Peter Langhorne Professor of Stroke Care University of Glasgow · Secondary prevention • Great...
Transcript of Peter Langhorne Professor of Stroke Care University of Glasgow · Secondary prevention • Great...
Reading between the guidelines Acute stroke and TIA
Peter Langhorne
Professor of Stroke Care
University of Glasgow
NICE / RCP guidelines for stroke
Clinical practice guidelines on the
management of stroke and TIA (2008)
• Recognition and diagnosis
• Acute care
– Reperfusion
– Maintain homeostasis
– Prevent complications
• Early rehabilitation
• Secondary prevention
• Early Supported Discharge/community
rehabilitation
• Long term support and review
• Service governance
General principles – pathway approach
A&E
service
Hyperacute
stroke area
Comprehensive
stroke unit
Early
supported
discharge
service
Inpatient
rehabilitation Outpatient
service
Ongoing
support/
Rehab’n
What might an excellent stroke service look like?
Suspected
Stroke/
TIA
Specialist
services
TIA pathway
Clinical stroke?
TIA pathway
Start aspirin (300mg)
Specialist assessment <24 hrs Clinical stroke?
Brain imaging in TIA
Examples where brain imaging is helpful in the
management of TIA:
– people with TIA where haemorrhage needs to be
excluded, for example long duration symptoms or people
on anticoagulants (early CT scan; MRI)
– where alternative diagnosis (for example migraine,
epilepsy or tumour) is being considered (MRI; CT?)
– people being considered for carotid endarterectomy
(CEA) where it is uncertain whether the stroke is in the
anterior or posterior circulation (MRI)
TIA pathway
Carotid endarterectomy
Absolute stroke risk reduction vs delay to operation
Benefit of surgery Severe stenosis Moderate stenosis
0-2 2-4 4-12 >12
Time from symptoms to operation (weeks)
Performed within 1 week of first presentation
(deferred for 72 hours in people treated with intravenous thrombolysis)
Secondary prevention
• Great improvements in stroke management and outcome
• Main benefits from prevention and stroke units
• Developments now need to focus on rapid delivery of treatments
• Need to ensure service developments do not undo the gains achieved thus far
• Regional networking may offer benefits and “future-proofing”
TIA and Ischaemic stroke
Blood pressure
(Aim for <130/80 )
Thiazide, Calcium antagonists
ACE inhibitor
Statin therapy Atorvastatin
(Simvastatin)
Antiplatelet therapy
(sinus rhythm)
Clopidogrel
Aspirin/ DP retard
Anticoagulant therapy
(AF/cardioembolic)
Warfarin
(Direct Acting Oral Anticoagulants)
Surgical/ radiological Severe carotid stenosis (CEA)
Lifestyle Smoking cessation, diet, exercise, driving
Stroke pathway Clinical stroke?
Stroke pathway
Most within 1 hr
Indications for immediate imaging
Brain imaging should be performed immediately
for people with acute stroke if :
– indications for thrombolysis
– on anticoagulation treatment
– depressed level of consciousness
– progressive or fluctuating symptoms
– papilloedema, neck stiffness or fever
– severe headache at onset of stroke symptoms
Plain CT scanning is the main emergency modality
Indications for immediate imaging
Brain imaging should be performed immediately
for people with acute stroke if :
– indications for thrombolysis
– on anticoagulation treatment
– depressed level of consciousness
– progressive or fluctuating symptoms
– papilloedema, neck stiffness or fever
– severe headache at onset of stroke symptoms
Access to CT angiography etc
Stroke pathway
Percutaneous clot removal
Mechanical
thrombectomy
Proximal intracranial
large vessel occlusion
NIHSS >5
Procedure within 5hrs
Intracerebral haemorrhage
Reverse clotting disorder
Lower BP to 140mmHg for 7 days
(if onset <6hrs with systolic BP
>150mmHg)
(unless GCS<5, death expected, surgery
planned)
Acute stroke - general care
Dysphagia management
(early NG + bridle)
Early mobilisation (24-48hr)
Manage hydration,
pyrexia, oxygen, blood
sugar (blood pressure)
Aspirin if no contraindication
Intermittent Pneumatic Compression
Stockings to prevent DVT if immobile
MDT care in
stroke unit
Secondary prevention
• Great improvements in stroke management and outcome
• Main benefits from prevention and stroke units
• Developments now need to focus on rapid delivery of treatments
• Need to ensure service developments do not undo the gains achieved thus far
• Regional networking may offer benefits and “future-proofing”
TIA and Ischaemic stroke
Blood pressure
(Aim for <130/80 )
Thiazide, Calcium antagonists
ACE inhibitor
Statin therapy Atorvastatin
(Simvastatin)
Antiplatelet therapy
(sinus rhythm)
Clopidogrel
Aspirin/ DP retard
Anticoagulant therapy
(AF/cardioembolic)
Warfarin
(Direct Acting Oral Anticoagulants)
Surgical/ radiological Severe carotid stenosis (CEA)
Lifestyle Smoking cessation, diet, exercise, driving
Cervical artery dissection, paroxysmal AF, PFO, intracranial stenosis
Secondary prevention
• Great improvements in stroke management and outcome
• Main benefits from prevention and stroke units
• Developments now need to focus on rapid delivery of treatments
• Need to ensure service developments do not undo the gains achieved thus far
• Regional networking may offer benefits and “future-proofing”
Haemorrhagic stroke
Blood pressure
(Aim for <130/80 )
Thiazide, Calcium antagonists
ACE inhibitor
Statin therapy -
Antiplatelet therapy
(sinus rhythm)
??
Anticoagulant therapy
(AF/cardioembolic)
-
Surgical/ radiological (Aneurysm or arteriovenous malformation)
Lifestyle Smoking cessation, diet, exercise, driving
The management of stroke
• Focus on rapid delivery of treatments while maintaining effective pathway of care
– Multidisciplinary stroke unit care
– Rapid secondary prevention
• New focus on recent major improvements in stroke management
– Reperfusion (mechanical thrombectomy/ iv thrombolysis) for subset of ischaemic stroke patients
– Selective neurosurgical interventions
• Greater use of new direct oral anticoagulants, improved reperfusion strategies, early rehabilitation