Openingthe
theoccluded
occluded Reduce
Reduceinfarct
infarctsize
size&&
reperfusion
reperfusion artery
artery reverse
reverseneurologic
neurologicdeficit
deficit
Optimize
Optimizecollateral
collateral Keeping
Keepingthe
theischemic
ischemic Prevent
Preventcritical
criticalischemia
ischemia&&
flow penumbra
penumbraviable
viable infarction
flow infarction
But not sufficient
Avoid
Avoidsecondary
secondarybrain Maintain
brain Maintainnormal
normalcellular
cellular
injury
injury function
function
17
SAVE THE PENUMBRA !!!!
penumbra
core
1 hour 2 hour 3-4 hour 4-6 hour
Core =~1:1 ~ 2-3 : 1 ~ 4-5 : 1 ? 10-20 : 1

penumbra
18
Webinar | Prevention Strategies and Ischemic Stroke Management
1. Acute therapy and optimization of neurological status
Main goal  open the artery and re-established blood flow
• IV TPA is the only FDA-approved treatment for ischemic stroke in

the USA
• Neuroprotective agents(hypothermia, other drugs) are under

investigation
19
Outline
Acute Reperfusion Treatments : Intravenous Thrombolysis
Effective
Effectiveininimproving
improving After
Afteran
anischemic
ischemic
IVIVthrombolysis
thrombolysiswith
withrtPA
rtPA outcomes
outcomes stroke
stroke
Up
Uptoto33hours
hoursafter
after Up
Uptoto4,5
4,5hours
hoursafter
after
US
USFDA
FDA symptom
symptomonset
onset symptom
symptomonset
onset
AHA/American
Eligible Sroke Association
Initial Eligiblefor
forreperfusion
reperfusion
Initialevaluation
evaluation therapy
therapy
After
Aftersymptom
symptomonset,
onset,medical
medicalcondition
conditionthat
thatcould
couldcontraindicate
contraindicatethrombolysis,
thrombolysis,Neurologic
Neurologic
examination
examinationtotocalculate
calculatethe
the(NIHSS)
(NIHSS)score,
score,aacapillary
capillaryglucose
glucoselevel,
level,blood
bloodpressure,
pressure,and
andbrain
brain
imaging
imaging
Rabinstein AA. Update on Treatment of Acute Ischemic Stroke. Contin Lifelong Learn Neurol . 2020;268–86.
20
21
22
Graphic
Graphicillustrating
illustratingthe
thesequence
sequenceofofsteps
stepsinincontemporary
contemporaryacute
acutestroke
stroketherapy.
therapy.
Powers WJ, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018
guidelines for the early management of acute ischemic stroke., Stroke. 2019.
23
24
25
Stroke. 2014;45:e222-e225.
Thrombolytic therapy within 6 hours reduces the proportion of dead or dependent

patients after stroke, but most benefit occurs in patients treated within the first 3
hours and declines with later treatment. Most data are available for r-tPA. The
benefits of treatment apply to older and younger patients, and regardless of the
type of imaging assessment or extent of early visible infarction. This overall benefit
was apparent despite an increase in symptomatic ICH and early deaths.
26
JAMA Neurol,March 2019
A multicenter, double-blind, placebo-controlled RCT to study the efficacy and safety of

IVT with alteplase in patients with an acute stroke of unknown onset time, guided by
MRI
Of the 503 patients randomized in theWAKE-UP trial, 108 patients (74 men [68.5%]) had
imaging-defined lacunar infarcts, whereas 395 patients (251 men [63.5%]) had
nonlacunar infarcts
CONCLUSIONS
The results indicate that the association of IV alteplase with functional
outcome does not differ in patients with imaging-defined lacunar infarcts
compared with those experiencing other stroke subtypes.
27
Webinar
Update in |Acute
Prevention Strategies
Ischemic Strokeand Ischemic Stroke Management
Treatment
IVIVrecombinant
recombinanttissue
tissueplasminogen
plasminogenactivator
activator(rtPA)
(rtPA)(alteplase)
(alteplase)for
foracute
acuteischemic
ischemicstroke
stroke
28
PLOS ONE | DOI:10.1371/ 2015
Conclusion:
This meta-analysis determined that IAT conferred a significantly greater
probability of achieving a favorable outcome compared with IVT. There
was also a significant difference in mortality rates between IAT and IVT.
The studies included in this analysis were small and heterogeneous;
therefore, larger randomized prospective clinical studies are necessary
to further investigate this issue
29
30
Distribution
Distributionofofscores
scoreson
on90-d
90-dmodified
modifiedRankin
RankinScale
Scale
Koga M, et al. Thrombolysis With Alteplase at 0.6 mg/kg for Stroke With Unknown Time of Onset. Stroke. 2020;
31
1. Acute therapy and optimization of
neurological status (cont.d)
• Maintenance of cerebral perfusion  euvolemia, support BP, bed

flat
• Do not treat hypertension acutely, unless :
1. was treated by TPA
2. end organ damage ( CHF, MCI, HE,
dissecting aortic aneurysm etc)
3. SBP> 220 mmHg or DBP > 120 mmHg
• Use short-acting agent : labetalol, nicardipine
• Goal : BP reduction 10-15%
32
1. Acute therapy and optimization of
neurological status (cont.d)
• Antiplatelet : aspirin effective for acute treatment

• Anticoagulant : not effective for acute treatment, only for secondary
prevention in AF and cardioembolic stroke
Never start anticoagulant without brain imaging
• Hyperglycemia : treat glucose aggressively
• Hyperthermia : treat aggressively with acetaminophen and cooling
blanket
33
2. Etiological work-up for secondary prevention
• Screening for arterial stenosis/obstruction  MRA, carotid

ultrasound, TCD, DSA, CTA
• Cardiac evaluation  EKG, echocardiogram
• Recurrent stroke risk factors screening :
* monitor BP
* obtain fasting lipid panel
* screen for diabetes
* screen for hyperhomocysteinemia
* smoking cessation
34
3. Prevention of neurological deterioration or medical
complications
• DVT prophylaxis
• Aspiration precautions
• Gastrointestinal ulcer prophylaxis
• Take out indwelling urinary catheter as soon as possible
• Monitor platelet counts if on heparin
35
4. Prevention of neurological deterioration or medical complications :
Drug therapy in the first 72 hours :
1. Antiplatelet : * aspirin 81-325 mg OD

* clopidogrel 75mg OD
* aspirin 25 mg + dypiridamole 200 mg OD
2. DVT prophylaxis : heparin, LMWH, compression stocking
3. Anticoagulant for cardioembolic stroke : heparin, coumadin,
NOAC (dabigatran, rivaroxaban)
4. Insulin to treat hyperglycemia
5. Acetaminophen to treat hypertermia
6. Statins : target LDL < 100 mg%
7. Antihypertensive : ACEI, ARB, diuretics, beta blockers, Ca-channnel blockers
36
Outline
Antiplatelet treatment (AHA Recommendation)
Within
Within24-48
24-48hours
hoursafter
after
Administration
Administrationofofaspirin
aspirin onset
onset
Reducing
Reducingischemic
ischemicstroke
strokefor
foraa
For
Forthose
thosetreated
treatedwith
withIVIV Delayed
Delayeduntil
until24
24hours
hours period
periodup
uptoto90
90days
daysfrom
fromonset
onset
alteplase
alteplase
Within
Within24
24hrhrafter
aftersymptom
symptom
Minorcardioembolic
Minorcardioembolic Dual
Dualantiplatelet
antiplatelettherapy
therapy(aspirin
(aspirin onset
onsetand
andcontinued
continuedforfor21
21
ischemic
ischemicstroke
stroke(NIHSS
(NIHSS≤≤3)3) &&clopidogrel
clopidogrel days
days
Who did not receive IV alteplase
The In the treatment of AIS

Theefficacy
efficacyofofthe
theIVIV Not
glycoprotein Notwell
wellestablished
established
glycoproteinIIb/IIIa
IIb/IIIainhibitor
inhibitor
Tirofiban & epitifibatide
37
Arachidonic
Arachidonicacid
acid
COX1
COX1inhibitors
inhibitors Cyclo-oxygenase1
Cyclo-oxygenase1
ADP
ADPrec.
rec.inhibitors
inhibitors
Aspirin
(-)
Aspirin Clopidogrel, ticagrelor, prasugrel
PGH Clopidogrel, ticagrelor, prasugrel
PGH2 2
Mechanism
Mechanismofofaction
actionofof
PGI (-)
different
differentantiplatelet
antiplateletdrugs.
drugs. TXA PGI2/PG
2/PG
ADP
ADP
TXA2 2 EE2
2
TPβ
TPβrec.
rec. TPα
TPαrec.
rec. P2Y
P2Y1212rec.
rec. PAR1
PAR1rec.
rec.
Bultas J. Antiplatelet Adenylate

therapy-a Adenylatecyclase
cyclase
pharmacologist’s
ATP
ATP cAMP
cAMP AMP
AMP
perspective. 2013.
VASP
VASP VASP-P
VASP-P
GP
GPIIb/IIIa
IIb/IIIarec.
rec.activation
activation GP
GPIIb/IIIa
IIb/IIIarec.
rec.inactivation
inactivation
thrombocyte aggregation
thrombocyte aggregation thrombocyte stabilisation
thrombocyte stabilisation
38
The benefit of clopidogrel-aspirin occurs
predominantly within the first 21 days, and
outweighs the low, but ongoing risk
of major hemorrhage. When considered with the
results of the CHANCE trial (Clopidogrel in High-
Risk Patients With Non-disabling Cerebrovascular
Events), a similar trial treating with clopidogrel-
aspirin for 21 days and showing no increase in
major hemorrhage, these results suggest that
limiting clopidogrel-aspirin use to 21 days may
maximize
benefit and reduce risk after high-risk transient
ischemic attack or minor
ischemic stroke.
39
Time
Timecourse
courseofofthe
the
absolute treatment
absolute treatment
difference
difference
Johnston SC, et al. Time
Course for Benefit and Risk of
Clopidogrel and Aspirin After
Acute Transient Ischemic
Attack and Minor Ischemic
Stroke. Circulation. 2019
40
Hazard
Hazardrates
ratesby
byweek
weekafter
afterrandomization.
randomization.
Johnston SC, et al. Time Course for Benefit and Risk of Clopidogrel and Aspirin After Acute Transient Ischemic Attack and Minor
Ischemic Stroke. Circulation. 2019
41
Conclusion
Stroke remains a disease of immense public health significance in the 21stst
1
century despite the advances in our understanding
Acute ischemic stroke is a medical emergency in which every minute

2
counts.
3 There is a trend to be more aggressive to treat acute ischemic stroke patients
Timely successful reperfusion is the most effective treatment for

4
Patients with acute ischemic stroke
5 Stroke prevention has generally focused on modifiable risk factors.

43

Prevention Strategies and Ischemic Stroke Management

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Prevention Strategies and Ischemic Stroke Management

Uploaded by

Copyright:

Available Formats

Webinar

Aldy Safruddin Rambe

2 Diagnostic Approach in Acute Ischemic Stroke

3 Role of Primary and Secondary Ischemic Stroke Prevention

4 Principles of Acute Ischemic Stroke Care

5 Acute Reperfusion Treatments : Intravenous Thrombolysis

Webinar | Prevention Strategies and Ischemic Stroke Management 2

Webinar | Prevention Strategies and Ischemic Stroke Management 3

Webinar | Prevention Strategies and Ischemic Stroke Management 4

Webinar | Prevention Strategies and Ischemic Stroke Management 5

Webinar | Prevention Strategies and Ischemic Stroke Management 6

Webinar | Prevention Strategies and Ischemic Stroke Management 7

Webinar | Prevention Strategies and Ischemic Stroke Management 8

Webinar | Prevention Strategies and Ischemic Stroke Management 9

Webinar | Prevention Strategies and Ischemic Stroke Management 10

Webinar | Prevention Strategies and Ischemic Stroke Management 12

Webinar | Prevention Strategies and Ischemic Stroke Management 13

Webinar | Prevention Strategies and Ischemic Stroke Management 14

• The penumbra is the zone of reversible ischemia around the core of

• The brain tissue in the penumbra is particularly succeptible to

• It is salvageable in the first few hours after ischemic stroke onset

1 hour 2 hour 3-4 hour 4-6 hour

Core =~1:1 ~ 2-3 : 1 ~ 4-5 : 1 ? 10-20 : 1

Main goal  open the artery and re-established blood flow

• IV TPA is the only FDA-approved treatment for ischemic stroke in

• Neuroprotective agents(hypothermia, other drugs) are under

Thrombolytic therapy within 6 hours reduces the proportion of dead or dependent

A multicenter, double-blind, placebo-controlled RCT to study the efficacy and safety of

• Maintenance of cerebral perfusion  euvolemia, support BP, bed

• Antiplatelet : aspirin effective for acute treatment

• Screening for arterial stenosis/obstruction  MRA, carotid

1. Antiplatelet : * aspirin 81-325 mg OD

The In the treatment of AIS

Bultas J. Antiplatelet Adenylate

Acute ischemic stroke is a medical emergency in which every minute

3 There is a trend to be more aggressive to treat acute ischemic stroke patients

Timely successful reperfusion is the most effective treatment for

5 Stroke prevention has generally focused on modifiable risk factors.

Webinar | Prevention Strategies and Ischemic Stroke Management 42

You might also like