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1、TheEuropeanStrokeOrganization-ESO-ExecutiveCommitteeandWritingCommitteeGuidelines for Management of Ischaemic Stroke 2008MISSIONOFESOToreducetheincidenceandburdenofstrokebychangingthewaystrokeisviewedandtreatedinEuropeGuidelinesIschaemicStroke2008ESOGuidelines2008Content:Education,ReferralandEmergen
2、cyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationGuidelinesIschaemicStroke2008ESOWritingCommitteeChair:WernerHacke,Heidelberg,GermanyCo-Chairs:Marie-GermaineBousser,Paris,FranceGaryFord,Newcastle,UKGuidelinesIschaemicStroke2008ESOWri
3、tingCommitteeEducation,ReferralandEmergencyroomCo-Chairs:MichaelBrainin,Krems,Austria;JosFerro,Lisbon,PortugalMembers:CharlotteCordonnier,Lille,France;HeinrichP.Mattle,Bern,Switzerland;KeithMuir,Glasgow,UK;PeterD.Schellinger,Erlangen,GermanyStrokeUnitsCo-Chairs:Hans-ChristophDiener,Essen,Germany;Pet
4、erLanghorne,Glasgow,UKMembers:AntonyDavalos,Barcelona,Spain;GaryFord,Newcastle,UK;VeronikaSkvortsova,Moscow,RussiaGuidelinesIschaemicStroke2008ESOWritingCommitteeImagingandDiagnosticsCo-Chairs:MichaelHennerici,Mannheim,Germany;MarkkuKaste,Helsinki,FinlandMembers:HughS.Markus,London,UK;E.BerndRingels
5、tein,Mnster,Germany;RdigervonKummer,Dresden,Germany;JoannaWardlaw,Edinburgh,UKPreventionCo-Chairs:PhilBath,Nottingham,UK;DidierLeys,Lille,FranceMembers:lvaroCervera,Barcelona,Spain;LszlCsiba,Debrecen,Hungary;JanLodder,Maastricht,TheNetherlands;NilsGunnarWahlgren,StockholmGuidelinesIschaemicStroke200
6、8ESOWritingCommitteeGeneralTreatmentCo-Chairs:ChristophDiener,Essen,Germany;PeterLanghorne,Glasgow,UKMembers:AntonyDavalos,Barcelona,Spain;GaryFord,Newcastle,UK;VeronikaSkvortsova,Moscow,RussiaAcuteTreatmentandTreatmentofComplicationsCo-Chairs:AngelChamorro,Barcelona,Spain;BoNorrving,Lund,SwedenMemb
7、ers:ValericaCaso,Perugia,Italy;Jean-LouisMas,Paris,France;VictorObach,Barcelona,Spain;PeterA.Ringleb,Heidelberg,Germany;LarsThomassen,Bergen,NorwayGuidelinesIschaemicStroke2008ESOWritingCommitteeRehabilitationCo-Chairs:KennedyLees,Glasgow,UK;DaniloToni,Rome,ItalyMembers:StefanoPaolucci,Rome,Italy;Ju
8、haniSivenius,Kuopio,Finland;KatharinaStibrantSunnerhagen,Gteborg,Sweden;MarionF.Walker,Nottingham,UK;Substantial assistance:YvonneTeuschl,IsabelHenriques,TerenceQuinnGuidelinesIschaemicStroke2008DefinitionsofLevelsofEvidenceLevelAEstablishedasuseful/predictiveornotuseful/predictiveforadiagnosticmeas
9、ureorestablishedaseffective,ineffectiveorharmfulforatherapeuticintervention;requiresatleastoneconvincingClassIstudyoratleasttwoconsistent,convincingClassIIstudies.LevelBEstablishedasuseful/predictiveornotuseful/predictiveforadiagnosticmeasureorestablishedaseffective,ineffectiveorharmfulforatherapeut
10、icintervention;requiresatleastoneconvincingClassIIstudyoroverwhelmingClassIIIevidence.LevelCEstablishedasuseful/predictiveornotuseful/predictiveforadiagnosticmeasureorestablishedaseffective,ineffectiveorharmfulforatherapeuticintervention;requiresatleasttwoClassIIIstudies.GoodClinicalPractice(GCP)Rec
11、ommendedbestpracticebasedontheexperienceoftheguidelinedevelopmentgroup.UsuallybasedonClassIVevidenceindicatinglargeclinicaluncertainty,suchGCPpointscanbeusefulforhealthworkers.GuidelinesIschaemicStroke2008ClassificationofEvidenceEvidence classification scheme for a therapeutic interventionClassIAnad
12、equatelypowered,prospective,randomized,controlledclinicaltrialwithmaskedoutcomeassessmentinarepresentativepopulationoranadequatelypoweredsystematicreviewofprospectiverandomizedcontrolledclinicaltrialswithmaskedoutcomeassessmentinrepresentativepopulations.ClassIIProspectivematched-groupcohortstudyina
13、representativepopulationwithmaskedoutcomeassessmentorarandomized,controlledtrialinarepresentativepopulationthatlacksonecriterionforclassIevidence.ClassIIIAllothercontrolledtrials(includingwell-definednaturalhistorycontrolsorpatientsservingasowncontrols)inarepresentativepopulation,whereoutcomeassessm
14、entisindependentofpatienttreatment.ClassIVEvidencefromuncontrolledstudies,caseseries,casereports,orexpertopinion.GuidelinesIschaemicStroke2008ClassificationofEvidenceEvidence classification scheme for a diagnostic measureClassIAprospectivestudyinabroadspectrumofpersonswiththesuspectedcondition,using
15、agoldstandardforcasedefinition,wherethetestisappliedinablindedevaluation,andenablingtheassessmentofappropriatetestsofdiagnosticaccuracy.ClassIIAprospectivestudyofanarrowspectrumofpersonswiththesuspectedcondition,orawell-designedretrospectivestudyofabroadspectrumofpersonswithanestablishedcondition(by
16、goldstandard)comparedtoabroadspectrumofcontrols,wheretestisappliedinablindedevaluation,andenablingtheassessmentofappropriatetestsofdiagnosticaccuracy.ClassIIIEvidenceprovidedbyaretrospectivestudywhereeitherpersonswiththeestablishedconditionorcontrolsareofanarrowspectrum,andwheretestisappliedinablind
17、edevaluation.ClassIVEvidencefromuncontrolledstudies,caseseries,casereports,orexpertopinion.GuidelinesIschaemicStroke2008ESOGuidelines2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationGuidelinesI
18、schaemicStroke2008Education,Referral,EmergencymanagementStrokeasanEmergencyBackgroundStrokeisthemostimportantcauseofmorbidityandlongtermdisabilityinEurope1DemographicchangesarelikelytoresultinanincreaseinbothincidenceandprevalenceStrokeisalsothesecondmostcommoncauseofdementia,themostfrequentcauseofe
19、pilepsyintheelderly,andafrequentcauseofdepression2,31:LopezADetal.Lancet(2006)367:1747-17572:RothwellPMetal.Lancet(2005)366:1773-17833:OBrienJTetal.LancetNeurol(2003)2:89-98GuidelinesIschaemicStroke2008Education,Referral,EmergencymanagementStrokeasanEmergencyBackgroundStrokeisamedicalandoccasionally
20、asurgicalemergencyThemajorityofischaemicstrokepatientsdonotreachthehospitalquicklyenoughThedelaybetweenstrokeonsetandhospitaladmissionis;reducediftheEmergencyMedicalSystems(EMS)areusedincreasedifdoctorsoutsidethehospitalareconsultedfirstGuidelinesIschaemicStroke2008Education,Referral,Emergencymanage
21、mentStrokeasanEmergencyEmergencycareinacutestrokedependsonafour-stepchain:Rapidrecognitionof,andreactionto,strokesignsandsymptomsImmediateEMScontactandpriorityEMSdispatchPrioritytransportwithnotificationofthereceivinghospitalImmediateemergencyroomtriage,clinical,laboratoryandimagingevaluation,accura
22、tediagnosis,andadministrationofappropriatetreatmentsatthereceivinghospital.GuidelinesIschaemicStroke2008Education,Referral,EmergencymanagementStrokeasanEmergencyDelaysduringacutestrokemanagementhavebeenidentifiedatthreedifferentlevels1atthepopulationlevel,duetofailuretorecognizethesymptomsofstrokean
23、dcontactemergencyservicesattheleveloftheemergencyservicesandemergencyphysicians,duetoafailuretoprioritizetransportofstrokepatientsatthehospitallevel,duetodelaysinneuroimagingandinefficientin-hospitalcare1:KwanJetal.AgeAgeing(2004)33:116-121GuidelinesIschaemicStroke2008Education,Referral,Emergencyman
24、agementEducationRecommendationsEducationalprogrammestoincreaseawarenessofstrokeat the population level are recommended (Class II,Level B) Educational programmes to increase stroke awarenessamongprofessionals(paramedics,emergencyphysicians)arerecommended(Class II, Level B)GuidelinesIschaemicStroke200
25、8Education,Referral,EmergencymanagementReferralRecommendations (1/2)Immediate EMS contact and priority EMS dispatch arerecommended(Class II, Level B)Prioritytransportwithadvancenotificationofthereceivinghospitalisrecommended(Class III, Level B)Suspected stroke victims should be transported withoutde
26、laytothenearestmedicalcentrewithastrokeunitthatcanprovideultra-earlytreatment(Class III, Level B)Patients with suspected TIA should be referred withoutdelaytoaTIAclinicorastrokeunit(Class III, Level B)GuidelinesIschaemicStroke2008Education,Referral,EmergencymanagementReferralRecommendations (2/2)Dis
27、patchersandambulancepersonnelshouldbetrainedtorecognisestrokeusingsimpleinstrumentssuchastheFace-Arm-Speech-Test(Class IV, GCP)Immediate emergency room triage, clinical, laboratoryandimaging evaluation, accuratediagnosis, therapeuticdecisionandadministrationofappropriatetreatmentsarerecommended(Clas
28、s III, Level B)In remote or rural areas helicopter transfer andtelemedicineshouldbeconsideredtoimproveaccesstotreatment(Class III, Level C)GuidelinesIschaemicStroke2008Education,Referral,EmergencymanagementEmergencyManagementThetimewindowfortreatmentofpatientswithacutestrokeisnarrowAcuteemergencyman
29、agementofstrokerequiresparallelprocessesoperatingatdifferentlevelsofpatientmanagementAcuteassessmentofneurologicalandvitalfunctionsparallelsthetreatmentofacutelylife-threateningconditionsTimeisthemostimportantfactorGuidelinesIschaemicStroke2008Education,Referral,EmergencymanagementEmergencyManagemen
30、tTheinitialexaminationshouldincludeObservationofbreathingandpulmonaryfunctionandconcomitantheartdiseaseAssessmentofbloodpressureandheartrateDeterminationofarterialoxygensaturationBloodsamplesforclinicalchemistry,coagulationandhaematologystudiesObservationofearlysignsofdysphagiaTargetedneurologicalex
31、aminationCarefulmedicalhistoryfocussingonriskfactorsforarteriosclerosisandcardiacdiseaseGuidelinesIschaemicStroke2008DiagnosticsAncillaryDiagnosticTestsInallpatientsBrainImaging:CTorMRIECGLaboratoryTestsCompletebloodcountandplateletcount,prothrombintimeorINR,PTTSerumelectrolytes,bloodglucoseCRPorsed
32、imentationrateHepaticandrenalchemicalanalysisGuidelinesIschaemicStroke2008DiagnosticsAncillaryDiagnosticTestsInselectedpatientsDuplex/DopplerultrasoundMRAorCTADiffusionandperfusionMRorperfusionCTEchocardiography,ChestX-rayPulseoximetryandarterialbloodgasanalysisLumbarpunctureEEGToxicologyscreenGuide
33、linesIschaemicStroke2008Education,Referral,EmergencymanagementEmergencyManagementRecommendationsOrganizationofpre-hospitalandin-hospitalpathwaysandsystemsforacutestrokepatientsisrecommended(Class III, Level C)Allpatientsshouldreceivebrainimaging,ECG,andlaboratorytests.Additionaldiagnosticexamination
34、sarenecessaryinselectedpatients(Class IV, GCP)GuidelinesIschaemicStroke2008ESOGuidelines2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationGuidelinesIschaemicStroke2008Education,Referral,Emergenc
35、ymanagementStrokeUnitAstrokeunitIsadedicatedandgeographicallydefinedpartofahospitalthattakescareofstrokepatientsHasspecialisedstaffwithcoordinatedmultidisciplinaryexpertapproachtotreatmentandcareComprisescoredisciplines:medical,nursing,physiotherapy,occupationaltherapy,speechandlanguagetherapy,socia
36、lwork11:LanghornePetal.AgeAgeing(2002)31:365-371GuidelinesIschaemicStroke2008Education,Referral,EmergencymanagementStrokeUnitTypicalcomponentsofstrokeunitsincludeAssessmentMedicalassessmentanddiagnosis,earlyassessmentofnursingandtherapyneedsEarlymanagementpoliciesEarlymobilisation,preventionofcompli
37、cations,treatmentofhypoxia,hyperglycaemia,pyrexiaanddehydrationOngoingrehabilitationpoliciesCoordinatedmultidisciplinaryteamcareEarlyassessmentsofneedsafterdischargeGuidelinesIschaemicStroke2008Education,Referral,EmergencymanagementStrokeUnitTreatmentatastrokeunitcomparedtotreatmentinageneralward1re
38、ducesmortality(absoluteriskreductionof3%)reducesdependency(5%)reducesneedforinstitutionalcare(2%)Alltypesofpatients,irrespectiveofgender,age,strokesubtypeandstrokeseverity,appeartobenefitfromtreatmentinstrokeunits11:StrokeUnitTrialistsCollaborationCochraneRev(2007)GuidelinesIschaemicStroke2008Educat
39、ion,Referral,EmergencymanagementStrokeServicesandStrokeUnitsRecommendationsAll stroke patients should be treated in a stroke unit(Class I, Level A)Healthcare systems must ensure that acute strokepatientscanaccesshightechnologymedicalandsurgicalstrokecarewhenrequired(Class III, Level B)Thedevelopment
40、ofclinicalnetworks,includingtelemedicine,isrecommendedtoexpandtheaccesstohightechnologyspecialiststrokecare(Class II, Level B)GuidelinesIschaemicStroke2008ESOGuidelines2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofCom
41、plicationsRehabilitationGuidelinesIschaemicStroke2008DiagnosticsEmergencyDiagnosticTestsDifferentiatebetweendifferenttypesofstrokeAssesstheunderlyingcauseofbrainischaemiaAssessprognosisProvideabasisforphysiologicalmonitoringofthestrokepatientIdentifyconcurrentdiseasesorcomplicationsassociatedwithstr
42、okeRuleoutotherbraindiseasesGuidelinesIschaemicStroke2008DiagnosticsEmergencyDiagnosticTestsCranialComputedTomography(CT)ImmediateplainCTscanningdistinguishesreliablybetweenhaemorrhagicandischaemicstrokeDetectssignsofischaemiaasearlyas2hafterstrokeonset1Helpstoidentifyotherneurologicaldiseases(e.g.n
43、eoplasms)Mostcost-effectivestrategyforimagingacutestrokepatients21:vonKummerRetal.Radiology(2001)219:95-1002:WardlawJetal.Stroke(2004)35:2477-2483GuidelinesIschaemicStroke2008DiagnosticsEmergencyDiagnosticTestsMagneticResonanceImaging(MRI)Diffusion-weightedMRI(DWI)ismoresensitivefordetectionofearlyi
44、schaemicchangesthanCTDWIcanbenegativeinpatientswithdefinitestroke1IdentifiesischaemiclesionsintheposteriorfossareliablyDetectsevensmallintracerebralhaemorrhagesreliablyonT2*sequencesMRIisparticularlyimportantinacutestrokepatientswithunusualpresentations1:AyHetal.CerebrovascDis(2002)14:177-186Guideli
45、nesIschaemicStroke2008DiagnosticsEmergencyDiagnosticTestsMismatchConceptMismatchbetweentissueabnormalonDWIandtissuewithreducedperfusionmayreflecttissueatriskoffurtherischaemicdamage1Thereisdisagreementonhowtobestidentifyirreversibleischaemicbraininjuryandtodefinecriticallyimpairedbloodflow2Thereisno
46、clearevidencethatpatientswithparticularperfusionpatternsaremoreorlesslikelytobenefitfromthrombolysis31:JansenOetal.Lancet(1999)353:2036-20372:KaneIetal.Stroke(2007)38:3158-31643:AlbersGWetal.AnnNeurol(2006)60:508-517GuidelinesIschaemicStroke2008DiagnosticsEmergencyDiagnosticTestsUltrasoundstudiesCer
47、ebrovascularultrasoundisfastandnon-invasiveandcanbeadministeredusingportablemachines.Itisthereforeapplicabletopatientsunabletoco-operatewithMRAorCTA1CombinationsofultrasoundimagingtechniquesandMRAcanproduceexcellentresultsthatareequaltoDigitalsubtractionangiography(DSA)21:AllendrferJetal.LancetNeuro
48、logy(2005)5:835-8402:NederkoornPetal.Stroke(2003)34:1324-1332GuidelinesIschaemicStroke2008DiagnosticsEmergencyDiagnosticTestsImaginginTIA-patientsUpto10%recurrenceriskinthefirst48hours1Simpleclinicalscoringsystemscanbeusedtoidentifypatientsatparticularlyhighrisk1Upto50%ofpatientswithTIAshaveacuteisc
49、haemiclesionsonDWI.Thesepatientsareatincreasedriskofearlyrecurrentdisablingstroke2ThereiscurrentlynoevidencethatDWIprovidesbetterstrokepredictionthanclinicalriskscores31:RothwellPetal.LancetNeurol(2005)5:323-3312:CouttsSetal.AnnNeurol(2005)57:848-8543:RedgraveJetal.Stroke(2007)38:1482-1488Guidelines
50、IschaemicStroke2008DiagnosticsEmergencyDiagnosticTestsElectrocardiogram(ECG)Cardiacabnormalitiesarecommoninacutestrokepatients1Arrhythmiasmayinducestroke,strokemaycausearrhythmiasHoltermonitoringissuperiortoroutineECGforthedetectionofatrialfibrillation(AF)2ItisunclearwhethercontinuousECGrecordingatt
51、hebedsideisequivalenttoHoltermonitoringforthedetectionofAF1:ChristensenHetal.NeurolSci(2005)234:991032:GunalpMetal.AdvTher(2006)23:854-60GuidelinesIschaemicStroke2008DiagnosticsEmergencyDiagnosticTestsEchocardiography(TTE/TOE)Echocardiographycandetectmanypotentialcausesofstroke1Itisparticularlyrequi
52、redinpatientswithhistoryofcardiacdisease,ECGpathologies,suspectedsourceofembolism,suspectedaorticdisease,suspectedparadoxicalembolismTransoesophagealechocardiography(TOE)mightbesuperiortotransthoracicechocardiography(TTE)forthedetectionofpotentialcardiacsourcesofembolism21:LerakisSetal.AmJMedSci(200
53、5)329:310-62:deBruijnSFetal.Stroke(2006)37:2531-4GuidelinesIschaemicStroke2008DiagnosticsEmergencyDiagnosticTestsLaboratorytestsHaematology(RBC,WBC,plateletcount)BasicclottingparametersElectrolytesRenalandhepaticchemistryBloodGlucoseCRP,sedimentationrateGuidelinesIschaemicStroke2008Education,Referra
54、l,EmergencymanagementDiagnosticImagingRecommendationsInpatientswithsuspectedTIAorstroke,urgentcranialCT(Class I),oralternativelyMRI(Class II),isrecommended(Level A)IfMRIisused,theinclusionofdiffusionweightedimaging(DWI)andT2*-weightedgradientechosequencesisrecommended(Class II, Level A)Inpatientswit
55、hTIA,minorstroke,orearlyspontaneousrecoveryimmediatediagnosticwork-up,includingurgentvascularimaging(ultrasound,CT-angiography,orMRangiography)isrecommended(Class I, Level A)GuidelinesIschaemicStroke2008DiagnosticsOtherDiagnosticsRecommendations (1/2)InpatientswithacutestrokeandTIA,earlyevaluationof
56、physiological parameters, routine blood tests, andelectrocardiography (ECG) is recommended (Class I, Level A)All acute stroke and TIA patients should have a 12-channelECG.ContinuousECGrecordingisrecommended for ischaemic stroke and TIA patients(Class I, Level A)GuidelinesIschaemicStroke2008Diagnosti
57、csOtherDiagnosticsRecommendations (2/2)ForstrokeandTIApatientsseenaftertheacutephase,24-hour Holter ECG monitoring should be performedwhenarrhythmiasaresuspectedandnoothercausesofstrokearefound (Class I, Level A)ForallstrokeandTIApatients,asequenceofbloodtestsisrecommendedEchocardiography is recomme
58、nded in selected patients(Class III, Level B)GuidelinesIschaemicStroke2008ESOGuidelines2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationGuidelinesIschaemicStroke2008PrimaryPreventionPrimaryPrev
59、entionContentManagementofvascularriskfactorsAntithrombotictherapyCarotidsurgeryandangioplastyGuidelinesIschaemicStroke2008PrimaryPreventionVascularRiskFactorsConditionsandlifestylecharacteristicsidentifiedasariskfactorsforstrokeHighbloodpressureHighCholesterolAtrialfibrillationHyper-homocysteinaemia
60、DiabetesmellitusSmokingCarotidarterydiseaseHeavyalcoholuseMyocardialinfarctionPhysicalinactivityObesityGuidelinesIschaemicStroke2008PrimaryPreventionHighbloodpressure(BP)BackgroundHighbloodpressure(120/80mmHg)isthemostimportantandprevalentmodifiableriskfactorforstrokeSignificantreductionofstrokeinci
61、dencewithadecreaseinBP1NoclassofantihypertensiveisclearlysuperiorLIFE:lorsatanissuperiortoatenolol2ALLHAT:chlorthalidoneismoreeffectivethanamlodipineandlisinopril31:NealBetal.Lancet(2000)356:1955-642:DahlofBetal.Lancet(2002)359:995-1003.3:ManciaGetal.EurHeartJ(2007)28:1462-536GuidelinesIschaemicStro
62、ke2008PrimaryPreventionBackgroundIndependentriskfactorforischaemicstrokeImprovingglucosecontrolmaynotreducestroke1BPinpatientswithdiabetesshouldbe130/80mmHg2Statintreatmentreducestheriskofmajorvascularevents,includingstroke3Elevatedbloodglucoseintheearlyphaseofstrokeisassociatedwithdeathandpoorrecov
63、eryDiabetesmellitus1:TurnerRCetal.JAMA(1999)281:2005-122:ManciaGJ:HypertensSuppl(2007)25:S7-123:SeverPSetal.DiabetesCare(2005)28:1151-7GuidelinesIschaemicStroke2008PrimaryPreventionBackgroundStatintreatmentreducestheincidenceofstrokefrom3.4%to2.7%1Nosignificanteffectforpreventionoffatalstroke1HeartP
64、rotectionStudyfoundanexcessofmyopathyofoneper10,000patientsperannum2NodatasupportstatintreatmentinpatientswithLDL-cholesterol60g/day)1BPelevationmightbeareasonableexplanation3Lightalcoholconsumption(150mg/dl3,9mMol/l)shouldbemanagedwithlifestylemodification(Class IV, Level C)andastatin(Class I, Leve
65、l A)Cigarette smoking should be discouraged (Class III, Level B)Heavyuseofalcoholshouldbediscouraged(Class III, Level B)Regular physical activity is recommended (Class III, Level B)GuidelinesIschaemicStroke2008PrimaryPreventionRiskFactorManagementRecommendations (4/4)A diet low in salt and saturated
66、 fat, high in fruit andvegetablesandrichinfibreisrecommended(Class III, Level B)Subjects with an elevated body mass index arerecommendedtotakeaweight-reducingdiet(Class III, Level B)Antioxidant vitamin supplements are not recommended(Class I, Level A)Hormonereplacementtherapyisnotrecommendedforthepr
67、imarypreventionofstroke(Class I, Level A)GuidelinesIschaemicStroke2008PrimaryPreventionBackgroundInlowriskpersonslowdoseaspirinreducedcoronaryevents,butnotstroke1Inwomenover45yearsaspirinreducestheriskofischaemicstroke(OR0.76;95%CI0.63-0.93)2AspirinreducesMIinpatientswithasymptomaticcarotidarterydis
68、ease3AntithromboticTherapy1:BartolucciAetal.:AmJCardiol(2006)98:746-7502:BergerJetal.:JAMA(2006)295:306-3133:HobsonR,2ndetal.:JVascSurg(1993)17:257-263GuidelinesIschaemicStroke2008PrimaryPreventionBackgroundAveragestrokerateof5%peryearAspirinreducesstroke(RR0.78)inpatientswithnon-valvularAF1Warfarin
69、(INR2.0-3.0)ismoreeffectivethanaspirinatreducingstroke(RR0.36;95%CI0.26-0.51)1Combinationofaspirinandclopidogrelislesseffectivethanwarfarinandhasasimilarbleedingrate2Atrialfibrillation(AF)1:HartRGetal.:AnnInternMed(2007)146:857-8672:ConnollySetal.:Lancet(2006)367:1903-1912GuidelinesIschaemicStroke20
70、08PrimaryPreventionBackgroundAnticoagulationwithanINRbelow2.0isnoteffectiveIncreasedriskforbleedingcomplicationswithanINR3.5Patients75, or who are younger but have riskfactors such as high blood pressure, left ventriculardysfunction,ordiabetesmellitus(Class I, Level A)GuidelinesIschaemicStroke2008Pr
71、imaryPreventionAntithromboticTherapyRecommendations (4/4)Patients with AF who are unable to receive oralanticoagulantsshouldbeofferedaspirin(Class I, Level A)Patients with AF who have mechanical prosthetic heartvalves should receive long-term anticoagulation with atargetINRbasedontheprosthesistype,b
72、utnotlessthanINR23(Class II, Level B)Low dose aspirin is recommended for patients withasymptomaticinternalcarotidartery(ICA)stenosis50%toreducetheirriskofvascularevents(Class II, Level B)GuidelinesIschaemicStroke2008PrimaryPreventionBackground1,2Carotidendarterectomy(CEA)isstillamatterofcontroversyi
73、nasymptomaticindividualsRRRforstenosis60%NASCETis38-53%ARRis5.9-12.6%NNTtoavoidonestroke/yearis63-166Thecombinedsurgicalriskmustnotexceed3%Asymptomaticcarotidartery(ICA)stenosis1:ACAS:JAMA(1995)273:1421-8.2:ACST:Lancet(2004)363:1491-1502GuidelinesIschaemicStroke2008PrimaryPreventionSpecificissuesNop
74、rospectivetrialstestedthebenefitofantiplateletdrugsinpatientswithasymptomaticcarotidstenosis1Theipsilateralstrokeriskincreaseswiththedegreeofthestenosis2PatientswithanocclusionofthecontralateralICAdonotbenefitfromendarterectomy3WomenhavelowerbenefitfromCEAthanmen3Aspirinreducesstrokeriskduringandaft
75、erCEA4Asymptomaticcarotidartery(ICA)stenosis1:ChambersBRetal.:CochraneReview(2005)2:ECSTGroup:Lancet(1995)345:209-123:BakerWHetal.:Stroke(2000)31:2330-44:EngelterSetal.:CochraneReviews(2003)GuidelinesIschaemicStroke2008PrimaryPreventionCarotidSurgeryandAngioplastyRecommendationsCarotid surgery is no
76、t recommended for asymptomaticindividualswithsignificantcarotidstenosis(NASCET60-99%), except in those at high risk of stroke (Class I, Level C)Carotid angioplasty, with or without stenting, is notrecommended for patients with asymptomatic carotidstenosis(Class IV, GCP)Patientsshouldtakeaspirinbefor
77、eandafterCEA(Class I, Level A)GuidelinesIschaemicStroke2008SecondaryPreventionSecondaryPreventionContentManagementofvascularriskfactorsAntithrombotictherapySurgeryandangioplastyGuidelinesIschaemicStroke2008SecondaryPreventionBloodpressurecontrolBackgroundAntihypertensivedrugsreducestrokerecurrenceri
78、skafterstrokeorTIA(RR0.76;95%CI0.63-0.92)1TargetBPlevelandreductionshouldbeindividualizedThereductioninstrokeoccursregardlessofbaselineBPandtypeofstroke21:RashidPetal.:Stroke(2003)34:2741-82:PROGRESSgroup:Lancet(2001)358:1033-41GuidelinesIschaemicStroke2008SecondaryPreventionBackgroundInpeoplewithty
79、pe2diabeteswithpreviousstrokepioglitazonereducesfatalornonfatalstroke(HR0.53;95%CI0.34-0.85;P=0.0085)1Inadditionthereisatrendtoreducethecombinedendpointofdeathandmajorvascularevents(HR0.78;95%CI0.60-1.02;P=0.067)1Diabetesmellitus1:WilcoxRetal.:Stroke(2007)38:865-73GuidelinesIschaemicStroke2008Second
80、aryPreventionBackgroundAtorvastatin(80mg)reducesstrokerecurrenceby16%1Simvastatin(40mg)reducesriskofvasculareventsinpatientswithpriorstroke,andofstrokeinpatientswithothervasculardisease(RR0.76)2ARRforstatintreatmentislow(NNT112-143for1year)1Statinwithdrawalattheacutestageofstrokemaybeharmful3HighCho
81、lesterol1:AmarencoPetal.:NEnglJMed(2006)355:549-5592:HeartProtectionStudy:Lancet(2002)360:7-223:BlancoMetal.:Neurology(2007)69:904-10GuidelinesIschaemicStroke2008SecondaryPreventionBackgroundBetacaroteneincreasedtherisk(RR1.10)ofcardiovasculardeath1Antioxidantsupplementsmayincreasemortality2Folate,B
82、12,B6vitaminsgiventolowerhomocysteinelevelsmaynotreducestrokerecurrenceandmayincreasevascularevents3Vitamins1:VivekananthanDetal.:Lancet(2003)361:2017-20232:BjelakovicGetal.:JAMA(2007)297:842-8573:BonaaKetal.:NEnglJMed(2006)354:1578-1588GuidelinesIschaemicStroke2008SecondaryPreventionBackgroundOestr
83、ogentherapyisnoteffectiveinsecondarypreventionafterTIAorstrokeandmayincreasestrokeseverity1HormoneReplacementTherapy1:ViscoliCMetal.:NEnglJMed(2001)345:1243-9.GuidelinesIschaemicStroke2008SecondaryPreventionBackgroundSleep-disorderedbreathing(SDB)isbothariskfactorandaconsequenceofstrokeMorethan50%of
84、strokepatientshaveSDB,mostlyintheformofobstructivesleepapnoea(OSA).SDBislinkedwithpoorerlong-termoutcomeandincreasedlong-termstrokemortality1ContinuouspositiveairwaypressureisthetreatmentofchoiceforOSA.Sleep-disorderedBreathing1:BassettiCL:SeminNeurol(2005)25:19-32GuidelinesIschaemicStroke2008Second
85、aryPreventionRiskFactorManagementRecommendations (1/3)Blood pressure should be checked regularly. Bloodpressureloweringisrecommendedaftertheacutephase,includinginpatientswithnormalbloodpressure(Class I, Level A)Blood glucose should be checked regularly. Diabetesshould be managed with lifestyle modif
86、ication andindividualizedpharmacologicaltherapy(Class IV, GCP)Inpatientswithtype2diabeteswhodonotneedinsulin,treatmentwithpioglitazoneisrecommendedafterstroke(Class III, Level B)GuidelinesIschaemicStroke2008SecondaryPreventionRiskFactorManagementRecommendations (2/3)Statintherapyisrecommended(Class
87、I, Level A)Cigarettesmokingshouldbestopped(Class III, Level C)Heavyuseofalcoholshouldbediscouraged(Class IV, GCP)Regular physical activity is recommended (Class IV, GCP)Adietlowinsaltandsaturatedfat,highinfruitandvege-tables,andrichinfibreisrecommended(Class IV, GCP)GuidelinesIschaemicStroke2008Seco
88、ndaryPreventionRiskFactorManagementRecommendations (3/3)Subjects with an elevated body mass index arerecommendedtotakeaweight-reducingdiet(Class IV, Level C)Antioxidantvitaminssupplementsarenotrecommended(Class I, Level A)Hormone replacement therapy is not recommended forthesecondarypreventionofstro
89、ke(Class I, Level A)Sleep-disordered breathing such as obstructive sleepapnoea is recommended to be treated with continuouspositiveairwaypressurebreathing(Class III, Level GCP)GuidelinesIschaemicStroke2008SecondaryPreventionAntithromboticTherapyBackground:Aspirin13%relativeriskreductionforstrokeafte
90、rTIAorstroke1Mostwidelystudieddosagesofaspirinare50-150mgTheincidenceofGI-disturbanceswithaspirinisdosedependentNodifferenceineffectivenessamongstlow(75years)withoutorganfailureorseriouscardiacdysfunctionbenefitfromCEA1Womenwithsymptomaticstenosis70%shouldundergoCEA.Womenwithmoderatestenosisshouldbe
91、treatedmedically21:RothwellPMetal.:Lancet(2004)363:915-9242:RothwellPMetal.:Stroke(2004)35:2855-61GuidelinesIschaemicStroke2008SecondaryPreventionCarotidEndarterectomyEffectoftimefromlastsymptomaticeventtorandomisationonthe5-yearrelativerisk(RR)ofipsilateralischaemicstrokeandanyoperativestrokeordeat
92、hwithCEA(pooleddatafromECSTandNASCET1)1:RothwellPMetal.:Stroke(2004)35:2855-61GuidelinesIschaemicStroke2008SecondaryPreventionCarotidEndarterectomySpecificissuesThebenefitfromCEAislowerwithlacunarstrokePatientswithleuko-araiosisshouldbemadeawareoftheincreasedoperativeriskOcclusionofthecontralateralI
93、CAcarriesahigherperioperativeriskContinuationofaspirinisrequireduntilsurgery,butheparinmaybeusedinveryseverestenosisAllgradingofstenosesshouldbeaccordingtoNASCET-criteriaGuidelinesIschaemicStroke2008SecondaryPreventionCarotidArteryStenting(CAS)BackgroundNorandomizedtrialhasdemonstratedequivalentperi
94、proceduralriskforCAScomparedtoCEAintreatmentofsymptomaticcarotidarterystenosisAEuropeanstudyonlymarginallyfailedtoprovethenon-inferiorityofCAScomparedtoCEAAFrenchstudywasstoppedprematurelybecauseofa2.5foldhigherriskofanystrokeordeathafterCAS21:RinglebPAetal.:Lancet(2006)368:1239-12472:MasJLetal.:NEJ
95、M(2006)355:1660-1671GuidelinesIschaemicStroke2008SecondaryPreventionCarotidArteryStentingMetaanalysisCASvs.CEAEndpoint:anyperiproceduralstrokeordeath1:KastrupAetal.:ActaChirBelg(2007)107:119-28GuidelinesIschaemicStroke2008SecondaryPreventionIntracranialOcclusiveDiseaseBackgroundExtracranial-Intracra
96、nialbypassisnotbeneficialinpreventingstrokeinpatientswithMCAorICAstenosisorocclusion1Norandomizedcontrolledtrialshaveevaluatedangioplasty,stenting,orbothforintracranialstenosisSeveralnon-randomizedtrialshaveshownfeasibilityandacceptablesafetyofintracranialstenting,buttheriskofre-stenosisremainshigh2
97、,31:TheEC/ICBypassGrp:NEnglJMed(1985)313:1191-2002:BoseAetal.:Stroke(2007)38:1531-73:SSYLVIAStudyinvestigators:Stroke(2004)35:1388-92GuidelinesIschaemicStroke2008SecondaryPreventionSurgeryandAngioplastyRecommendations (1/4)CEAisrecommendedforpatientswith7099%stenosis(NASCETcriteria)(Class I, Level A
98、).CEAshouldonlybeperformed in centres with a perioperative complicationrate (all strokes and death) of less than 6% (Class I, Level A)CEAshouldbeperformedassoonaspossibleafterthelast ischaemic event, ideally within 2 weeks (Class II, Level B)GuidelinesIschaemicStroke2008SecondaryPreventionSurgeryand
99、AngioplastyRecommendations (2/4)CEAmaybeindicatedforcertainpatientswithstenosisof5069% (NASCET criteria); males with very recenthemisphericsymptoms aremostlikelytobenefit (Class III, Level C). CEA for stenosis of 5069% (NASCETcriteria) should only be performed in centres with aperioperativecomplicat
100、ionrate(allstrokeanddeath)oflessthan3%(Class I, Level A)CEA is not recommended for patients with stenosis oflessthan50%(NASCETcriteria)(Class I, Level A)GuidelinesIschaemicStroke2008SecondaryPreventionSurgeryandAngioplastyRecommendations (3/4)Patientsshouldremainonantiplatelettherapybothbeforeandaft
101、ersurgery(Class I, Level A)Carotid percutaneous transluminal angioplasty and/orstenting(CAS)isonlyrecommendedinselectedpatients(Class I, Level A).Itshouldberestrictedtothefollowingsubgroups of patients with severe symptomatic carotidartery stenosis: those with contra-indications to CEA,stenosisatasu
102、rgicallyinaccessiblesite,re-stenosisafterearlierCEA,andpost-radiationstenosis(Class IV, GCP)GuidelinesIschaemicStroke2008SecondaryPreventionSurgeryandAngioplastyRecommendations (4/4)Patientsshouldreceiveacombinationofclopidogrelandaspirinimmediatelybeforeandforatleast1monthsafterstenting(Class IV, G
103、CP)Endovascular treatment may be considered in patientswithsymptomaticintracranialstenosis(Class IV, GPC)GuidelinesIschaemicStroke2008SecondaryPreventionESOGuidelines2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofCompl
104、icationsRehabilitationGuidelinesIschaemicStroke2008SecondaryPreventionGeneralStrokeTreatmentContentMonitoringPulmonaryandairwaycareFluidbalanceBloodpressureGlucosemetabolismBodytemperatureGuidelinesIschaemicStroke2008SecondaryPreventionMonitoringContinuousmonitoringHeartrateBreathingrateO2saturation
105、DiscontinuousmonitoringBloodpressureBloodglucoseVigilance(GCS),pupilsNeurologicalstatus(e.g.NIHstrokescaleorScandinavianstrokescale)GuidelinesIschaemicStroke2008SecondaryPreventionPulmonaryfunctionBackgroundAdequateoxygenationisimportantImprovebloodoxygenationbyadministrationof2lO2Riskforaspirationi
106、npatientswithsidepositioningHypoventilationmaybecausedbypathologicalrespirationpatternRiskofairwayobstruction(vomiting,oropharyngealmuscularhypotonia):mechanicalairwayprotectionGuidelinesIschaemicStroke2008SecondaryPreventionBloodpressureBackgroundElevatedinmostpatientswithacutestrokeBPdropsspontane
107、ouslyduringthefirstdaysafterstrokeBloodflowinthecriticalpenumbrapassivelydependentonthemeanarterialpressureTherearenoadequatelysizedrandomised,controlledstudiesguidingBPmanagementGuidelinesIschaemicStroke2008SecondaryPreventionBloodpressureSpecificissuesElevatedBP(e.g.upto200mmHgsystolicor110mmHgdia
108、stolic)maybetoleratedintheacutephaseofischaemicstrokewithoutinterventionBPmaybeloweredifthisisrequiredbycardiacconditionsUpperlevelofsystolicBPinpatientsundergoingthrombolytictherapyis180mmHgAvoidandtreathypotensionAvoiddrasticreductioninBPGuidelinesIschaemicStroke2008SecondaryPreventionGlucosemetab
109、olismBackgroundHighglucoselevelsinacutestrokemayincreasethesizeoftheinfarctionandreducefunctionaloutcomeHypoglycemiacanmimicacuteischaemicinfarctionRoutineuseofglucosepotassiuminsulin(GKI)infusionregimesinpatientswithmildtomoderatehyperglycaemiadidnotimproveoutcome1Itiscommonpractisetotreathyperglyc
110、emiawithinsulinwhenbloodglucoseexceeds180mg/dl2(10mmol/l)1:GrayCSetal.:LancetNeurol(2007)6:397-4062:LanghornePetal.:AgeAgeing(2002)31:365-71.GuidelinesIschaemicStroke2008SecondaryPreventionBodytemperatureBackgroundFeverisassociatedwithpoorerneurologicaloutcomeafterstrokeFeverincreasesinfarctsizeinex
111、perimentalstrokeManypatientswithacutestrokedevelopafebrileinfectionTherearenoadequatelysizedtrialsguidingtemperaturemanagementafterstrokeItiscommonpracticetreatfever(anditscause)whenthetemperaturereaches37.5CGuidelinesIschaemicStroke2008SecondaryPreventionGeneralStrokeTreatmentRecommendations (1/4)I
112、ntermittentmonitoringofneurologicalstatus,pulse,bloodpressure,temperatureandoxygensaturationisrecommended for 72 hours in patients with significantpersistingneurologicaldeficits(Class IV, GCP)OxygenshouldbeadministeredifsPO2fallsbelow95%(Class IV, GCP)Regular monitoring of fluid balance and electrol
113、ytes isrecommendedinpatientswithseverestrokeorswallowingproblems(Class IV, GCP)GuidelinesIschaemicStroke2008SecondaryPreventionGeneralStrokeTreatmentRecommendations (2/4)Normalsaline(0.9%)isrecommendedforfluidreplacementduringthefirst24hoursafterstroke(Class IV, GCP)Routine blood pressure lowering i
114、s not recommendedfollowingacutestroke(Class IV, GCP)Cautious blood pressure lowering is recommended inpatientswithanyofthefollowing;extremelyhighbloodpressures(220/120mmHg)onrepeatedmeasurements,or severe cardiac failure, aortic dissection, or hyper-tensiveencephalopathy(Class IV, GCP)GuidelinesIsch
115、aemicStroke2008SecondaryPreventionGeneralStrokeTreatmentRecommendations (3/4)Abruptbloodpressureloweringshouldbeavoided(Class II, Level C)Low blood pressure secondary to hypovolaemia orassociatedwithneurologicaldeteriorationinacutestrokeshouldbetreatedwithvolumeexpanders(Class IV GCP)Monitoringserum
116、glucoselevelsisrecommended(Class IV, GCP)Treatmentofserumglucoselevels180mg/dl(10mmol/l)withinsulintitrationisrecommended(Class IV, GCP) GuidelinesIschaemicStroke2008SecondaryPreventionGeneralStrokeTreatmentRecommendations (4/4)Severe hypoglycaemia (50mg/dl 37.5C) shouldpromptasearchforconcurrentinf
117、ection(Class IV, GCP)Treatment of pyrexia (37.5C) with paracetamol andfanningisrecommended(Class III, Level C)Antibioticprophylaxisisnotrecommendedinimmunocompetentpatients(Class II, Level B)GuidelinesIschaemicStroke2008SecondaryPreventionESOGuidelines2008Content:Education,ReferralandEmergencyroomSt
118、rokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationGuidelinesIschaemicStroke2008SecondaryPreventionSpecificStrokeTreatmentContentThrombolytictherapyEarlyantithrombotictreatmentTreatmentofelevatedintracranialpressurePreventionandmanagementofcom
119、plicationsGuidelinesIschaemicStroke2008SecondaryPreventionThrombolyticTherapy(i.v.rtPA)Background(NINDS1,ECASSI2+II3,ATLANTIS4)IntravenousrtPA(0.9mg/kg,max90mg)givenwithin3hoursofstrokeonset,significantlyimprovesoutcomeinpatientswithacuteischaemicstrokeBenefitfromtheuseofi.v.rtPAbeyond3hoursissmalle
120、r,butmaybepresentuptoatleast4.5hoursSeveralcontraindications1:NINDSrt-PAGrp:NewEnglJMed(1995)333:1581-15872:HackeWetal.:JAMA(1995)274:1017-10253:HackeWetal.:Lancet(1998)352:1245-12514:ClarkWMetal.:Jama(1999)282:2019-26.GuidelinesIschaemicStroke2008SecondaryPreventionThrombolyticTherapy(i.v.rtPA)Spec
121、ificissuesApooledanalysisofthe6i.v.rtPAtrialsconfirmsthati.v.thrombolysismayworkupto4.5hours1Cautionisadvisedwhenconsideringi.v.rtPAinpersonswithseverestroke(NIHSSS25),oriftheCTdemonstratesextendedearlyinfarctssignsThrombolytictherapymustbegivenbyanexperiencedstrokephysicianaftertheimagingofthebrain
122、isassessedbyphysiciansexperiencedinreadingthisimagingstudy21:HackeWetal.:Lancet(2004)363:768-742:WahlgrenNetal.:Lancet(2007)369:275-82GuidelinesIschaemicStroke2008SecondaryPreventionThrombolyticTherapy(i.v.rtPA)SpecificissuesFactorsassociatedwithincreasedbleedingrisk1elevatedserumglucosehistoryofdia
123、betesbaselinesymptomseverityadvancedageincreasedtimetotreatmentpreviousaspirinusehistoryofcongestiveheartfailureNINDSprotocolviolationsNoneofthesereversedtheoverallbenefitofrtPA1:LansbergMGetal.:Stroke(2007)38:2275-8GuidelinesIschaemicStroke2008SecondaryPreventionThrombolyticTherapy(i.v.rtPA)Riskand
124、outcomefrom6,483patientsoftheSITS-Mosttreatedwithiv-rtPAwithina3hourtimewindow11:WahlgrenNetal.:Lancet(2007)369:275-82GuidelinesIschaemicStroke2008SecondaryPreventionThrombolyticTherapy(i.v.rtPA)MismatchbasedtherapyTheuseofmultimodalimagingcriteriamaybeusefulforpatientselection1,2Availabledataonmism
125、atch,asdefinedbymultimodalMRIorCT,aretoolimitedtoguidethrombolysisinroutinepractice3Dataregardingtheuseofintravenousdesmoteplaseadministered3to9hoursafteracuteischaemicstrokeinpatientsselectedonthebasisofperfusion/diffusionmismatchareconflicting1:KhrmannMetal.:LancetNeurol(2006)5:661-72:ChalelaJetal
126、.:Lancet(2007)369:293-2983:KaneIetal.:JNNP(2007)78:485-490GuidelinesIschaemicStroke2008SecondaryPreventionThrombolyticTherapy(i.a.)Background:theuseofi.a.rtPA,i.a.urokinaseOnlycasesandsomeprospectiveuncontrolledcaseseriesFacts:aboutuseofi.a.pro-urokinaseEfficacydemonstratedinsmallRCT,6hwindow1Notapp
127、rovedandsubstancenotavailable1:FurlanAetal.:JAMA(1999)282:2003-11GuidelinesIschaemicStroke2008SecondaryPreventionSpecificTreatmentRecommendations (1/5)IntravenousrtPA(0.9mg/kgBW,maximum90mg),with10%ofthedosegivenasabolusfollowedbya60-minuteinfusion, is recommended within 3 hours of onset ofischaemic
128、stroke(Class I, Level A)Intravenous rtPA may be of benefit also for acuteischaemic stroke beyond 3 hours after onset (Class I, Level B) but is not recommended for routine clinicalpractice.Theuseofmultimodalimagingcriteriamaybeusefulforpatientselection(Class III, Level C)GuidelinesIschaemicStroke2008
129、SecondaryPreventionSpecificTreatmentRecommendations (2/5)Blood pressures of 185/110mmHg or higher must beloweredbeforethrombolysis(Class IV, GCP)IntravenousrtPAmaybeusedinpatientswithseizuresatstrokeonset,iftheneurologicaldeficitisrelatedtoacutecerebralischaemia(Class IV, GCP)Intravenous rtPA may al
130、so be administered in selectedpatientsover80yearsofage, althoughthisisoutsidethecurrentEuropeanlabelling(Class III, Level C)GuidelinesIschaemicStroke2008SecondaryPreventionSpecificTreatmentRecommendations (3/5)Intra-arterialtreatmentofacuteMCAocclusionwithina6-hourtimewindowisrecommendedasanoption(C
131、lass II, Level B)Intra-arterial thrombolysis is recommended for acutebasilarocclusioninselectedpatients(Class III, Level B)Intravenous thrombolysis for basilar occlusion is anacceptablealternativeevenafter3hours(Class III, Level B)GuidelinesIschaemicStroke2008SecondaryPreventionAntiplatelettherapyBa
132、ckgroundAspirinwastestedinlargeRCTsinacute(48h)stroke1,2Significantreductionwasseenindeathanddependency(NNT70)andrecurrenceofstroke(NNT140)Aphase3trialfortheglycoprotein-IIb-IIIaantagonistabciximabwasstoppedprematurelybecauseofanincreasedrateofbleeding31:International-Stroke-Trial:Lancet(1997)349:15
133、69-15812:CAST-Collaborative-Group:Lancet(1997)349:1641-16493:AdamsHP,Jr.etal.:Stroke(2007)GuidelinesIschaemicStroke2008SecondaryPreventionAnticoagulationUnfractionatedheparinNoformaltrialavailabletestingstandardi.v.heparinISTshowednonetbenefitfors.c.heparintreatedpatientsbecauseofincreasedriskofICH1
134、LowmolecularweightheparinNobenefitonstrokeoutcomeforlowmolecularheparin(nadroparin,certoparin,tinzaparin,dalteparin)Heparinoid(orgaran)TOASTtrialneutral21:International-Stroke-Trial:Lancet(1997)349:1569-15812:TOASTInvestigators:JAMA(1998)279:1265-72.GuidelinesIschaemicStroke2008SecondaryPreventionNe
135、uroprotectionNoadequatelysizedtrialhasyetshownsignificanteffectinpredefinedendpointsforanyneuroprotectivesubstanceAmeta-analysishassuggestedamildbenefitforcitocoline11:DavalosAetal.:Stroke(2002)33:2850-7GuidelinesIschaemicStroke2008SecondaryPreventionSpecificTreatmentRecommendations (4/5)Aspirin(160
136、325mgloadingdose)shouldbegivenwithin48hoursafterischaemicstroke(Class I, Level A)If thrombolytic therapy is planned or given, aspirin orotherantithrombotictherapyshouldnotbeinitiatedwithin24hours(Class IV, GCP)Theuseofotherantiplateletagents(singleorcombined)is not recommended in the setting of acut
137、e ischaemicstroke(Class III, Level C)Theadministrationofglycoprotein-IIb-IIIainhibitorsisnotrecommended(Class I, Level A)GuidelinesIschaemicStroke2008SecondaryPreventionSpecificTreatmentRecommendations (5/5)Early administration of unfractionated heparin, lowmolecularweightheparinorheparinoidsisnotre
138、commended for the treatment of patients withischaemicstroke(Class I, Level A)Currently,thereisnorecommendationtotreatischaemicstrokepatientswithneuroprotectivesubstances(Class I, Level A)GuidelinesIschaemicStroke2008SecondaryPreventionElevatedIntracranialPressureBasicmanagementHeadelevationupto30Pai
139、nreliefandsedationOsmoticagents(glycerol,mannitol,hypertonicsaline)VentilatorysupportBarbiturates,hyperventilation,orTHAM-bufferAchievenormothermiaHypothermiamayreducemortality11:SteinerTetal.:Neurology(2001)57(Suppl2):S61-8.GuidelinesIschaemicStroke2008SecondaryPreventionElevatedIntracranialPressur
140、eMalignantMCA/hemisphericinfarctionPooledanalysisofthreeEuropeanRCTs(N=93)1,2:Significantlydecreasesmortalityafter30daysSignificantlymorepatientswithmRS4ormRS50yearsisapredictorforpooroutcome31:VahediKetal.:LancetNeurol(2007)6:215-222:JttlerEetal.:Stroke(2007)38:2518-253:GuptaRetal.:Stroke(2004)35:5
141、39-43GuidelinesIschaemicStroke2008SecondaryPreventionElevatedIntracranialPressureAbsoluteriskreduction(ARR)andoddsratio(OR)forunfavourableoutcomeat12months:combinedanalysisofdecompressiontrials11:VahediKetal.:LancetNeurol(2007)6:215-22GuidelinesIschaemicStroke2008SecondaryPreventionElevatedIntracran
142、ialPressureRecommendations (1/2)Surgical decompressive therapy within 48 hours aftersymptom onset is recommended in patients up to 60yearsofagewithevolvingmalignantMCAinfarcts(Class I, Level A)Osmotherapycanbeusedtotreatelevatedintracranialpressurepriortosurgeryifthisisconsidered(Class III, Level C)
143、GuidelinesIschaemicStroke2008SecondaryPreventionElevatedIntracranialPressureRecommendations (2/2)Norecommendationcanbegivenregardinghypothermictherapy in patients with space-occupying infarctions(Class IV, GCP)Ventriculostomy or surgical decompression can beconsidered for treatment of large cerebell
144、ar infarctionsthatcompressthebrainstem(Class III, Level C)GuidelinesIschaemicStroke2008SecondaryPreventionESOGuidelines2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationGuidelinesIschaemicStroke
145、2008SecondaryPreventionManagementofComplicationsAspirationandpneumoniaBacterialpneumoniaisoneofthemostimportantcomplicationsinstrokepatients1PreventivestrategiesWithholdoralfeedinguntildemonstrationofintactswallowing,preferableusingastandardizedtestNasogastric(NG)orpercutaneousenteralgastrostomy(PEG
146、)FrequentchangesofthepatientspositioninbedandpulmonaryphysicaltherapyProphylacticadministrationoflevofloxacinisnotsuperiortooptimalcare21:WeimarCetal.:EurNeurol(2002)48:133-402:ChamorroAetal.:Stroke(2005)36:1495-500GuidelinesIschaemicStroke2008SecondaryPreventionManagementofComplicationsUrinarytract
147、infectionsMosthospital-acquiredurinarytractinfectionsareassociatedwiththeuseofindwellingcatheters1IntermittentcatheterizationdoesnotreducetheriskofinfectionIfurinaryinfectionisdiagnosed,appropriateantibioticsshouldbechosenfollowingbasicmedicalprinciples1:GerberdingJL:AnnInternMed(2002)137:665-70cGui
148、delinesIschaemicStroke2008SecondaryPreventionManagementofComplicationsDeepveinthrombosisandpulmonaryembolismRiskmightbereducedbygoodhydrationandearlymobilizationLow-doseLMWHreducestheincidenceofbothDVT(OR0.34)andpulmonaryembolism(OR0.36),withoutasignificantlyincreasedriskofintracerebral(OR1.39)orext
149、racerebralhaemorrhage(OR1.44)1,21:DienerHCetal.:Stroke(2006)37:139-442:ShermanDGetal.:Lancet(2007)369:1347-55GuidelinesIschaemicStroke2008SecondaryPreventionManagementofComplicationsPressureulcerUseofsupportsurfaces,frequentrepositioning,optimizingnutritionalstatus,andmoisturizingsacralskinareapprop
150、riatepreventivestrategies1SeizuresProphylacticanticonvulsivetreatmentisnotbeneficialAgitationCausaltreatmentmustprecedeanytypeofsedationorantipsychotictreatment1:ReddyMetal.:JAMA(2006)296:974-84GuidelinesIschaemicStroke2008SecondaryPreventionManagementofComplicationsFallsArecommonineverystageofstrok
151、etreatmentRiskfactorsincludecognitiveimpairment,depression,polypharmacyandsensoryimpairment1Amultidisciplinarypackagefocusingonpersonalandenvironmentalfactorsmightbepreventive2Exercise,calciumsupplementsandbisphosphonatesimprovebonestrengthanddecreasefractureratesinstrokepatients3,41:AizenEetal.:Arc
152、hGerontolGeriatr(2007)44:1-122:OliverDetal.:BMJ(2007)334:823:PangMYetal.:ClinRehabil(2006)20:97-1114:SatoYetal.:CerebrovascDis(2005)20:187-92GuidelinesIschaemicStroke2008SecondaryPreventionManagementofComplicationsDysphagiaandfeedingDysphagiaoccursinupto50%ofpatientswithunilateralhemiplegicstrokeand
153、isanindependentrisk-factorforpooroutcome1Forpatientswithcontinuingdysphagia,optionsforenteralnutritionincludeNGorPEGfeedingPEGdoesnotprovidebetternutritionalstatusorimprovedclinicaloutcome,comparedtoNG2,31:MartinoRetal.:Stroke(2005)36:2756-632:DennisMSetal.:Lancet(2005)365:764-723:CallahanCMetal.:JA
154、mGeriatrSoc(2000)48:1048-54GuidelinesIschaemicStroke2008SecondaryPreventionManagementofComplicationsRecommendations (1/4)Infectionsafterstrokeshouldbetreatedwithappropriateantibiotics(Class IV, GCP)Prophylacticadministrationofantibioticsisnotrecommended, and levofloxacin can be detrimental inacutest
155、rokepatients(Class II, Level B)Earlyrehydrationandgradedcompressionstockingsarerecommended to reduce the incidence of venousthromboembolism(Class IV, GCP)Early mobilization is recommended to prevent compli-cationssuchasaspirationpneumonia,DVTandpressureulcers(Class IV, GCP)GuidelinesIschaemicStroke2
156、008SecondaryPreventionManagementofComplicationsRecommendations (2/4)Low-doses.c.heparinorlowmolecularweightheparinsshouldbeconsideredforpatientsathighriskofDVTorpulmonaryembolism(Class I, Level A)Administration of anticonvulsants is recommended topreventrecurrentseizures(Class I, Level A)Prophylacti
157、cadministrationofanticonvulsantstopatientswith recent stroke who have not had seizures is notrecommended(Class IV, GCP)An assessment of falls risk is recommended for everystrokepatient(Class IV, GCP)GuidelinesIschaemicStroke2008SecondaryPreventionManagementofComplicationsRecommendations (3/4)Calcium
158、/vitamin-D supplements are recommended instrokepatientsatriskoffalls(Class II, Level B)Bisphosphonates(alendronate,etidronateandrisedronate) are recommended in women with previousfractures(Class II, Level B)In stroke patients with urinary incontinence, specialistassessment and management is recommen
159、ded (Class III, Level C)Swallowing assessment is recommended but there areinsufficient data to recommend a specific approach fortreatment(Class III, GCP)GuidelinesIschaemicStroke2008SecondaryPreventionManagementofComplicationsRecommendations (4/4)Oraldietarysupplementsareonlyrecommendedfornon-dyspha
160、gicstrokepatientswhoaremalnourished(Class II, Level B) Earlycommencementofnasogastric(NG)feeding(within48 hours) is recommended in stroke patients withimpairedswallowing(Class II, Level B)Percutaneousenteralgastrostomy(PEG)feedingshouldnotbeconsideredinstrokepatientsinthefirst2weeks(Class II, Level
161、B)GuidelinesIschaemicStroke2008SecondaryPreventionESOGuidelines2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationGuidelinesIschaemicStroke2008SecondaryPreventionRehabilitationEarlyrehabilitation
162、Morethan40%ofstrokepatientsneedactiverehabilitationActiverehabilitationshouldstartearly,providingthepatientisclinicallystablePassiverehabilitationshouldbegivenifthepatientisunconsciousorparalysedRehabilitationshouldbecontinuedaslongasperceptablerecoveryistakingplaceGuidelinesIschaemicStroke2008Secon
163、daryPreventionRehabilitationMultidisciplinarystroketeamforrehabilitationStrokephysicianNursesexperiencedinstrokemanagementPhysiotherapisttrainedinstrokerehabilitationOccupationaltherapistskilledinstrokeSpeechtherapistfamiliarwithspeechproblemsinstrokepatientsNeuropsychologistaccustomedtostrokerehabi
164、litationSocialworkerfamiliarwiththeproblemsofstrokepatientsGuidelinesIschaemicStroke2008SecondaryPreventionSettingofRehabilitationRecommendations (1/2)Admission to a stroke unit is recommended for acutestroke patients to receive coordinated multidisciplinaryrehabilitation(Class I, Level A)Early disc
165、harge from stroke unit care is possible inmedicallystablepatientswithmildormoderateimpairmentprovidingthatrehabilitationisdeliveredinthecommunity by a multidisciplinary team with strokeexpertise(Class I, Level A)GuidelinesIschaemicStroke2008SecondaryPreventionSettingofRehabilitationRecommendations (
166、2/2)Rehabilitationshouldbecontinuedafterdischargeduringthefirstyearafterstroke(Class II, Level A)Earlyinitiationofrehabilitationisrecommended(Class III, Level C)It is recommended that the duration and intensity ofrehabilitationisincreased(Class II, Level B)GuidelinesIschaemicStroke2008SecondaryPreve
167、ntionElementsofRehabilitationRecommendations (1/3)Physiotherapyisrecommended,buttheoptimalmodeofdeliveryisunclear(Class I, Level A)Occupational therapy is recommended, but the optimalmodeofdeliveryisunclear(Class I, Level A)Whileassessmentforcommunicationdeficitsisrecommended,thereareinsufficientdat
168、atorecommendspecifictreatments(Class III, GCP)Informationshouldbeprovidedtopatientandcarersbutevidence does not support use of a dedicated strokeliaisonserviceforallpatients(Class II, Level B)GuidelinesIschaemicStroke2008SecondaryPreventionElementsofRehabilitationRecommendations (2/3)Rehabilitationm
169、ustbeconsideredforallstrokepatients,but there is limited evidence to guide appropriatetreatmentforthemostseverelydisabled(Class II, Level B)Whileassessmentforcognitivedeficitsappearsdesirable, there are insufficient data to recommendspecifictreatments(Class I, Level A)Patients should be monitored fo
170、r depression duringhospitalstayandthroughoutfollowup(Class IV, Level B)GuidelinesIschaemicStroke2008SecondaryPreventionElementsofRehabilitationRecommendations (3/3)Drugtherapyandnon-druginterventionsarerecommendedtoimprovemood(Class I, Level A)Drugtherapyshouldbeconsidered totreatpoststrokeemotionalism(Class II, Level B)Tricyclicoranticonvulsanttherapyarerecommendedtotreat post-stroke neuropathic pain in selected patients(Class III, Level B)Botulinumtoxinshouldbeconsideredtotreatpost-strokespasticity,butfunctionalbenefitsareuncertain(Class III, Level B)GuidelinesIschaemicStroke2008
