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Stroke emergency treatment for 26th march 00
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Stroke emergency treatment for 26th march 00

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  • 1. Emergency Treatment of Stroke
  • 2. Normal Brain Physiology 2-3% of body weight 15% of cardiac output 20% of all O2 25% of all glucose
  • 3. Cerebral Ischaemia - Threshold Normal flow, normal function Synaptic transmission failure Membrane pump failure 20 50 10 0 Time in hours CBF (ml/100g brain) Low flow, raised O2 extraction, normal function 1 2 3 4 5
  • 4. Cerebral infarct <3hrs Onset Infarct Ischaemic penumbra
  • 5. Cerebral infarct 6hrs Infarct Ischaemic penumbra
  • 6. Cerebral infarct 24hrs Infarct Ischaemic penumbra
  • 7. NA, Dopamine Ca2+ i  Ischaemic Brain Injury Ischaemia - 02  glucose  Anoxic depolarisation  lactate Glutamate Hi  Free Fe2+ Free radicals Lipolysis NO synthase Proteolysis
  • 8. Cerebral Arterial territory Anterior cerebral Middle cerebral Posterior cerebral Anterior choroidal
  • 9.
    • ANY ONE OF THESE:-
    • Two out of three as TACI
      • Higher Dysfunction
      • Dysphasia
      • Visuospatial
      • Homonymous Hemianopia
      • Motor / Sensory Deficit
      • >2/3 Face / Arm / Leg
    • Higher Dysfunction Alone
    • Limited Motor / Sensory Deficit
    Partial Ant. Cir. Syndrome (PACS)
  • 10.
    • ALL OF THESE:-
    • Higher Dysfunction
      • Dysphasia
      • Visuospatial
    • Homonymous Hemianopia
    • Motor / Sensory Deficit
      • >2/3 Face / Arm / Leg
    Total Ant. Cir. Syndrome
  • 11. Lacunar syndromes (LACS)
    • ANY ONE OF THESE:-
    • Pure Motor Stroke (>2/3 Face/Arm/Leg)
    • Pure Sensory Stroke (>2/3 Face/Arm/Leg)
    • Sensorimotor Stroke (>2/3 Face/Arm/Leg)
    • Ataxic Hemiparesis
  • 12. Posterior Cir. syndrome (POC)
    • ANY OF THESE FEATURES
    • Cranial Nerve Palsy AND Contralateral Motor/Sensory Deficit
    • Bilateral Motor OR Sensory Deficit
    • Conjugate Eye Movement problems
    • Cerebellar Dysfunction WITHOUT Ipsilateral Long Tract Signs
    • Isolated Homonymous Hemianopia
  • 13. Stroke types Al 35-44 yr Infarct 80% 42% Athero-thrombo-embolism 50% Intracranial small vessel 25% Cardioembolic 20% Rare 5% PICH 10% 10% SAH 5% 38% Unknown 5% 10% 75%
  • 14. Stroke - questions
    • Is it a stroke ?
    • What type of stroke ?
    • Why did it happen ?
    • How does it affect the patient ?
    • What is the prognosis ?
  • 15. Pre Hospital Care
    • 1. Early recognition of Stroke warning signal by patient
    • 2. Call ED if a person has symptoms of acute stroke.
    • 3. Emergency transport and care
  • 16. ED immediate care of Stroke
    • 1. Check Vitals, general assessment
    • 2. Stabilize: Respiration, circulation
    • 3. Control Seizure
    • 4. Reduce intracranial tension
    • 5. Maintain blood sugar
    • 6. Maintain temperature
  • 17. Emergency tests
    • Complete blood count, PCV, TRBC, platelet, smear for MP,
    • Blood sugar, blood urea, serum creatinine, serum electrolyte,
    • Blood gas,
    • SGOT, SGPT,
    • PT, PTT
    • HIV, Hepatitis profile
    • ECG / X-ray / CBC /
  • 18. Stroke Emergency Imaging
    • CT / CTA
    • MRI / MRA/ / PI/ DI
    • Echocardiography
    • Carotid doppler,
    • Transcranial doppler
    • Cerebral Angiography
    • SPECT
  • 19. Early sign CT - Infarction
  • 20. MRA & MRI in Stroke
  • 21.  
  • 22. When TIA is an emergency?
    • High risk TIA,S
      • 1. A high grade vascular stenosis
      • 2. An antiplatelet failure
      • 3. A cardioembolic
      • 4. Crescendo TIA.
      • Heparin-> warfarin if a long term anticoagulation is required
      • Aspirin if anticoagulant contraindicated
  • 23. Carotid endarterectomy in TIA’s
    • High grade (>60%) ipsilateral carotid stenosis with TIA has high risk (30%) of stroke within first week
    • CE reduces mortality in such cases
  • 24. “ Patients who have improved neurologically but have a persistent neurologic deficit when seen, should be managed as a recent stroke ”
  • 25. “ Role of Neuro-protection in Stroke is not clear and not recommended routinely ”
  • 26. Aspirin in Acute Stroke
    • “ In acute stroke aspirin is the only proven antiplatelet agent. It should be commenced as soon as the diagnosis of cerebral infarction has been made, using a starting dose of 150-300mg a day and continuing until decisions have been made about secondary prevention”
  • 27. Anticoagulant in Acute Stroke
    • Not shown to prevent progression
    • LMH long term improved
    • Hemorrhagic transformation is high
    • Cardioembolic infarct
      • Immediate for small infarct
      • Delayed for large infarct
    • Heparin - 1000 units/hr. PTT 1.5
    • Heparinoid - 2500 to 3200 units SC BD
  • 28. Thrombolysis in acute stroke Within 3 hour of Stroke Small Vessel Medium Vessel IV rTPA/URK Large Vessel IA rTPA/URK Stop
  • 29. IV rTPA for Acute Ischaemic Stroke
    • Patient - within 3 hours of onset
    • - Normal CT scan
    • - BP <180/100 mmHg.
    • - No bleeding tendency
    • Dose - 0.9mg /Kg. (max 90mg)
    • - 10% bolus, Rest 60 min. infusion
    • Risk - ICH in 6% of patients
    • Promise - Reduced morbidity by 30%
  • 30. Left Coronary angiogram showing severe atherosclerosis
  • 31. Right middle cerebral artery block following coronary angiogram
  • 32. Right middle cerebral artery reperfusion (AP) following IA Urokinase
  • 33. Outcome of Thrombolytic therapy
  • 34. Complication of Thrombolytic Therapy
  • 35. Emergency CE in acute Stroke
    • 1. Stroke in evolution with a minimal fixed neurologic deficit,
    • 2. A moderately severe neurologic deficit of abrupt onset when the surgery can be completed within the first 3 hours after the onset of deficit, and
    • 3. CT scan without evidence of hemorrhagic transformation of an infarct or edema.
  • 36. Dec 31 st 1999 Jan 21 st 2000 Feb 11 th 2000 Emergency Carotid Endarterectomy DOA 5 th Feb 00
  • 37. Subarachnoid hemorrhage
    • Bed rest Analgesic
    • Blood pressure control
    • Oral nimodipine 60mg q6hx21 days
    • Angiography for localization of bleeding
    • If aneurysm
    • Immediate surgical clipping for
      • Grade 1-3 patient without contraindication
      • Grade 4-5 with intracerebral clot and deterioration
  • 38. Primary Intracerebral hemorrhage
    • Small (<3cm) hematoma has good prognosis
    • Large hematoma (>6cm) in comatose patient have poor prognosis.
    • Surgical evacuation for 3-6cm superficial lobar hematoma in a conscious patient
    • Cerebellar hematoma with deteriorating level of consciousness
    • Control of BP
  • 39. Thank You