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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 Time in hours CBF (ml/100g brain) Low flow, raised O2 extraction, normal function 1 2 3 4 5
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 metabolic rate of O 2 Autoregulation, no symptoms Exhausted reserve Ischaemic symptoms
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 Hi   Free Fe2+  Free radicals Lipolysis   NO synthase  Proteolysis
Cerebral Arterial territory Anterior cerebral Middle cerebral Posterior cerebral Anterior choroidal
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Partial Ant. Cir. Syndrome (PACS)
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Total Ant. Cir. Syndrome
Lacunar syndromes (LACS) ,[object Object],[object Object],[object Object],[object Object],[object Object]
Posterior Cir. syndrome (POC)   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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%
Stroke primary prevention ,[object Object]
Stroke secondary prevention ,[object Object],[object Object],[object Object]
Stroke ,[object Object],[object Object],[object Object],[object Object],[object Object]
Risk factors for stroke recurrence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Platelet aggregation Platelet aggregation Thrombus in lumen ADP platelet membrane receptor Clopidrogel Aspirin Thromboxane Dipyridamole Increase Cyclic AMP and GMP
Stroke type - first ever ,[object Object],[object Object],[object Object],[object Object],All   35-44  yr
Stroke - questions ,[object Object],[object Object],[object Object],[object Object],[object Object]
Pre Hospital Care ,[object Object],[object Object],[object Object]
ED immediate care of Stroke ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Emergency tests ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Stroke Emergency Imaging ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Early sign CT - Infarction
MRA & MRI in Stroke
 
When TIA is an emergency? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Carotid endarterectomy in TIA’s ,[object Object],[object Object]
“ Patients who have improved neurologically but have a persistent neurologic deficit when seen, should be managed as a recent stroke ”
“ Role of Neuro-protection in Stroke is not clear and not recommended routinely ”
Aspirin in Acute Stroke ,[object Object]
Anticoagulant in Acute Stroke ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Thrombolytic Therapy of Acute Ischemic stroke
Patients ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Inclusion Criteria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Exclusion Criteria ,[object Object],[object Object],[object Object],[object Object],[object Object]
Exclusion Criteria cont.. ,[object Object],[object Object],[object Object]
Thrombolysis in acute stroke Within 3 hour of Stroke Small Vessel Medium Vessel IV rTPA/URK Large Vessel IA rTPA/URK Stop
Thrombolytic Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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 ,[object Object],[object Object],[object Object],[object Object]
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 PCA ACA Recovery
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 - 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
Left Coronary angiogram showing severe atherosclerosis
Right   middle cerebral artery block following coronary angiogram
Right middle cerebral artery reperfusion (AP) following IA Urokinase
Conclusion ,[object Object],[object Object],[object Object],[object Object],[object Object]
Emergency CE in acute Stroke ,[object Object],[object Object],[object Object]
Dec 31 st  1999 Jan 21 st  2000 Feb 11 th  2000 Emergency Carotid Endarterectomy DOA 5 th  Feb 00
Thank You

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Stroke treatment for 12th oct 00

  • 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.
  • 12.
  • 13.
  • 14.
  • 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.
  • 17.
  • 18.
  • 19.
  • 20. Platelet aggregation Platelet aggregation Thrombus in lumen ADP platelet membrane receptor Clopidrogel Aspirin Thromboxane Dipyridamole Increase Cyclic AMP and GMP
  • 21.
  • 22.
  • 23.
  • 24.
  • 25.
  • 26.
  • 27. Early sign CT - Infarction
  • 28. MRA & MRI in Stroke
  • 29.  
  • 30.
  • 31.
  • 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.
  • 35.
  • 36. Thrombolytic Therapy of Acute Ischemic stroke
  • 37.
  • 38.
  • 39.
  • 40.
  • 41. Thrombolysis in acute stroke Within 3 hour of Stroke Small Vessel Medium Vessel IV rTPA/URK Large Vessel IA rTPA/URK Stop
  • 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
  • 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
  • 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.
  • 56.
  • 57. Dec 31 st 1999 Jan 21 st 2000 Feb 11 th 2000 Emergency Carotid Endarterectomy DOA 5 th Feb 00