ACUTE ISCHEMIC STROKE

MANAGEMENT

dr. ALDRIN C LEMAN, SpS

Department of Neurology
RSUD LANTO DG PASEWANG JENEPONTO
 Demographics of Stroke

• Women have about 60,000 more strokes than men.

• Native Americans have the highest prevalence.

• Modifiable risk factors must be addressed in our aging

population with the propensity to stroke.

© 2009, American Heart Association. All rights reserved.

 Stroke

Ischemic stroke
• Caused by a blocked blood vessel in the brain.

Hemorrhagic Stroke
• Caused by a ruptured blood vessel in the brain.

© 2009, American Heart Association. All rights reserved.

 Stroke Subtypes

Ischemic Hemorrhagic
80% 20%
 Etiology of Ischemic Strokes

• 20%  large vessel atherothrombotic causes

• 25%  small vessel disease

• 20%  cardiac sources

• 30%  unknown causes

© 2009, American Heart Association. All rights reserved.

 Risk factors for Ischemic Stroke

• Hypertension • High Cholesterol

• Diabetes • Male gender

• Heart Disease • Age

• Smoking • Ethnicity/Race

© 2009, American Heart Association. All rights reserved.

 In a Typical Acute Ischemic
Stroke, Every Minute Until
Reperfusion the Brain Loses:
• 1.9 million neurons

• 14 billion synapses

• 7.5 miles myelinated fibers

-- Saver, Stroke 2006

EMERGENCY STROKE MANAGEMENT FLOW CHART

Suspected Stroke
History and Physical

Blood tests
Consult ECG and Chest X-ray
Neurologist CT or MRI brain

Acute
Hemorrhagic Non Acute Stroke
Acute Ischemic
Stroke Tumor
Stroke Migraine
SAH Seizures
ICH onset < 3 hours
Demyelination

Guidelines for
Guidelines for
Management of See Thrombolysis
Management of
Intracerebral Ischemic Stroke Checklist
Hemorrhage
 AHA/ASA GUIDELINE
Guidelines for the Prevention of Stroke
in Patients With Stroke or Transient Ischemic Attack

Recommendation for Treatable Vascular Risk Factors

 AHA/ASA Guideline
Recommendations on Hypertension

BP reduction is recommended for both prevention of recurrent stroke and

prevention of other vascular events in persons who have had an ischemic
stroke or TIA and are beyond the first 24 hours (Class I; Level of Evidence A)

Because this benefit extends to persons with and without a documented

history of hypertension, this recommendation is reasonable for all patients
with ischemic stroke or TIA who are considered appropriate for BP reduction
(Class IIa; Level of Evidence B).
 AHA/ASA Guideline
Recommendations on Hypertension

An absolute target BP level and reduction are uncertain and should be

individualized, but benefit has been associated with an average reduction of
approximately 10/5 mm Hg, and normal BP levels have been defined as
<120/80 mm Hg by JNC 7 (Class IIa; Level of Evidence B)

Several lifestyle modifications have been associated with BP reduction and

are a reasonable part of a comprehensive antihypertensive therapy (Class
IIa; Level of Evidence C). These modifications include salt restriction; weight
loss; consumption of a diet rich in fruits, vegetables, and low-fat dairy
products; regular aerobic physical activity; and limited alcohol consumption.
Class IIa; Level C
 AHA/ASA Guideline
Recommendations on Hypertension

The optimal drug regimen to achieve the recommended level of reduction is

uncertain because direct comparisons between regimens are limited. The
vailable data indicate that diuretics or the combination of diuretics and an
ACEI are useful (Class I; Level of Evidence A).

The choice of specific drugs and targets should be individualized on the basis
of pharmacological properties, mechanism of action, and consideration of
pecific patient characteristics for which specific agents are probably
indicated (eg, extracranial cerebrovascular occlusive disease, renal
mpairment, cardiac disease, and diabetes) (Class IIa; Level of Evidence B).
(New recommendation)
 AHA/ASA Guideline
Recommendations on Diabetes

Use of existing guidelines for glycemic control and BP targets in patients

with diabetes is recommended for patients who have had a stroke or TIA
(Class I; Level of Evidence B). (New recommendation)
 AHA/ASA Guideline
Recommendations on Lipids

Statin therapy with intensive lipid-lowering effects is recommended to

reduce risk of stroke and cardiovascular events among patients with
ischemic stroke or TIA who have evidence of atherosclerosis, an LDL-C level
100 mg/dL, and who are without known CHD (Class I; Level of Evidence B).

For patients with atherosclerotic ischemic stroke or TIA and without known
CHD, it is reasonable to target a reduction of at least 50% in LDL-C or a
target LDL-C level of < 70 mg/dL to obtain maximum benefit (Class IIa; Level
of Evidence B). (New recommendation)
 AHA/ASA Guideline
Recommendations on Lipids

For patients with atherosclerotic ischemic stroke or TIA and without known
CHD, it is reasonable to target a reduction of at least 50% in LDL-C or a
target LDL-C level of 70 mg/dL to obtain maximum benefit (Class Iia; Level of
Evidence B). (New recommendation)

Patients with ischemic stroke or TIA with elevated cholesterol or comorbid

coronary artery disease should be otherwise managed according to NCEP III
guidelines, which include lifestyle modification, dietary guidelines, and
medication recommendations (Class I; Level of Evidence A).

Patients with ischemic stroke or TIA with low HDL-C may be considered for
treatment with niacin or gemfibrozil (Class IIb; Level of Evidence B)
 AHA/ASA GUIDELINE
Guidelines for the Prevention of Stroke
in Patients With Stroke or Transient Ischemic Attack

Recommendation for Modifiable Behavioral Risk Factors

 AHA/ASA Guideline
Recommendations on Alcohol Consumption

Patients with ischemic stroke or TIA who are heavy drinkers should eliminate
or reduce their consumption of alcohol (Class I; Level of Evidence C).

Light to moderate levels of alcohol consumption (no more than 2 drinks per
day for men and 1 drink per day for nonpregnant women) may be
reasonable; nondrinkers should not be counseled to start drinking (Class IIb;
Level of Evidence B).
 AHA/ASA Guideline
Recommendations on Cigarette Smoking

Healthcare providers should strongly advise every patient with stroke or TIA
who has smoked in the past year to quit (Class I; Level of Evidence C).

It is reasonable to avoid environmental (passive) tobacco smoke (Class IIa;

Level of Evidence C).

Counseling, nicotine products, and oral smoking cessation medications are

effective for helping smokers to quit (Class I; Level of Evidence A)
 AHA/ASA Guideline
Recommendations on Physical Activity

For patients with ischemic stroke or TIA who are capable of engaging in
physical activity, at least 30 minutes of moderate-intensity physical exercise,
typically defined as vigorous activity sufficient to break a sweat or
noticeably raise heart rate, 1 to 3 times a week (eg, walking briskly, using an
exercise bicycle) may be considered to reduce risk factors and comorbid
conditions that increase the likelihood of recurrent stroke (Class IIb; Level of
Evidence C).

For those individuals with a disability following ischemic stroke, supervision

by a healthcare professional, such as a physical therapist or cardiac
rehabilitation professional, at least on initiation of an exercise regimen, may
be considered (Class IIb; Level of Evidence C)
 AHA/ASA Guideline
Recommendations on Metabolic Syndrome

At this time, the utility of screening patients for the metabolic syndrome
after stroke has not been established (Class IIb; Level of Evidence C). (New
recommendation)
For patients who are screened and classified as having the metabolic
syndrome, management should include counseling for lifestyle modification
(diet, exercise, and weight loss) for vascular risk reduction (Class I; Level of
Evidence C). (New recommendation)
Preventive care for patients with the metabolic syndrome should include
appropriate treatment for individual components of the syndrome that are
also stroke risk factors, particularly dyslipidemia and hypertension (Class I;
Level of Evidence A). (New recommendation)
 AHA/ASA GUIDELINE
Guidelines for the Prevention of Stroke
in Patients With Stroke or Transient Ischemic Attack

Recommendations for Antithrombotic Therapy

for Noncardioembolic Stroke or TIA
(Oral Anticoagulant and Antiplatelet Therapies)
 AHA/ASA Guideline
For patients with noncardioembolic ischemic stroke or TIA, the use of
antiplatelet agents rather than oral anticoagulation is recommended to
reduce risk of recurrent stroke and other cardiovascular events (Class I; Level
of Evidence A).

Aspirin (50 mg/d to 325 mg/d) monotherapy (Class I; Level of Evidence A),
the combination of aspirin 25 mg and extended-release dipyridamole 200
mg twice daily (Class I; Level of Evidence B), and clopidogrel 75 mg
monotherapy (Class IIa; Level of Evidence B) are all acceptable options for
initial therapy. The selection of an antiplatelet agent should be
individualized on the basis of patient risk factor profiles, cost, tolerance, and
other clinical characteristics.
 AHA/ASA Guideline
The addition of aspirin to clopidogrel increases risk of hemorrhage and is not
recommended for routine secondary prevention after ischemic stroke or TIA
(Class III; Level of Evidence A).

For patients allergic to aspirin, clopidogrel is reasonable (Class IIa; Level of

Evidence C).

For patients who have an ischemic stroke while taking aspirin, there is no
evidence that increasing the dose of aspirin provides additional benefit.
Although alternative antiplatelet agents are often considered, no single
agent or combination has been studied in patients who have had an event
while receiving aspirin (Class IIb; Level of Evidence C).
NIHSS