Gestione intra-ospedaliera dell ictus acuto Giancarlo Agnelli Università di Perugia
Nel comune di Perugia (~150.000 abitanti) g ( ) ~450 stroke/anno (60 emorragie) Nel bacino di utenza ospedale di Perugia (~ 300.000 abitanti) ~900 stroke/anno (120 emorragie)
Organizzazione in rete nell ictus Requisiti essenziali Rete dell Emergenza-Urgenza Organizzazione per livelli di intensità di cura Adeguatezza tecnologica (teleconsulto radiologico)
Organizzazione in rete nell ictus Elevato standard tecnologico Assistenza per intensità di cura Protocolli condivisi Area vasta di Medicina Urgenza
The spectrum of clinical presentation of stroke The spectrum of clinical outcome of stroke The spectrum of clinical management of stroke
Gestione della fase acuta dell ictus Terapia della fase acuta Gestione delle complicanze
Gestione della fase acuta dell ictus ischemico Terapia della fase acuta Gestione delle complicanze
Terapia della fase acuta dell ictus ischemico Reperfusion therapy Antithrombotic therapy Neuroprotective therapy Stroke Unit
Terapia della fase acuta dell ictus ischemico Reperfusion therapy Antithrombotic therapy Neuroprotective therapy Stroke Unit
Alterazioni funzionali in corso di ictus ischemico CORE ZONA COMPROMESSA IN MANIERA IRREVERSIBILE PENOMBRA ISCHEMICA ZONA DANNEGGIATA IN MANIERA REVERSIBILE ZONA INTEGRA IPEREMICA
Thrombolytic trials with rt-pa (N=2955) Wardlaw, Cochrane Database Syst Rev 2003 Symptomatic intracranial 322(240431) 3.22 (2.40,4.31) bleeding 1.16 (0.94,1.44) Deaths during follow up Deaths during follow-up ( 3 hrs) Death/dependency at the end of follow-up Death/dependency at the end of follow-up ( 3 hrs) 0.92 (0.65,1.30) 079(068092) 0.79 (0.68,0.92) 055(042072) 0.55 (0.42,0.72) 0.1 1 10 Thrombolysis better Thrombolysis worse
Thrombolytic trials with rt-pa (N=2955) Number Needed to Treat < 6 hrs 18 < 3 hrs 7 Number Needed to Harm 34 Wardlaw, Cochrane Database Syst Rev 2003
Stroke onset to treatment Pooled analysis of ATLANTIS, ECASS and NINDS N = 2775 60 140 160 180 200 220 240 260 280 300 320 340 360 The ATLANTIS, ECASS and NINDS rt-pa Study Group Investigators, 2004
Thrombolysis - Selection of patients Age 18-80 Acute focal neurological deficit (not improving) Stroke severity, NIH SS < 26 Onset >30 minutes, <3 hours No recent stroke, trauma, surgery, GI/urinary bleeds No recent (<48 hours) anticoagulation BP < 185/110 Normal PT& APTT & platelets l count Blood glucose (2.7-22.2 )
Extending the time window IV thrombolysis, all ischemic stroke IA or IV/IA thrombolysis IV thrombolysis, penumbral selection IV thrombolysis with AP agents Devices to remove clots
Terapia della fase acuta dell ictus ischemico Reperfusion therapy Antithrombotic therapy Neuroprotective therapy Stroke Unit
Organized inpatient care for stroke (stroke unit) Stroke Units vs General Wards N = 4911 mortality OR 0,86; IC95 0,71-0,94; P=0.005 mortality/nursing home OR 0,80; IC95 071-0 0,71-0,90; P=0.00020002 dependency OR 0,78; IC95 0,68-0,89; P=0.0003 The Cochrane Library, Issue 1, 2000
Stroke. 1999 Aug;30(8):1524-7. Stroke unit treatment. 10-year follow-up SU GW indipendenza 12.7% 5.5% istituzionalizione 80.9% 92.8% mortalità 75.7% 7% 87.3%
Gestione della fase acuta dell ictus Terapia della fase acuta Gestione delle complicanze
Stroke: cardiovascular complications Cardiovascular adverse events (acute) Cardiovascular co-morbidity
Cardiovascular comorbidity Hypertension 63 DM 22 CHD 53 * IMA 22 Cardiac arrhythmia 30 Angina 21 CHF 17 PAD 17 * Large artery cerebrovascular disease
In-hospital complications in ischemic stroke Prospective study in consecutive patients n = 814; n = 685 ischemic stroke (84.2% ) n % Acute MI 25 3.1 Acute heart failure 40 4.9 Risk factors for AMI: history of angina, recent MI &TIA and PAD Risk factors for AHF: history of AHF and cardioembolic stroke Micheli et al., 2009
In-hospital complications in ischemic stroke Prospective study in consecutive patients n = 814; n = 685 ischemic stroke (84.2% ) Death and disability at 3-months n % Acute MI and or AHF 32 60.4% General population 119 15.9% Micheli et al., 2009
Stroke: Troponin I elevation and in hospital outcome Tnl (ng/ml) <0.1 0.1-0.39 0.4 P Patients (n) 277/330 (83.9) 35/330 (10.6) 18/330 (5.5) Death 20/277 (7.2) 13/35 (37.1) 8/18 (44.4) <0.001 Death or non-fatal MI Death or any nonfatal CV event 23/273 (8.4) 14/34 (41.2) 9/17 (52.9) <0.001 38/273 (13.9) 15/34 (44.1) 9/17 (52.9) <0.001 Di Angelantonio et al., J Neurol Neurosurg Psychiatry 2005
Risk of DVT without prophylaxis in hospitalized patients Acute ischemic stroke 50 Orthopedic surgery 50 General surgery 20 Internal medicine 17 0 10 20 30 40 50 60 (%) Geerts et al. Chest, 2004; Leizorovicz et al. Circulation. 2004
Low dose and high dose UFH or LMWH compared to placebo for VTE prevention in acute ischemic stroke DVT PE ICH OR 95% CI OR 95% CI OR 95% CI Low dose UFH 0.17 0.11-0.26 0.96 0.53-1.72 1.78 0.79-4.04 High dose UFH No studies performed 0.52 0.26-1.05 4.84 2.36-9.96 Low dose LMWH 0.34 0.19-0.59 0.36 0.15-0.87 1.39 0.53-3.67 High dose LMWH 0.07 0.02-0.29 0.44 0.18-1.11 2.01 1.02-3.96 Low dose UFH = <15.000 IU daily Low dose LMWH = 6.000 IU daily or 86 IU/kg/day Kamphuisen & Agnelli, Thromb Res 2006
ICH after ischemic stroke & disability HT1 or HT2 Death and disability 30-45% PH1 or PH2 Death and disability 50-85% Paciaroni et al., Stroke 2008
Treatment options for ischemic stroke Conclusions Death/dependency Utility Stroke Unit 0.78 (0.68-0.89) Very wide Aspirin 0.94 (0.91-0.98) Wide Thrombolysis 066(053 0.66 (0.53-0.83) Narrow Ineffective: Anticoagulation Unproven: Neuroprotection