Stroke

Medicine Board Review 29/03/60
“Stroke”
Scope of Stroke! Not cover all in this day

• Anatomy of the brain and blood supply
• Diagnosis of stroke, its mimics and

chameleons
• Early management of acute ischemic

stroke or TIA
• Secondary prevention of ischemic stroke

or TIA
• Rehabilitation, Primary prevention, Silent

brain infarction etc.

Circle of Willis Vascular distribution

Vascular distribution

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Brain stem lesion 29/03/60

• “Rules of four” Rules of four

(Gates, P. The rule of 4 of the brainstem: a • In the rule of 4 there are 4 rules
simplified method for understanding
brainstem anatomy and brainstem vascular – There are 4 structures in the ‘midline‘
syndromes for the non-neurologist. Internal beginning with M
Medicine Journal 2005; 35: 263-266)
– There are 4 structures to the ‘side‘ (lateral)
beginning with S

– There are 4 cranial nerves in the medulla, 4 in
the pons and 4 above the pons(2 in the
midbrain)

– The 4 motor nuclei that are in the midline are
those that divide equally into 12 except for 1
and 2, that is 3, 4, 6 and 12
(5, 7, 9 and 11 are in the lateral brainstem)

Rules of four Rules of four

The 4 medial structures and the associated The 4 ‘side’ (lateral) structures and the
deficits are: associated deficits are:

◦ Motor pathway (or corticospinal tract) ◦ Spinocerebellar pathway
◦ Medial Lemniscus ◦ Spinothalamic pathway
◦ Medial longitudinal fasciculus: ◦ Sensory nucleus of the 5th cranial nerve:
◦ Motor nucleus and nerve:
(this nucleus is a long vertical structure that extends
(3, 4, 6 or 12) in the lateral aspect of the pons down into the
medulla)
◦ Sympathetic pathway:

Medullary syndrome Pontine syndrome

Lacunar syndrome lesion 1.5 cm
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Ddx ตั้ง แต่ corona radiata to basis pontis



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EARLY MANAGEMENT IN ACUTE Diagnosis: Patient History
ISCHEMIC STROKE OR TIA
• The time of symptom onset (or last known to be normal)
Physical Examination • Stroke mimics; Artherosclerosis risks and cardiac diseases
• History that related to other stroke mechanism, eligibility
• ABC, Vital signs (4 extremities?),
Cardiovascular system to intervention etc.

• Other cause of stroke such as ก็มีอาหาร ปวดเป็นหายๆมา
vasculitis? IE? CVST?
• disection ปวดหัว ปวดคอ
• The initial neuro exam should be brief • embolic ใจสั่น เจ็บหน้าอก
but thorough
Investigation
• Using stroke scale such as NIHSS
Diagnostic tests in all patients
• Neuroimagings
• Blood glucose
• Serum electrolytes
• CBC with platelet count
• Coagulogram

– Prothrombin time (PT)
– International normalized ratio (INR)
– Activated partial thromboplastin time (APTT)
• Renal function test
• ECG, Cardiac enzymes
• Oxygen saturation

Jauch ED, et al. Stroke 2013

Investigation Imaging study

• Diagnostic tests in selected patient • Non-contrast-enhanced CT (NECT) of
– Liver function tests the brain**
– Chest radiography
– Arterial blood gas • MRI of the brain (esp. DWI, GRE)
– Lumbar puncture • Vascular imaging: CTA, MRA, U/S
– Electroencephalogram (EEG)
– Toxicology screen (TCD, CDUS)
– Pregnancy test • Perfusion CT and MRI
– VDRL
– TT, ECT 4

Jauch ED, et al. Stroke 2013



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Pantano P, et al. Stroke. 1999 Left occipital infarction (PCA)

Acute Rt. Old Lt.
posterior
MCA watershed
infarction infarction

Insular ribbon sign, Cortical ribbon sign http://radiologykey.com/cerebrovascular-diseases/
Lenticular obscuration (obscuration of BGG)

Loss of gray-white differentiation
Sulcal effacemenRtadiologymri.blogspot.com

Hyperdense MCA sign Dot sign Hemorrhagic transformation

Keith W, et al. Lancet Neurology 2006 Radiopaedia.org

จะดำรอบๆ เยอะมาก แล้วขาว
ตรงกลาง (ขาวไม่เยอะ)

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ICH ดำล้อมรอบนิดๆ

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Acute stroke care in general Acute stroke care

• Supplemental oxygen? • Intravenous fluids
– Normal saline for maintenance or replacement in
– Maintain > 94% (Class I, Level of evidence C) hypovolemia (Class I, Level C)
– Not recommend in nonhypoxic pt.
• Glycemic control
(Class III, Level B) – Persistent hyperglycemia in 1st 24 hr is associated
with worse clinical outcome, reasonable to treat
• Hyperthermia – Goal: Blood glucose 140-180 (Class IIa, Level C)

– Increase mortality should find sources and • Blood pressure control
treated, using antipyretics (Class I, Level C) – When SBP >220 or DBP >120 mmHg in non
fibrinolysis case (Class I, Level C)
• Cardiac monitoring – Goal: lower BP for 15% during the first 24 hr
– Initiation of anti-HT in 24 hr is relatively safe.
– Recommend to screen for AF and arrhythmia Restarting after 24 hr in preexisting HT and neuro
– Should be performed at least 1st 24 hours stable is reasonable (Class IIa, Level C)

(Class I, Level B) Jauch ED, et al. Stroke 2013

Jauch ED, et al. Stroke 2013 Anti HT ถ้าให้ดีควรเริ่มหลัง 24 hr

• Blood Reperfusion therapy
pressure
control in • Including IV rtPA (Alteplase), IA rtPA, Mechanical
IV rt-PA thrombectomy
case (I, B)
• IV rtPA (0.9 mg/kg, max dose 90 mg) within 3 hours
– Before rt-PA of onset of ischemic stroke
< 185/110 (Class I; Level A)

– After rt-PA • The door-to-needle time within 60 min from
< 180/105 hospital arrival (Class I; Level A)
(1st 24 hr)
• IV rtPA is reasonable in patients whose BP can be
Jauch ED, et al. Stroke 2013 lowered safely (to below 185/110 mm Hg) with
antihypertensive agents, with the physician
หลัง 24 hr แล้ว ยาความดันจะให้ตัวไหนก็ได้
assessing the stability of the blood pressure before
starting intravenous rtPA (Class I; Level B)
ไม่มีข้อมูลว่าตัวไหนดีกว่าตัวไหน
Jauch ED, et al. Stroke 2013

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Endovascular therapy Endovascular therapy

• Patients should receive endovascular therapy • In carefully selected patients with anterior circulation
with a stent retriever if they meet all the occlusion who have contraindications to IV rtPA,
following criteria (Class I; Level of Evidence A): endovascular therapy with stent retrievers completed
– Prestroke mRS score 0 to 1, within 6 hours of stroke onset is reasonable
– Acute ischemic stroke receiving intravenous r-tPA (Class IIa; Level C)
within 4.5 hours of onset according to guidelines
from professional medical societies, • Although the benefits are uncertain, the use of
– Causative occlusion of the ICA or proximal MCA endovascular therapy with stent retrievers may be
(M1), reasonable for carefully selected patients in whom
– Age ≥18 years, treatment can be initiated (groin puncture) within 6 hours
– NIHSS score of ≥6, of symptom onset and who have causative occlusion of the
– ASPECTS of ≥6, and M2 or M3 portion of the MCAs, ACA, VA, BA, or PCA
– Treatment can be initiated (groin puncture) within 6 (Class IIb; Level C).
hours of symptom onset
Powers WJ, et al. Stroke 2015. • If endovascular therapy is contemplated, a noninvasive
intracranial vascular study is strongly recommended during
the initial imaging evaluation of the acute stroke patient
but should not delay intravenous r-tPA if indicated
(Class I; Level A)
Powers WJ, et al. Stroke 2015.

Antiplatelet Antiplatelet

• 2 major trial of aspirin • Combination antiplatelet

– IST (International Stroke Trial) – CHANCE trial

• ASA 300 mg within 48 hour • Minor stroke in Chinese population
• Reduce 14-day recurrence ischemic stroke • NIHSS ≤ 3 or ABCD ≥ 4
• Excluded isolated sensory, visual change, dizziness
(2.8 vs 3.9%) significantly
or vertigo without evidence of acute infarction on
– CAST (Chinese Acute Stroke Trial) imaging
• Also excluded patient with high hemorrhagic risk
• ASA 160 mg within 48 hour or have certain disability
• 14% reduction in total mortality at 4 weeks
Clopidogrel with aspirin in acute minor stroke or transient
(3.3 vs 3.9%) ischemic attack. N Eng J Med 2013 Jul 4;369(1):11-9.

Courtesy slides from Dr.Chaisak Adapted Courtesy slides from Dr.Chaisak

CHANCE study design Antiplatelet

• CHANCE trial

– ASA + Plavix vs ASA alone
– Plavix 300 mg stat then 75 mg/d + ASA

75 mg/d for 21 days then plavix 75
mg/d for 3 months
– Significant reduction in all stroke
(HR=0.68) with same hemorrhagic
complication

Clopidogrel with aspirin in acute minor stroke or transient
ischemic attack. N Eng J Med 2013 Jul 4;369(1):11-9.

Courtesy slides from Dr.Chaisak

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29/03/60

Antiplatelets in acute stroke Stroke unit

• Oral administration of ASA (initial dose is 325 • The use of comprehensive specialized
mg) within 24 to 48 hours after stroke onset is stroke care (stroke units) that
recommended for treatment of most patients incorporates rehabilitation is
(Class I; Level A) recommended
(Class I; Level of Evidence A)
• The usefulness of clopidogrel for the treatment
of acute ischemic stroke is not well established ลดการเกิด recurrent ได้เท่าๆ rTPA
(Class IIb; Level C).
Jauch ED, et al. Stroke 2013
• The administration of aspirin (or other
antiplatelet agents) as an adjunctive therapy
within 24 hours of intravenous fibrinolysis is not
recommended (Class III; Level C).

• Double antiplatelets? (ASA+Clopidogrel,
ASA+Dypiridamole)

Jauch ED, et al. Stroke 2013

Prophylaxis craniectomy Prophylaxis craniectomy

• Malignant ischemic stroke classified • Meta analysis (DECIMAL, DESTINY, DESTINY
by presence of severe brain edema to II, HAMLET)
produce IICP and herniation
• Outcome
• Mortality rate 78% due to herniation
• Clinical feature of malignant MCA – Mortality (mRS=6) at one year was lower
(NNT=2.4) all ages
infarction
– Death or major disability (mRS > 3) at one year
– Gaze preference, VF deficit, hemiplegia, was reduced (NNT=7.7) but subgroup age > 60
and aphasia or neglect there was no significant reduction

– NIHSS > 15 (right), > 20 (left) – Death or severe disability (mRS > 4) at one year
was reduced all ages
Courtesy slides from Dr.Chaisak
– There was no benefit to perform surgery after
48 hours after stroke onset.

Courtesy slides from Dr.Chaisak

Age < 60 , in 48 hr , large 2/3 MCA territory

SECONDARY PREVENTION OF ISCHEMIC Secondary prevention
STROKE AND TIA
• Risk factors control

– Hypertension
– Dyslipidemia
– Disorder of Glucose metabolism and DM
– OSA
– Cigarette and Alcohol

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Secondary prevention Secondary prevention

• Risk factors control • Risk factors control
– Hypertension
– Hypertension
• After the first several days – Dyslipidemia
• Start treatment when SBP ≥140 0r DBP ≥90 (I,B)
• Resume BP therapy for previously treated pt. (I,A) • Statin therapy in LDL ≥100 with or without
other ASCVD (I, B)
– Dyslipidemia
– Disorder of Glucose metabolism and DM • Goal LDL < 100 mg/dl (I, C)
– OSA
– Cigarette and Alcohol – Disorder of Glucose metabolism and DM
– OSA
Kernan WN, et al. Stroke 2014 – Cigarette and Alcohol

Kernan WN, et al. Stroke 2014

Secondary prevention Secondary prevention

• Risk factors control • Risk factors control

– Hypertension – Hypertension
– Dyslipidemia – Dyslipidemia
– Disorder of Glucose metabolism and DM – Disorder of Glucose metabolism and DM
– OSA
• All pt should be screened for DM with FBS,
HbA1c or OGTT. HbA1c is preferred. (IIa, C) • Sleep study might be considered: high
prevalence and Rx improve outcome (IIb, B)
• Use the ADA guideline
• CPAP might be considered (IIb, B)
– OSA
– Cigarette and Alcohol – Cigarette and Alcohol

Kernan WN, et al. Stroke 2014 Kernan WN, et al. Stroke 2014

Secondary prevention Secondary prevention

• Risk factors control • Interventional approaches

– Hypertension – Extracranial carotid disease
– Dyslipidemia
– Disorder of Glucose metabolism and DM • Carotid enarterctomy (CEA) in;
– OSA
– Cigarette and Alcohol – Ipsilateral severe (70-99%) carotid stenosis (I, A)
– Ipsi. moderate (50-69%) carotid stenosis
• Advice smoker in the past 2 years to quit (I, C)
• Heavy drinker should eliminate or reduce depending on pt-specific factors (I, B)
– CAS as an alternative to CEA (IIa, B)
alcohol (I,C)
• Light-mod alcohol may be reasonable (IIb,B) – Extracranial vertebrobasilar disease
– Intracranial atherosclerosis

Kernan WN, et al. Stroke 2014

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29/03/60

Slide courtesy of Dr.Pimwalai Secondary prevention

• Interventional approaches

– Extracranial carotid disease
– Extracranial vertebrobasilar disease

• Routine preventive therapy with anti-
thrombotic, lipid lowering, BP control and
lifestyle optimization (I, C)

• Endovascular stent or surgery may
considered if medical treatment fail (IIb, C)

– Intracranial atherosclerosis

Kernan WN, et al. Stroke 2014

Secondary prevention Secondary prevention

• Interventional approaches • Nonvalvular Atrial fibrillation
– VKA therapy (I, A), Apixaban (I, A), Dabigratan
– Extracranial carotid disease (I, B), Rivaloxaban (IIa, B)
– Extracranial vertebrobasilar disease – If VKA, target INR 2-3 (I, A)
– Intracranial atherosclerosis – If unable to take anticoagulant, ASA alone in
recommended (I, A), additional of clopidogrel
• 50-99% stenosis of major intracranial arteries might be reasonable (IIb, B)
ASA 325 mg is preferred more than warfarin, and – Initiation of anticoagulant within 14 d is
keep SBP < 140 and high-intensity statin (I, B) reasonable, or delayed in some cases (IIa, B)

• Recent event (<30 d) with 70-99% stenosis, ASA + Kernan WN, et al. Stroke 2014
clopidogrel 75mg/d may reasonable (IIb, B)
ถ้าไม่ severe รอ 14 วัน

Kernan WN, et al. Stroke 2014 ถ้า severe เริ่มได้เลย ?

ESC guideline 2016

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CVST 29/03/60

• Anticoagulation is reasonable for Pregnancy and Stroke
patients with acute CVST, even in
selected patients with intracranial • In the presence of a high-risk condition that would require anticoagulation
hemorrhage (Class IIa; Level B). outside of pregnancy, the following options are reasonable:
– a. LMWH twice daily throughout pregnancy, with dose adjusted to achieve the LMWH
• In CVST patients without a recognized manufacturer’s recommended peak anti-Xa activity 4 hours after injection, or
thrombophilia, it is reasonable to – b. Adjusted-dose UFH throughout pregnancy, administered subcutaneously every 12
administer anticoagulation for ≥3 hours in doses adjusted to keep the midinterval activated partial thromboplastin time
months, followed by antiplatelet at least twice control or to maintain an anti-Xa heparin level of 0.35 to 0.70 U/mL, or
therapy (Class IIa; Level C). – c. UFH or LMWH (as above) until the 13th week, followed by substitution of a VKA
until close to delivery, when UFH or LMWH is resumed.
(Class IIa; Level C)

• For pregnant women receiving adjusted-dose LMWH therapy for a high-risk
condition that would require anticoagulation outside of pregnancy, and when
delivery is planned, it is reasonable to discontinue LMWH ≥24 hours before
induction of labor or cesarean section (Class IIa; Level C).

• In the presence of a low-risk situation in which antiplatelet therapy would be
the treatment recommendation outside of pregnancy, UFH or LMWH, or no
treatment may be considered during the first trimester of pregnancy depending
on the clinical situation (Class IIb; Level C).

• In the presence of a low-risk situation in which antiplatelet therapy would be
the treatment recommendation outside of pregnancy, low-dose aspirin (50–150
mg/d) is reasonable after the first trimester of pregnancy (Class IIa; Level B).

Breastfeeding THANK YOU

• In the presence of a high-risk condition
that would require anticoagulation
outside of pregnancy, it is reasonable to
use warfarin, UFH, or LMWH (Class IIa;
Level C).

• In the presence of a low-risk situation in
which antiplatelet therapy would be the
treatment recommendation outside of
pregnancy, low-dose aspirin use may be
considered (Class IIb; Level C).

Stroke in the young ให้ไปหาอะไรเพิ่มบ้าง


• Aortic disection เจอบ่อยขึ้น


• AF เจอบ่อยขึ้น

• Angiopathy

Migrain like headache

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