Ischemic Stroke

Intern Dr Ishan Subedi

Intern Dr Ran Singh
Approach to acute ischemic stroke
• Rapid Recognition of symptom of Suspected Stroke or TIA
• FAST: Outside hospital setting
• Exclude Hypoglycemia as a cause of neurological deficit
• ROSIER (Recognition of Stroke in the Emergency Room): For people admitted
to ER
Brain Imaging with NCCT in
suspected Acute stroke
• indications for thrombolysis or thrombectomy
• on anticoagulant treatment
• a known bleeding tendency
• a depressed level of consciousness (Glasgow Coma Score below 13)
• unexplained progressive or fluctuating symptoms
• papilloedema, neck stiffness or fever
• severe headache at onset of stroke symptoms.
• If thrombectomy might be indicated: perform imaging with CT
contrast angiography following initial non-enhanced CT.
• Without indication of immediate NCCT :Perform scanning as soon as
possible and within 24 hours of symptom onset
Pharmacological treatments and
thrombectomy
• Thrombolysis:
• Within 4.5 hours of symptom onset and when intracranial haemorrhage has
been excluded.
• Alteplase and Tenecteplase.
• Administer alteplase or tenecteplase only within a well-organised
stroke service
• staff trained in delivering thrombolysis and in monitoring for any
complications associated with thrombolysis
• immediate access to imaging and re-imaging, and staff trained to interpret
the images.
Thrombectomy
• Within 6 hour of symptom onset together with thrombolysis in
patient who have
• acute ischaemic stroke and
• confirmed occlusion of the proximal anterior circulation demonstrated by
computed tomographic angiography (CTA) or magnetic resonance
angiography
• Offer thrombectomy to people who were last known to be well
between 6 hours and 24 hours with
• Acute ischaemic stroke and confirmed occlusion of the proximal anterior
circulation demonstrated by CTA or MRA and
• if there is the potential to salvage brain tissue, by imaging : CT perfusion or
diffusion-weighted MRI sequences showing limited infarct core volume
• Consider thrombectomy together with intravenous thrombolysis as
for people last known to be well up to 24 hours :
• who have acute ischaemic stroke and confirmed occlusion of the proximal
posterior circulation (basilar or posterior cerebral artery)
• if there is the potential to salvage brain tissue
Aspirin and Anticoagulant treatment
People with acute ischemic stroke
• within 24 hours and intracerebral haemorrhage excluded by brain
imaging:
• aspirin 300 mg orally if they do not have dysphagia or
• aspirin 300 mg rectally or by enteral tube if they do have dysphagia.
• Continue aspirin daily 300 mg until 2 weeks after the onset of stroke
symptoms
• Then start definitive long-term antithrombotic treatment.
• PPI
• Alternative antiplatelet agent to anyone with acute ischaemic stroke
who is allergic or intolerant of aspirin.
• Do not use anticoagulation treatment routinely for the treatment of
acute stroke
Acute venous stroke
• Cerebral venous sinus thrombosis :
• full-dose anticoagulation treatment
• initially full-dose heparin and then warfarin [international normalised ratio 2
to 3]
• unless there are comorbidities that preclude its use.
Stroke with arterial dissection
• Anticoagulants or antiplatelet agents to people who have stroke
secondary to acute arterial dissection.
Anticoagulation treatment for other
comorbidities
• Disabling ischaemic stroke patient with atrial fibrillation
• aspirin 300 mg for the first 2 weeks before anticoagulation
treatment
• Prosthetic valves who have disabling cerebral infarction and
at significant risk of haemorrhagic transformation
• stop anticoagulation treatment for 1 week and substitute
aspirin 300 mg.
• Ischaemic stroke and symptomatic proximal deep vein thrombosis or
pulmonary embolism
• anticoagulation treatment in preference to treatment with aspirin
Statin treatment
• Immediate initiation of statin treatment is not recommended in
people with acute stroke
• Continue statin treatment in people with acute stroke who are
already receiving statins
Maintenance or restoration of
homeostasis
• Give supplemental oxygen to people who have had a stroke only if
their oxygen saturation drops below 95%.
• Maintain a blood glucose concentration between 4 and 11 mmol/litre
in people with acute stroke.
Blood pressure control for people
with acute ischaemic stroke
• Only if there is a hypertensive emergency with:
• hypertensive encephalopathy
• hypertensive nephropathy
• hypertensive cardiac failure/myocardial infarction
• aortic dissection
• pre-eclampsia/eclampsia.
• Blood pressure reduction to 185/110 mmHg or lower should be
considered in people who are candidates for intravenous
thrombolysis.
Optimal positioning and early
mobilisation for people with acute
stroke
Indication of thrombolysis
• Primary indication :All Ischaemic strokes presenting within 4.5 hours
of symptom onset.
Absolute Contraindications
• Evidence of intracranial haemorrhage on CT scan
• Previous history of intra-cranial haemorrhage SAH or arteriovenous
malformation (AVM)
• Warfarin or chronic liver disease, DOACs, or LMWH with INR > 1.7
• Known Intracranial neoplasms or AVM
• Systolic BP > 185 or diastolic BP > 110 mmHg, in-spite of intravenous
antihypertensive therapy
• Hypo or hyperglycaemia with blood glucose < 3 or > 22.0 mmol/L
• Active clinically apparent bleeding (oesophageal varices, peptic ulcer,
colitis, etc.)
Cautions / Relative
Contraindications
• Non-ischaemic pathology (e.g. functional, migraine, brain tumour
likely)
• Stroke within the preceding 3 months
• Rapidly resolving symptoms
• Head injury within 3 months
• GI bleed / trauma / surgery- within previous 1 month
• Endocarditis, recent MI, aortic aneurysm or ventricular aneurysm
• Pregnancy, or childbirth within the previous 4 weeks or breastfeeding
• Haemorrhagic retinopathy (e.g. untreated proliferative diabetic
retinopathy)
• Prolonged, traumatic CPR (more than 15 min +/- rib fractures, more
than one attempt at central line insertion)
• Platelet count < 100 000/mm3
• History of recent bleeding or any bleeding problem/ blood disorder
• Abnormal INR
AcT trial
• Comparison of Tenecteplase and Alteplase in Acute Ischaemic Stroke
Treatment
• Findings from the AcT Randomised Controlled Trial
Background
• Standard treatment for acute ischaemic stroke: Intravenous
thrombolysis with alteplase (bolus + infusion).
• Tenecteplase is hypothesized to improve reperfusion due to its single
bolus administration.
• Study objective: Compare tenecteplase vs. alteplase in stroke
treatment outcomes.
Study Methods
• Study Design: Multicentre, open-label, parallel-group, registry-linked,
randomised controlled trial (AcT).
• Locations: 22 primary and comprehensive stroke centres in Canada.
• Eligibility: Patients aged ≥18 years with disabling ischaemic
stroke,presenting within 4.5 hours of onset, and eligible for
thrombolysis under Canadian guidelines.
• Randomisation: 1:1 allocation using a validated balance algorithm.
• Intervention Groups:
• Tenecteplase: 0.25 mg/kg (max 25 mg, single bolus).
• Alteplase: 0.9 mg/kg (max 90 mg; 10% bolus + 60-min infusion).
Study Findings
• Participants: 1600 enrolled, 1577 in ITT analysis.
• Median age: 74 years (IQR 63-83).
• Gender: 47.9% female, 52.1% male.
• Primary Outcome:
• Tenecteplase: 36.9% (296/802) with mRS 0-1.
• Alteplase: 34.8% (266/765) with mRS 0-1.
• Risk Difference: 2.1% (95% CI -2.6 to 6.9) — Met non-inferiority threshold.
Safety Outcomes
• 24-hour Symptomatic Intracerebral Haemorrhage:
• Tenecteplase: 3.4% (27/800).
• Alteplase: 3.2% (24/763).
• 90-day Mortality:
• Tenecteplase: 15.3% (122/796).
• Alteplase: 15.4% (117/763).
Interpretation and Conclusion
• Key Takeaway: Tenecteplase (0.25 mg/kg) is a viable alternative to
alteplase for acute ischaemic stroke treatment.
• Advantages of Tenecteplase:
• Single bolus administration simplifies dosing.
• Comparable efficacy and safety to alteplase.
• Clinical Implication: Tenecteplase could replace alteplase as the
standard thrombolytic agent in stroke care.
Refrences
[Link] institute for Health and Care Excellence . Stroke and transient ischaemic
attack in over 16s: diagnosis and initial management NICE guideline [Internet].
2019 May. Available from:
[Link]
ic-attack-in-over-16s-diagnosis-and-initial-management-pdf-66141665603269
[Link] for thrombolytic therapy (Thrombolysis) and Mechanical Thrombectomy
in Acute Ischaemic Stroke [Internet]. Available from:
[Link]
3. Menon BK, Buck BH, Singh N, Deschaintre Y, Almekhlafi MA, Coutts SB, et al.
Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in
Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised,
controlled, non-inferiority trial. The Lancet [Internet]. 2022 Jul
16;400(10347):161–9. Available from:
[Link]