Management of Ischemic CVA

Sunil Kumar Daha

17th April ’17

Introduction• A cerebrovascular accident is the medical term for a stroke• Stroke is defined as a syndrome of rapid onset of cerebral deficit (usually

focal) lasting >24 h or leading to death, with no cause apparent other than a vascular one.

ManagementAimed at minimizing the volume of brain that is irreversibly damaged,

preventing complications, reducing the patient’s disability and handicap through rehabilitation, and reducing the risk of recurrent stroke or other vascular events

Treatment • Immediate management • Long-term management

Immediate managementSupportive/general medical measures

• Airway: confirm patency, bedside swallow test

• Check respiration and oxygen saturation

• Monitor BP, Pulse and maintain the circulation

• Measure blood glucose level and manage the hyper and hypoglycaemia

• Treat hyperpyrexia, urinary and stool incontinence

• Maintain hydration and nutrition

Contd.

Brain imaging

• CT should always be available. This will indicate haemorrhage, other pathology and sometimes infarction

• MRI is better overall, if immediately available or if event is later than 7 days

Contd.Cerebral Ischaemia/infarction

• If CT excludes haemorrhage, give immediate thrombolytic therapy.• Aspirin 300mg/day is given if thrombolytic is contraindicated (90% patient are

eligible)• rTPA within 3-4.5 hrs. of onset (10 % patients are eligible)• If large cerebral infarction: decompressive hemicraniotomy

Cerebral haemorrhage• If CT shows haemorrhage, give no drugs that could interfere with clotting• Neurosurgery may occasionally be needed

Long-term management

Medical therapy• Antihypertensive• Antiplatelet • Anticoagulant • Other measures

Surgical approachesLife style modification

Medical therapy

Risk factors should be identified and addressed

Antihypertensive therapy• To prevent primary and secondary stroke• Treatment if diastolic BP >100mmHg• BP should lowered slowly to avoid any sudden fall in perfusion

Contd.

Antiplatelet therapy: 90 % patients are eligible•Aspirin 300mg daily • Clopidogrel 75mg daily: if Aspirin is intolerable•Dipyridamole 200mg BD- if Clopidogrel is

contraindicated or event occur whilst Clopidogrel

Contd.Anticoagulants• Heparin and Warfarin : AF, dysrhythmias, uninfected cardiac valve

lesion, cardiomyopathies• Brain haemorrhage must be excluded by CT/MRI• Potentially dangerous in 2 weeks following infarction (risk of

provoking cerebral haemorrhage)

Other measures– Correct polycythaemia and any clotting abnormality – Statin (Atovastatin or Paravastatin) therapy

Surgical approachesInternal carotid endarterectomy• Recommended if internal carotid artery stenosis >70%• Reduces the risk of further TIA/stroke by 75%• Percutaneous transluminal angioplasty (stenting) is an alternative

Life style modificationTo prevent the risk of stroke

• Avoid smoke/alcohol• Regular exercise• Improve eating habits: foods low in saturated fat, trans fat, cholesterol, sodium and

added sugars• Blood Pressure checked regularly• Discontinuation of OCP if taking• Control of blood glucose level• Have regular medical checkups

Algorithm for long term management of stroke

References• Davidson’s Principles and Practice of Medicine 22nd edition• Harrison’s Principal of internal medicine, 19th edition• Kumar and Clark's, Clinical Medicine, 8th Edition• Essential Medical pharmacology, KD Tripathi, 6th edition

Thank You