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Stroke treatment for 12th oct 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 auto regulation 60 160 Mean systemic BP
  • 5. Falling cerebral perfusion Cerebral perfusion pressure Cerebral blood volume O 2 extraction fraction Cerebral blood flow Cerebral metabolic rate of O 2 Autoregulation, no symptoms Exhausted reserve Ischaemic symptoms
  • 6. Cerebral infarct <3hrs Onset Infarct Ischaemic penumbra
  • 7. Cerebral infarct 6hrs Infarct Ischaemic penumbra
  • 8. Cerebral infarct 24hrs Infarct Ischaemic penumbra
  • 9. NA, Dopamine Ca2+ i  Ischaemic Brain Injury Ischaemia - 02  glucose  Anoxic depolarisation  lactate Glutamate Hi  Free Fe2+ Free radicals Lipolysis NO synthase Proteolysis
  • 10. Cerebral Arterial territory Anterior cerebral Middle cerebral Posterior cerebral Anterior choroidal
  • 11.
    • 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)
  • 12.
    • ALL OF THESE:-
    • Higher Dysfunction
      • Dysphasia
      • Visuospatial
    • Homonymous Hemianopia
    • Motor / Sensory Deficit
      • >2/3 Face / Arm / Leg
    Total Ant. Cir. Syndrome
  • 13. 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
  • 14. 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
  • 15. 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%
  • 16. Stroke primary prevention
    • Hypertension : 50% of stroke patients 50% of these known to their GP 50% of these on treatment ?% on adequate treatment
  • 17. Stroke secondary prevention
    • Of survivors, 30% chance CVA in 5 yr
    • Risk level = to that following M Infarct
    • Risk highest earlier on : 13% recurrence first year x 15 risk of age and sex matched pop.
  • 18. Stroke
    • Key assessments for secondary prevention
      • Blood pressure
      • Atrial fibrillation
      • Cholesterol
      • Lifestyle - smoking, diet, exercise, weight, alcohol
  • 19. Risk factors for stroke recurrence
    • CVA/TIA
    • BP
    • Carotid stenosis
    • Cardiac - CHF, arrhythmia, cardiomegaly
    • Diabetes
    • Hyperlipidaemia
    • P vascular disease
    • Smoking
    • Obesity
    • Inactivity
  • 20. Platelet aggregation Platelet aggregation Thrombus in lumen ADP platelet membrane receptor Clopidrogel Aspirin Thromboxane Dipyridamole Increase Cyclic AMP and GMP
  • 21. Stroke type - first ever
    • Infarct 80% 42%
    • PICH 10% 10%
    • SAH 5% 38%
    • Unknown 5% 10%
    All 35-44 yr
  • 22. Stroke - questions
    • Is it a stroke ?
    • What type of stroke ?
    • Why did it happen ?
    • How does it affect the patient ?
    • What is the prognosis ?
  • 23. 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
  • 24. 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
  • 25. 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 /
  • 26. Stroke Emergency Imaging
    • CT / CTA
    • MRI / MRA/ / PI/ DI
    • Echocardiography
    • Carotid doppler,
    • Transcranial doppler
    • Cerebral Angiography
    • SPECT
  • 27. Early sign CT - Infarction
  • 28. MRA & MRI in Stroke
  • 29.  
  • 30. 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
  • 31. 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
  • 32. “ Patients who have improved neurologically but have a persistent neurologic deficit when seen, should be managed as a recent stroke ”
  • 33. “ Role of Neuro-protection in Stroke is not clear and not recommended routinely ”
  • 34. 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”
  • 35. 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
  • 36. Thrombolytic Therapy of Acute Ischemic stroke
  • 37. Patients
    • Period: 1992- 00
    • Total ischemic strokes 756
    • Thrombolysis done 35
    • Male 27
    • Females 8
    • Age in years 20-80
  • 38. Inclusion Criteria
      • A. Clinical evidence for an ischemic stroke
      • B. Normal CT Scan
      • C. Age >18 years
      • D. Onset of stroke Ant cir 6 hr
      • Post cir 12 hr
      • E. Normal BT, CT, PT, PTT and platelet
  • 39. Exclusion Criteria
      • A. Stroke or serious head trauma in past 3 months
      • B. Major surgery or invasive procedure within past 14 days
      • C. GI or urinary bleeding within past 21 days
      • D. Puncture of noncompressible artery or biopsy of internal organ within past 7 days
      • E. Ongoing alcohol or drug abuse
  • 40. Exclusion Criteria cont..
      • F. Seizure preceding or during stroke
      • G. History of intracranial hemorrhage (including subarachnoid bleeds) or known history of cerebral vascular malformations (including aneurysms or arteriovenous malformations)
      • H. Pericarditis, endocarditis, septic emboli, recent pregnancy, or active inflammatory bowel disease
  • 41. Thrombolysis in acute stroke Within 3 hour of Stroke Small Vessel Medium Vessel IV rTPA/URK Large Vessel IA rTPA/URK Stop
  • 42. Thrombolytic Agents
    • Streptokinase: IA 1-1.5 lakh units
    • IV 2.5-10 lakh units
    • Urokinase: IV 5-10 lakh units
    • IA 5-10 lakh units
    • rTPA: IA 10-40 mg
    • IV 40-50 mg
  • 43. Route of Administration 21 6 15 URK 35 10 25 Total 5 2 3 rTPA 9 2 7 STK Total IA IV Drug
  • 44. End Point of Treatment
    • Total calculated dose given
    • Patient showed significant improvement
    • Significant bleeding complication
    • Severe allergic reaction
  • 45. Age Sex Distribution 13 2 11 60-80 35 7 28 Total 17 5 12 40-59 5 - 5 20-39 Total Female Male Age
  • 46. Arterial Territory and Severity 35 17 18 Total 9 7 2 PCA 26 10 16 ACA Total Unconscious Conscious Artery
  • 47. Outcome and Agent used 35 5 21 9 Total 9 2 4 3 Death 7 1 4 2 Dependent 19 2 13 4 Independent Total rTPA URK STK Recovery
  • 48. Outcome and Arterial Territory Unc Con Unc Con 35 7 2 10 16 Total 9 2 - 6 1 Death 7 1 - 3 3 Dep 19 4 2 1 12 Ind Total PCA ACA Recovery
  • 49. Outcome and Timing of Treatment 35 21 5 9 Total 9 6 - 3 Death 7 6 1 - Dep 19 9 4 6 Ind Total 3-6h 1-3h <1h Outcome
  • 50. Outcome and CT scan 32 6 26 Total 9 3 6 Death 7 2 5 Dependent 16 1 15 Independent Total Early Normal Outcome
  • 51. Complication of therapy 8 2 5 2 Toxic edema 1 - 1 - IC bleed 1 - 1 - IC spasm 1 - - 1 Hem trans 1 - 1 - Urinary bleed 3 - 1 2 Gastric bleed 2 1 1 - Gum bleed 2 1 1 - Anaphylaxis 2 1 1 - Bronchospasm 1 - 1 - Skin Rash Total rTPA URK STK Complication
  • 52. Left Coronary angiogram showing severe atherosclerosis
  • 53. Right middle cerebral artery block following coronary angiogram
  • 54. Right middle cerebral artery reperfusion (AP) following IA Urokinase
  • 55. Conclusion
    • Outcome was not related to the Drug used
    • Ant circulation minor stroke and posterior circulation stroke has better prognosis
    • Ant. circulation major stroke did well on IA thrombolysis.
    • Normal CT before treatment was not related to good outcome. But abnormal CT has poor outcome.
    • Hemorrhagic complication are dose related.
  • 56. 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.
  • 57. Dec 31 st 1999 Jan 21 st 2000 Feb 11 th 2000 Emergency Carotid Endarterectomy DOA 5 th Feb 00
  • 58. Thank You

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