How should a patient who has had a stroke be managed?
Acute stroke unit or ICU where comprehensive services available for both timely neurosurgical intervention and rehab available. Head up, BP 140-160, Normoxia, normocarbia, normoglycaemia, normothermia (avoid hyperthermia), VTE prohylaxis, pressure area care
If a patent post CVA developes raised ICP how should they be managed?
Maintain and secure airway, normoxia, normocarbia 35-40 - if blow pupil then can hyperventilate for short period, head up 30 degrees, strict BP control, , additional sedation, hypothermia 35-36, Glucose control 6-10, osmotic therapy = 3% NaCl, 100-200mls, if supratentorial consider craniectomy - esp if <60years
What is the evidence for craniotomy in supratentorial CVA (esp malignant MCA CVA)
50% reduction in mortality but majority of patents are unable to manage their own affairs - Massive morbidity in survivors
All industry sponsored and have some questionable reporting
Briefly outline NINDS study
multi-centre RCT; 600pts, tPA vs placebo. Outcome measures: NIHSS scores and mortality, and probability of favourable outcome. Showed no improvement at 24hrs, but improved outcome at 3-12/12 (OR 1.7) 2% reduction in dead or dependent patient at 3/12 - NNT 8
What are the major study design failures?
Poorly matched groups, unrealistic time frames-therefore not generalisable to ED, No control of post thrombolysis care/stroke centre care, high number of cardioembolic strokes - unrealistic, not reported median NIHSS scores
What was the rate of ICH?
6% ICH in tPA (0.6% in placebo) of which 50% were fatal
What was the overall mortality risk?
3% mortality risk overall (vs 1% in MI) from ICH. 3/12 mortality 17% in tPA vs 21% in placebo
Which groups were more likely to have incr risk ICH?
>80yrs and severe CVA
Briefly describe ECASS
multi-centre RCT; well matched; tPA vs placebo; <6hrs; 600 patients Post-hoc Analysis of <3hr group
Main findings of ECASS
Non-significant improvement of all outcomes with tPA, increased haemorrhage with tPA, significant increase mortality with tPA
Briefly describe ECASS II
multi-centre RCT; tPA vs placebo; <6hrs; 800 patients. No sts significant change in outcome or mortality, tPA have more ICH and cerebral oedema
Describe ECASS III
multi-centre RCT; tPA vs placebo; 3-4.5hrs; excluded severe stroke. Better modified Rankin/NIHSS score at 90/7 in tPA group (approx 50% vs 45%), lower mortality at 90/7 in tPA (7.7% vs 8.4%); no change in Barthel Index/Glasgow Outcome score
Overall ECASS series demonstrated
Need to use tPA within <3hrs to get any demonstrable benefit, ICH always more likely in tPA group, but improve functional outcome and mortality at 3/12 if used early and in well selected group - i.e not a MASSIVE CVA
When should Interventional radiology be considered?
if large vessel occlusion (esp basilar art / ICA / M1) + few morbidities and good prognosis, and <5hrs; important alternative as tPA poorly effective in large vessel lesions
Major advantages of Intra-arterial thrombolysis?
trt window >6hrs, decr dose of drugs, possibility of mechanical clot disruption
Only if CVA with proven cardioembolic source, otherwise no improvement and people probably do worse
What is the biggest recommendation of National Stroke Foundation?
manage in a stroke centre
What are the benefits of a stroke centre?
decr death and disability, more adherence to key principles, more patients eligible for stroke unit than thrombolysis so more impact; interdisciplinary team, early mobilisation, avoid bed rest, active encouragement
Treatment of ICH?
1. BP control, 2. Reverse anticoagulation, 3. ICP monitoring, 4. Craniotomy and evacuation 5. Intraventricular drain if blood in ventricles
Why and when do you actively manage BP in ICH?
Reduces haematoma volume. Rx if >200 / >120 or MAP >150. Aim 160/90 or MAP 110, CPP 60-80 (if normal ICP)
What do you use for BP control?
Labetalol 10-20mg IV over 1-2mins - repeat or double dose at 10mins (to max 300mg) or Sodium nitroprusside 0.5-10mcg/kg/min or GTN
3 indications for immediate OT
1. <1cm from surface + <60yrs, 2. Hydrocephalus or marked mass effect 3. Cerebellar haem >3cm (Cerebellar is surgical emergency)
3 indications for ICP monitoring
1. GCS <8 2. Clinical evidence of transtentorial herniation 3. Significant intraventricular haemorrhage or hydrocephalus
Pages linking here (main versions and versions by same user)