Current Guidelines In The

Management of Ischaemic Stroke

By
Dr Anyamele Ibuchim
Introduction
Epidemiology
Pathophysiology
Clinical Features
Investigations
Management
 Introduction
• Stroke: Rapidly developing signs of focal or
global disturbance of cerebral function, lasting
>24hours or leading to death, with no
apparent cause other than that of vascular
origin. (WHO 1970)
• Two broad types, Ischaemic(85%) and
haemorrhagic(15%)
 Introduction cont’d
• However, advances in understanding of stroke,
neuropathology and neuro-radiology revealed
inadequaces in this definition.
• AHA/ASA published a position statement in
2009 redifining Transient Ischaemic Attacks.
• This necessitated modifications in stroke
definition
 Introduction cont’d
• In 2013, the AHA/ASA brought out a consensus
document redefining Stroke, Ischaemic stroke,
silent CNS infarction, Intracerebral hemorrhage
and hemorrhagic stroke, silent intracerebral
hemorrhage, subarachnoid hemorrhage,
stroke from cerebral venous thrombosis, and
stroke not otherwise specified.
• The ESO and WHO were not part of this.
 Introduction cont’d
• These guidelines were updated in 2018 and
2019 to reflect changes in therapeutic
interventions.
• Our interest today is on ischaemic stroke
 Introduction cont’d
• CNS Infarction: Brain, spinal cord or retinal cell
death attributable to ischaemia, based on
1. Pathological, radiological or other objective
evidence of brain, spinal cord or retinal focal
ischaemic injury in a defined vascular territory, or
2. Clinical evidence of focal brain, spinal cord or
retinal ischaemic injury based on symptoms
persisting > 24hrs or leading to death, and other
etiologies excluded.
 Introduction cont’d
• Ischaemic stroke: Rapidly developing signs of
neurological dysfunction caused by CNS
infarction.

• TIA: Transient episodes of neurological

dysfunction caused by focal brain, spinal cord
or retinal ischaemia without evidence of
infarction.
 Introduction cont’d
• It should be noted that global ischaemia
should not be regarded as ischaemic stroke as
the pathophysiologic mechanisms are
different, as is the clinical presentation,
management and prognosis.
 Epidemiology
• Stroke is a major cause of morbidity and
mortality worldwide.
• Ischaemic strokes make up 85-87% of all
strokes
• According to the WHO, 15million people suffer
stroke worldwide each year
• Of this, 5million die, and another 5million are
left permanently disabled
 Epidemiology cont’d
• In the US, about 795000 people experience
new or recurrent stroke
• Leading cause of disability and 5th leading
cause of death.
• Epidemiologic studies indicate that about
82%-92% of strokes in the US are ischaemic
 Epidemiology cont’d
• In 2015, Owolabi et al observed that
community based studies in Africa revealed an
age standardised annual stroke incidence of
316/100,000, and prevalence of 981/100000
• A 10 year review of Stroke in the southwest in
2005 by Ogun et al revealed that Ischaemic
stroke comprised 49% of the strokes reviewed.
Pathophysiology
Pathophysiology cont’d
Pathophysiology cont’d
Pathophysiology cont’d
 Pathophysiology cont’d
 Note Poiseuille equations on non-laminar flow

 Infarcted core gets cerebral blood flow of <

10ml/100g/min
 Ischaemic Penumbra gets < 25ml/100g/min of
CBF
 Pathophysiology cont’d
• Normal MAP -- 70mmHg – 100mmHg

• Normal ICP -- 5mmHg – 15mmHg

 Clinical Features
• Aim is to establish that a stroke has indeed
occurred, and to rule out mimics.
• Take a good targeted history and conduct a
focused neurological examination
• If stroke is diagnosed, immediately activate
the stroke response team
Clinical Features
 Investigations
• Urgent non-contrast CT scan
 Has high sensitivity in detecting haemorrhage
in the acute period
• However, sensitivity in detecting infarcts
during the first 12 hours is low-- 31% to 60%

• MRI
 Investigations cont’d
• Cardio-metabolic work up

• Haematological work up, especially if

reperfusion strategies are planned

• Other ancillary investigations

Management
Treatment
 Treatment cont’d
• Note that IV t-PA was first approved in 1995
followed a landmark study by NINDS, and
dramatically transformed acute stroke care.

• In 2015, more sophisticated trials showed robust

outcomes for endovascular therapies
• The primary goal of advanced stroke
management remains revascularization and
prevention of secondary neuronal injury
 Treatment cont’d
• IV Thrombolysis and endovascular therapies
now available for selected patients.
• Recent trials have suggested that imaging
rather than known time of onset can guide
reperfusion strategies.
• The WAKE-UP study suggested that almost
50% of wake-up strokes and daytime strokes
of unknown onset are candidates for t-PA
 Treatment cont’d
• The EXTEND trial suggests that efficacy and
safety of IV t-PA can extend up to 9 hours and
revascularization up tp 24 hours

• Endovascular therapies– especially for large

vessel occlusion
 Treatment cont’d
HYPERTENSION—Permissive HTN allowed for
the 1st 24 to 48hrs, with intervention required
if > 220/120mmHg or reperfusion

Hypotension and hypovolemia avoided

 Treatment cont’d
• Ensure Glycaemic control

• Control cerebral edema– Both medically and

surgically if necessary
• Control Fever
• Rehabilitation
• Nutrition
• Secondary prevention
• Thank you for listening.