Emergency Treatment of Stroke
Normal Brain Physiology 2-3% of body weight 15% of cardiac output 20% of all O2 25% of all glucose
Cerebral Ischaemia - Threshold Normal flow, normal function Synaptic transmission failure Membrane pump failure 20 50 10 0...
Cerebral auto regulation 60 160 Mean systemic BP
Falling cerebral perfusion Cerebral perfusion pressure Cerebral blood volume O 2  extraction fraction Cerebral blood flow ...
Cerebral infarct <3hrs Onset Infarct Ischaemic penumbra
Cerebral infarct 6hrs Infarct Ischaemic penumbra
Cerebral infarct 24hrs Infarct Ischaemic penumbra
NA, Dopamine Ca2+ i   Ischaemic Brain Injury Ischaemia - 02     glucose   Anoxic depolarisation    lactate Glutamate H...
Cerebral Arterial territory Anterior cerebral Middle cerebral Posterior cerebral Anterior choroidal
<ul><li>ANY ONE OF THESE:-  </li></ul><ul><li>Two out of three as TACI  </li></ul><ul><ul><li>Higher Dysfunction  </li></u...
<ul><li>ALL OF THESE:-  </li></ul><ul><li>Higher Dysfunction  </li></ul><ul><ul><li>Dysphasia  </li></ul></ul><ul><ul><li>...
Lacunar syndromes (LACS) <ul><li>ANY ONE OF THESE:-  </li></ul><ul><li>Pure Motor Stroke (>2/3 Face/Arm/Leg)  </li></ul><u...
Posterior Cir. syndrome (POC)   <ul><li>ANY OF THESE FEATURES  </li></ul><ul><li>Cranial Nerve Palsy AND Contralateral Mot...
Stroke types  Al  35-44 yr Infarct  80% 42% Athero-thrombo-embolism  50% Intracranial small vessel   25% Cardioembolic   2...
Stroke primary prevention <ul><li>Hypertension : 50%  of stroke patients 50%  of these known to their GP 50%  of these on ...
Stroke secondary prevention <ul><li>Of survivors, 30% chance CVA in 5 yr </li></ul><ul><li>Risk level = to that following ...
Stroke <ul><li>Key assessments for secondary prevention </li></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><li>At...
Risk factors for stroke recurrence <ul><li>CVA/TIA </li></ul><ul><li>BP </li></ul><ul><li>Carotid stenosis </li></ul><ul><...
Platelet aggregation Platelet aggregation Thrombus in lumen ADP platelet membrane receptor Clopidrogel Aspirin Thromboxane...
Stroke type - first ever <ul><li>Infarct 80% 42% </li></ul><ul><li>PICH 10% 10% </li></ul><ul><li>SAH   5% 38% </li></ul><...
Stroke - questions <ul><li>Is it a stroke ? </li></ul><ul><li>What type of stroke ? </li></ul><ul><li>Why did it happen ? ...
Pre Hospital Care <ul><li>1. Early recognition of Stroke warning signal by patient </li></ul><ul><li>2. Call ED if a perso...
ED immediate care of Stroke <ul><li>1. Check Vitals, general assessment </li></ul><ul><li>2. Stabilize: Respiration, circu...
Emergency tests <ul><li>Complete blood count, PCV, TRBC, platelet, smear for MP,  </li></ul><ul><li>Blood sugar, blood ure...
Stroke Emergency Imaging <ul><li>CT / CTA  </li></ul><ul><li>MRI / MRA/ / PI/ DI </li></ul><ul><li>Echocardiography </li><...
Early sign CT - Infarction
MRA & MRI in Stroke
 
When TIA is an emergency? <ul><li>High risk TIA,S </li></ul><ul><ul><li>1. A high grade vascular stenosis </li></ul></ul><...
Carotid endarterectomy in TIA’s <ul><li>High grade (>60%) ipsilateral carotid stenosis with TIA has high risk (30%) of str...
“ Patients who have improved neurologically but have a persistent neurologic deficit when seen, should be managed as a rec...
“ Role of Neuro-protection in Stroke is not clear and not recommended routinely ”
Aspirin in Acute Stroke <ul><li>“ In acute stroke   aspirin is the only proven antiplatelet agent. It should be commenced ...
Anticoagulant in Acute Stroke <ul><li>Not shown to prevent progression </li></ul><ul><li>LMH long term  improved </li></ul...
Thrombolytic Therapy of Acute Ischemic stroke
Patients <ul><li>Period:  1992- 00 </li></ul><ul><li>Total ischemic strokes 756 </li></ul><ul><li>Thrombolysis done  35 </...
Inclusion Criteria <ul><ul><li>A. Clinical evidence for an ischemic stroke </li></ul></ul><ul><ul><li>B.  Normal CT Scan <...
Exclusion Criteria <ul><ul><li>A.  Stroke or serious head trauma in past 3 months </li></ul></ul><ul><ul><li>B. Major surg...
Exclusion Criteria cont.. <ul><ul><li>F. Seizure preceding or during stroke </li></ul></ul><ul><ul><li>G. History of intra...
Thrombolysis in acute stroke Within 3 hour of Stroke Small Vessel Medium Vessel IV rTPA/URK Large Vessel IA rTPA/URK Stop
Thrombolytic Agents <ul><li>Streptokinase:  IA  1-1.5 lakh units </li></ul><ul><li>IV  2.5-10 lakh units </li></ul><ul><li...
Route of Administration 21 6 15 URK 35 10 25 Total 5 2 3 rTPA 9 2 7 STK Total IA IV Drug
End Point of Treatment <ul><li>Total calculated dose given </li></ul><ul><li>Patient showed significant improvement </li><...
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
Arterial Territory and Severity 35 17 18 Total 9 7 2 PCA 26 10 16 ACA Total Unconscious Conscious Artery
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
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 PC...
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
Outcome and CT scan   32 6 26 Total 9 3 6 Death 7 2 5 Dependent 16 1 15 Independent Total Early Normal Outcome
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 - ...
Left Coronary angiogram showing severe atherosclerosis
Right   middle cerebral artery block following coronary angiogram
Right middle cerebral artery reperfusion (AP) following IA Urokinase
Conclusion <ul><li>Outcome was not related to the Drug used </li></ul><ul><li>Ant circulation minor stroke and posterior c...
Emergency CE in acute Stroke <ul><li>1. Stroke in evolution with a minimal fixed neurologic deficit, </li></ul><ul><li>2. ...
Dec 31 st  1999 Jan 21 st  2000 Feb 11 th  2000 Emergency Carotid Endarterectomy DOA 5 th  Feb 00
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Stroke treatment for 12th oct 00

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Stroke treatment for 12th oct 00

  1. 1. Emergency Treatment of Stroke
  2. 2. Normal Brain Physiology 2-3% of body weight 15% of cardiac output 20% of all O2 25% of all glucose
  3. 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. 4. Cerebral auto regulation 60 160 Mean systemic BP
  5. 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. 6. Cerebral infarct <3hrs Onset Infarct Ischaemic penumbra
  7. 7. Cerebral infarct 6hrs Infarct Ischaemic penumbra
  8. 8. Cerebral infarct 24hrs Infarct Ischaemic penumbra
  9. 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. 10. Cerebral Arterial territory Anterior cerebral Middle cerebral Posterior cerebral Anterior choroidal
  11. 11. <ul><li>ANY ONE OF THESE:- </li></ul><ul><li>Two out of three as TACI </li></ul><ul><ul><li>Higher Dysfunction </li></ul></ul><ul><ul><li>Dysphasia </li></ul></ul><ul><ul><li>Visuospatial </li></ul></ul><ul><ul><li>Homonymous Hemianopia </li></ul></ul><ul><ul><li>Motor / Sensory Deficit </li></ul></ul><ul><ul><li>>2/3 Face / Arm / Leg </li></ul></ul><ul><li>Higher Dysfunction Alone </li></ul><ul><li>Limited Motor / Sensory Deficit </li></ul>Partial Ant. Cir. Syndrome (PACS)
  12. 12. <ul><li>ALL OF THESE:- </li></ul><ul><li>Higher Dysfunction </li></ul><ul><ul><li>Dysphasia </li></ul></ul><ul><ul><li>Visuospatial </li></ul></ul><ul><li>Homonymous Hemianopia </li></ul><ul><li>Motor / Sensory Deficit </li></ul><ul><ul><li>>2/3 Face / Arm / Leg </li></ul></ul>Total Ant. Cir. Syndrome
  13. 13. Lacunar syndromes (LACS) <ul><li>ANY ONE OF THESE:- </li></ul><ul><li>Pure Motor Stroke (>2/3 Face/Arm/Leg) </li></ul><ul><li>Pure Sensory Stroke (>2/3 Face/Arm/Leg) </li></ul><ul><li>Sensorimotor Stroke (>2/3 Face/Arm/Leg) </li></ul><ul><li>Ataxic Hemiparesis </li></ul>
  14. 14. Posterior Cir. syndrome (POC) <ul><li>ANY OF THESE FEATURES </li></ul><ul><li>Cranial Nerve Palsy AND Contralateral Motor/Sensory Deficit </li></ul><ul><li>Bilateral Motor OR Sensory Deficit </li></ul><ul><li>Conjugate Eye Movement problems </li></ul><ul><li>Cerebellar Dysfunction WITHOUT Ipsilateral Long Tract Signs </li></ul><ul><li>Isolated Homonymous Hemianopia </li></ul>
  15. 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. 16. Stroke primary prevention <ul><li>Hypertension : 50% of stroke patients 50% of these known to their GP 50% of these on treatment ?% on adequate treatment </li></ul>
  17. 17. Stroke secondary prevention <ul><li>Of survivors, 30% chance CVA in 5 yr </li></ul><ul><li>Risk level = to that following M Infarct </li></ul><ul><li>Risk highest earlier on : 13% recurrence first year x 15 risk of age and sex matched pop. </li></ul>
  18. 18. Stroke <ul><li>Key assessments for secondary prevention </li></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><li>Atrial fibrillation </li></ul></ul><ul><ul><li>Cholesterol </li></ul></ul><ul><ul><li>Lifestyle - smoking, diet, exercise, weight, alcohol </li></ul></ul>
  19. 19. Risk factors for stroke recurrence <ul><li>CVA/TIA </li></ul><ul><li>BP </li></ul><ul><li>Carotid stenosis </li></ul><ul><li>Cardiac - CHF, arrhythmia, cardiomegaly </li></ul><ul><li>Diabetes </li></ul><ul><li>Hyperlipidaemia </li></ul><ul><li>P vascular disease </li></ul><ul><li>Smoking </li></ul><ul><li>Obesity </li></ul><ul><li>Inactivity </li></ul>
  20. 20. Platelet aggregation Platelet aggregation Thrombus in lumen ADP platelet membrane receptor Clopidrogel Aspirin Thromboxane Dipyridamole Increase Cyclic AMP and GMP
  21. 21. Stroke type - first ever <ul><li>Infarct 80% 42% </li></ul><ul><li>PICH 10% 10% </li></ul><ul><li>SAH 5% 38% </li></ul><ul><li>Unknown 5% 10% </li></ul>All 35-44 yr
  22. 22. Stroke - questions <ul><li>Is it a stroke ? </li></ul><ul><li>What type of stroke ? </li></ul><ul><li>Why did it happen ? </li></ul><ul><li>How does it affect the patient ? </li></ul><ul><li>What is the prognosis ? </li></ul>
  23. 23. Pre Hospital Care <ul><li>1. Early recognition of Stroke warning signal by patient </li></ul><ul><li>2. Call ED if a person has symptoms of acute stroke. </li></ul><ul><li>3. Emergency transport and care </li></ul>
  24. 24. ED immediate care of Stroke <ul><li>1. Check Vitals, general assessment </li></ul><ul><li>2. Stabilize: Respiration, circulation </li></ul><ul><li>3. Control Seizure </li></ul><ul><li>4. Reduce intracranial tension </li></ul><ul><li>5. Maintain blood sugar </li></ul><ul><li>6. Maintain temperature </li></ul>
  25. 25. Emergency tests <ul><li>Complete blood count, PCV, TRBC, platelet, smear for MP, </li></ul><ul><li>Blood sugar, blood urea, serum creatinine, serum electrolyte, </li></ul><ul><li>Blood gas, </li></ul><ul><li>SGOT, SGPT, </li></ul><ul><li>PT, PTT </li></ul><ul><li>HIV, Hepatitis profile </li></ul><ul><li>ECG / X-ray / CBC / </li></ul>
  26. 26. Stroke Emergency Imaging <ul><li>CT / CTA </li></ul><ul><li>MRI / MRA/ / PI/ DI </li></ul><ul><li>Echocardiography </li></ul><ul><li>Carotid doppler, </li></ul><ul><li>Transcranial doppler </li></ul><ul><li>Cerebral Angiography </li></ul><ul><li>SPECT </li></ul>
  27. 27. Early sign CT - Infarction
  28. 28. MRA & MRI in Stroke
  29. 30. When TIA is an emergency? <ul><li>High risk TIA,S </li></ul><ul><ul><li>1. A high grade vascular stenosis </li></ul></ul><ul><ul><li>2. An antiplatelet failure </li></ul></ul><ul><ul><li>3. A cardioembolic </li></ul></ul><ul><ul><li>4. Crescendo TIA. </li></ul></ul><ul><ul><li>Heparin-> warfarin if a long term anticoagulation is required </li></ul></ul><ul><ul><li>Aspirin if anticoagulant contraindicated </li></ul></ul>
  30. 31. Carotid endarterectomy in TIA’s <ul><li>High grade (>60%) ipsilateral carotid stenosis with TIA has high risk (30%) of stroke within first week </li></ul><ul><li>CE reduces mortality in such cases </li></ul>
  31. 32. “ Patients who have improved neurologically but have a persistent neurologic deficit when seen, should be managed as a recent stroke ”
  32. 33. “ Role of Neuro-protection in Stroke is not clear and not recommended routinely ”
  33. 34. Aspirin in Acute Stroke <ul><li>“ 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” </li></ul>
  34. 35. Anticoagulant in Acute Stroke <ul><li>Not shown to prevent progression </li></ul><ul><li>LMH long term improved </li></ul><ul><li>Hemorrhagic transformation is high </li></ul><ul><li>Cardioembolic infarct </li></ul><ul><ul><li>Immediate for small infarct </li></ul></ul><ul><ul><li>Delayed for large infarct </li></ul></ul><ul><li>Heparin - 1000 units/hr. PTT 1.5 </li></ul><ul><li>Heparinoid - 2500 to 3200 units SC BD </li></ul>
  35. 36. Thrombolytic Therapy of Acute Ischemic stroke
  36. 37. Patients <ul><li>Period: 1992- 00 </li></ul><ul><li>Total ischemic strokes 756 </li></ul><ul><li>Thrombolysis done 35 </li></ul><ul><li>Male 27 </li></ul><ul><li>Females 8 </li></ul><ul><li>Age in years 20-80 </li></ul>
  37. 38. Inclusion Criteria <ul><ul><li>A. Clinical evidence for an ischemic stroke </li></ul></ul><ul><ul><li>B. Normal CT Scan </li></ul></ul><ul><ul><li>C. Age >18 years </li></ul></ul><ul><ul><li>D. Onset of stroke Ant cir 6 hr </li></ul></ul><ul><ul><li>Post cir 12 hr </li></ul></ul><ul><ul><li>E. Normal BT, CT, PT, PTT and platelet </li></ul></ul>
  38. 39. Exclusion Criteria <ul><ul><li>A. Stroke or serious head trauma in past 3 months </li></ul></ul><ul><ul><li>B. Major surgery or invasive procedure within past 14 days </li></ul></ul><ul><ul><li>C. GI or urinary bleeding within past 21 days </li></ul></ul><ul><ul><li>D. Puncture of noncompressible artery or biopsy of internal organ within past 7 days </li></ul></ul><ul><ul><li>E. Ongoing alcohol or drug abuse </li></ul></ul>
  39. 40. Exclusion Criteria cont.. <ul><ul><li>F. Seizure preceding or during stroke </li></ul></ul><ul><ul><li>G. History of intracranial hemorrhage (including subarachnoid bleeds) or known history of cerebral vascular malformations (including aneurysms or arteriovenous malformations) </li></ul></ul><ul><ul><li>H. Pericarditis, endocarditis, septic emboli, recent pregnancy, or active inflammatory bowel disease </li></ul></ul>
  40. 41. Thrombolysis in acute stroke Within 3 hour of Stroke Small Vessel Medium Vessel IV rTPA/URK Large Vessel IA rTPA/URK Stop
  41. 42. Thrombolytic Agents <ul><li>Streptokinase: IA 1-1.5 lakh units </li></ul><ul><li>IV 2.5-10 lakh units </li></ul><ul><li>Urokinase: IV 5-10 lakh units </li></ul><ul><li>IA 5-10 lakh units </li></ul><ul><li>rTPA: IA 10-40 mg </li></ul><ul><li>IV 40-50 mg </li></ul>
  42. 43. Route of Administration 21 6 15 URK 35 10 25 Total 5 2 3 rTPA 9 2 7 STK Total IA IV Drug
  43. 44. End Point of Treatment <ul><li>Total calculated dose given </li></ul><ul><li>Patient showed significant improvement </li></ul><ul><li>Significant bleeding complication </li></ul><ul><li>Severe allergic reaction </li></ul>
  44. 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
  45. 46. Arterial Territory and Severity 35 17 18 Total 9 7 2 PCA 26 10 16 ACA Total Unconscious Conscious Artery
  46. 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
  47. 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
  48. 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
  49. 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
  50. 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
  51. 52. Left Coronary angiogram showing severe atherosclerosis
  52. 53. Right middle cerebral artery block following coronary angiogram
  53. 54. Right middle cerebral artery reperfusion (AP) following IA Urokinase
  54. 55. Conclusion <ul><li>Outcome was not related to the Drug used </li></ul><ul><li>Ant circulation minor stroke and posterior circulation stroke has better prognosis </li></ul><ul><li>Ant. circulation major stroke did well on IA thrombolysis. </li></ul><ul><li>Normal CT before treatment was not related to good outcome. But abnormal CT has poor outcome. </li></ul><ul><li>Hemorrhagic complication are dose related. </li></ul>
  55. 56. Emergency CE in acute Stroke <ul><li>1. Stroke in evolution with a minimal fixed neurologic deficit, </li></ul><ul><li>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 </li></ul><ul><li>3. CT scan without evidence of hemorrhagic transformation of an infarct or edema. </li></ul>
  56. 57. Dec 31 st 1999 Jan 21 st 2000 Feb 11 th 2000 Emergency Carotid Endarterectomy DOA 5 th Feb 00
  57. 58. Thank You
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