Acute brain attack 911


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  • Worldwide at any given time 15 million stroke survivors are awaiting a second stroke. Locally 400,000 stroke victims are waiting for the next one.
  • Defined as can raise arm above shoulder, clumsy hand, or can ambulate without assistance d. Like gait disturbance, unsteadiness, or clumsy hand.
  • Motor strength- 0-2/5; sensory complete hypo/anesthetic; global aphasia
  • The diagnosis of stroke is relatively straightforward. 80% of the diagnosis rely on clinical evaluation of the patient through the history, PE and Neurological Examination. One of the importance of a good Clinical Diagnosis of stroke is to Establish the Time of Onset of Symptoms with the anticipation of giving Thrombolysis. However, diagnostic errors based solely on clinical features still occur and the level of accuracy is insufficient to guide treatment decisions. Because clinical findings overlap, a brain imaging study is mandatory to distinguish ischemic stroke from hemorrhage or other structural brain lesions that may imitate stroke.
  • Therefore the Role of the Diagnostic Exam in Stroke is to . .
  • The more common stroke mimickers include . .
  • The Stroke Society of the Philippines came out with a consensus regarding the likelihood of an event NOT being a stroke and includes . .
  • The SSP Guidelines recommend the Emergent Diagnostic Exams to include:
  • Second line diagnostic studies are done to identify etiology and stroke mechanism. This includes...
  • Neuroimaging is an important part of the evaluation and treatment of acute stroke. The plain CT scan is recommended as a first line modality in suspected stroke cases. It is...
  • In a CT scan performed in patients with hyperacute stroke, 60% will turn out to be normal. However, the following signs may be seen:
  • The Hyperdense MCA sign is not yet indicative of infarction. The territory supplied is at risk for hypoperfusion. Whether infarction will take place depends on the collateral blood supply and recanalization. The loss of the insular stripe, obscurationof the lentiform nuclei and effacement of the sulci are indirect signs of a beginning edema from an infarction.
  • In acute ischemic stroke, the CT will show infarction of brain tissue as a...
  • In subacute and chronic infarctions, the area affected will have evidence of hypodensity that is hard to miss. Large cortical infarcts tend to be wedge-shaped while small subcortical infarcts are usually round and ovoid.
  • CT findings in intracerebral hemorrhages are quite distinct. They are hyperdense lesions that may or may not have a hypodense rim that suggests edema.
  • The most common cause of ICH is secondary to hypertension. It is important to note these common sites of ICH.
  • In SAH, the CT will show hyperdensities along the subarachnoid spaces, in between the sulci. This slide shows the diffuse distribution of the subarachnoid blood specially in the Sylvian fissures.
  • The MRA is another neurovascular imaging modality that is often used. It is an important non-invasive imaging of the vessels. One of its limitations however is the tendency to overestimate stenosis and is not reliable in detecting distal or branch intracranial occlusion.
  • Still, the gold standard for imaging the anterior and posterior circulation is the conventional 4 vessel angiography. It is used to determine the severity of stenosis and detection of …
  • AV malformations, aneurysms, venous angiomas and similar vascular abnormalities…
  • The cardiac evaluation is an important part of the evaluation of a patient with a stroke.
  • Acute brain attack 911

    3. 3. STROKE IMPACT <ul><li>STROKE IS BRAIN ATTACK ! </li></ul><ul><li>Sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathology. </li></ul><ul><li>No. 2 Killer worldwide </li></ul><ul><li>No. 1 Killer in Asia- Western Pacific, China, and Japan </li></ul><ul><li>20 million people every year with 5 million deaths </li></ul><ul><li>Locally: 500 strokes per 100,000 population </li></ul>
    4. 4. CLINICAL STROKE CLASSIFICATION <ul><li>TIA AND MILD STROKE </li></ul><ul><li>MODERATE STROKE </li></ul><ul><li>SEVERE STROKE </li></ul>
    5. 5. TIA and MILD STROKE <ul><li>Transient Ischemic Attack- deficits resolved within 24 hours including transient blindness in one eye </li></ul><ul><li>OR </li></ul><ul><li>ALERT Patient with any of the ff: </li></ul><ul><li>a. mild pure motor weakness of one side of the body. </li></ul><ul><li>b. pure sensory deficit </li></ul><ul><li>c. slurred speech but intelligible </li></ul><ul><li>d. vertigo with incoordination </li></ul><ul><li>e. visual field defects alone </li></ul><ul><li>f. combination of a and b </li></ul>
    6. 6. MODERATE STROKE <ul><ul><li>Awake patient with significant motor and/or sensory and/or language and/or visual deficit </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>Disoriented , drowsy, or stuporous patient but with purposeful response to painful stimuli </li></ul></ul>
    7. 7. SEVERE STROKE <ul><li>Comatose patient with nonpurposeful response, decorticate, </li></ul><ul><li>OR </li></ul><ul><li>Decerebrate posturing to painful stimuli or comatose patient with no response to painful stimuli </li></ul>
    8. 8. DIAGNOSING STROKE <ul><li>Clinical – (80%) </li></ul>2. Neuroimaging – (20%) * Establish the time of onset of symptoms * Cranial CT scan is the initial imaging study of choice Sudden, focal, Loss of function History, Physical & Neurological Exam
    9. 9. ROLE of DIAGNOSTIC EXAM <ul><li>Confirm & establish the clinical diagnosis </li></ul><ul><li>Rule out stroke “mimickers” </li></ul><ul><li>Determine pathologic type </li></ul><ul><li>Infarct, ICH, SAH </li></ul><ul><li>Determine etiology & stroke mechanism </li></ul><ul><li>Screen for medical & neurologic complications of stroke </li></ul>
    10. 10. COMMON STROKE “MIMICKERS” <ul><li>Seizures </li></ul><ul><li>Systemic infection </li></ul><ul><li>Brain tumor </li></ul><ul><li>Toxic-metabolic enceph </li></ul><ul><li>Positional vertigo </li></ul><ul><li>Syncope </li></ul><ul><li>Trauma </li></ul><ul><li>Subdural hematoma </li></ul><ul><li>Herpes enceph </li></ul><ul><li>Transient global amnesia </li></ul><ul><li>Dementia </li></ul><ul><li>Demyelinating dse </li></ul><ul><li>Cervical spine fracture </li></ul><ul><li>Myasthenia gravis </li></ul><ul><li>Parkinson’s dse </li></ul><ul><li>Hypertensive enceph </li></ul><ul><li>Conversion disorder </li></ul><ul><li>Bell’s palsy </li></ul>
    11. 11. DIFFERENTIAL DIAGNOSIS OF STROKE <ul><li>Pure hemifacial weakness (e.g. Bell’s palsy) </li></ul><ul><li>Fever prior to onset of symptoms </li></ul><ul><li>Trauma </li></ul><ul><li>Recurrent seizures </li></ul><ul><li>Weakness with atrophy </li></ul><ul><li>Recurrent headaches </li></ul>If any of the ff conditions is present, STROKE is probably UNLIKELY …. SSP Guidelines for the Prevention & Management of Brain Attack, 2003
    12. 12. With the advent of numerous diagnostic modalities, appropriate sequential diagnostic examinations are most important to confirm the clinical diagnosis of stroke. <ul><li>First-line (emergent) diagnostic exam </li></ul><ul><li>Second-line diagnostic investigations </li></ul>
    13. 13. CBC, PT/ PTT, Blood sugar Plain Cranial CT EMERGENT DIAGNOSTIC EXAM SSP Guidelines for the Prevention & Management of Brain Attack, 2003 Electrocardiogram
    14. 14. SECOND-LINE DIAGNOSTIC STUDIES (To Identify Etiology and Stroke Mechanism) <ul><li>Neurovascular Studies </li></ul><ul><ul><li>Carotid Duplex </li></ul></ul><ul><ul><li>Transcranial Doppler studies(TCD) </li></ul></ul><ul><ul><li>Catheter Angiography </li></ul></ul><ul><ul><li>CT Angiography </li></ul></ul><ul><ul><li>Magnetic Resonance Angiography (MRA) </li></ul></ul><ul><li>Cardiac investigation </li></ul><ul><ul><li>Echocardiography </li></ul></ul><ul><ul><li>24 hour Holter </li></ul></ul>
    15. 16. <ul><ul><li>Hematologic Studies </li></ul></ul><ul><ul><ul><li>Hypercoagulable states – Protein C, S, Fibrinogen Antithrombin III </li></ul></ul></ul>APAS - ANA, Anticardiolipin Ab, Lupus anticoagulant Homocysteine <ul><li>Drug Levels – e.g. Metamphetamine </li></ul><ul><li>Genetic – Familial homocystinuria, MELAS, </li></ul><ul><li>CADASIL </li></ul>SECOND-LINE DIAGNOSTIC STUDIES (To Identify Etiology and Stroke Mechanism) <ul><li>Biopsy – e.g Vasculitis, Temporal arteritis </li></ul>
    16. 17. Plain Cranial CT is recommended Neuroimaging in Acute Stroke Hyperacute 3 hours 12 hours 48 hours <ul><li>First-line modality imaging in suspected stroke cases </li></ul><ul><li>Widely available, relatively inexpensive, non - invasive & quick </li></ul><ul><li>Accurately differentiates hemorrhagic and ischemic strokes </li></ul><ul><li>Should be performed & interpreted ASAP </li></ul>
    17. 18. RATIONALE FOR NEUROIMAGING <ul><li>Identify the lesion (is it a stroke?) </li></ul><ul><li>Determine the type of stroke (ischemic or hemorrhage?) </li></ul><ul><li>Localize the stroke (where is it?) </li></ul><ul><li>Quantify the lesion (how large is it?) </li></ul><ul><li>Determine the age of the lesion </li></ul>
    18. 19. BASIC CONCEPTS <ul><li>Cranial computed (x-ray) tomography scan </li></ul><ul><li>Air, Fluid (e.g. CSF, infarction) = hypodense </li></ul><ul><li>Bone, calcification, blood = hyperdense </li></ul>
    19. 20. CT FINDINGS in HYPERACUTE INFARCTION (0 - 6 hrs) <ul><li>Almost 60% of CT scans done in the first few hours of ischemic stroke: NORMAL </li></ul><ul><li>However, the following signs may be seen: </li></ul><ul><ul><li>Hyperdense artery (“dense MCA sign”) </li></ul></ul><ul><ul><li>Obscuration of lentiform nuclei </li></ul></ul><ul><ul><li>Loss of grey-white interphase along lateral insula (“insular ribbon sign”) </li></ul></ul><ul><ul><li>Effacement of sulci </li></ul></ul>
    20. 21. Early signs of infarction on Cranial CT Dense Artery sign Insular Ribbon sign (loss of insular stripe) Obscuration of lentiform nuclei Effacement of sulci
    21. 22. CRANIAL CT in ACUTE ISCHEMIC STROKE <ul><li>Infarction: focal hypodense area in cortical, subcortical, or deep gray or white matter, following a vascular territory, or watershed distribution </li></ul>
    22. 23. CT FINDINGS in SUBACUTE / CHRONIC INFARCTION Wedge-shaped large cortical infarct Round / ovoid small subcortical infarcts
    23. 24. Subacute R-ICA infarct Subacute L-MCA infarct CT FINDINGS in SUBACUTE / CHRONIC INFARCTION
    24. 25. Hyperdense lesion in left lentiform nucleus with hypodense rim (vasogenic edema) CT FINDINGS in INTRACEREBRAL HEMORRHAGE
    25. 26. Common Sites of Hypertensive ICH
    26. 27. Common Sites of Hypertensive ICH
    27. 28. Cranial CT of Hemorrhagic Stroke <ul><li>Stroke Society of the Philippines recommendations for computation of hematoma volume </li></ul><ul><ul><li>Planimetric Method or Pixel Method </li></ul></ul><ul><ul><li>Modified Kothari method (ABC/2) </li></ul></ul>
    28. 29. <ul><ul><li>A - greatest hemorrhage diameter </li></ul></ul><ul><ul><li>B - diameter 90 degrees to A </li></ul></ul><ul><ul><li>C - no of CT slices with hemorrhage x </li></ul></ul><ul><ul><li>by the slice thickness * </li></ul></ul>Measurement of Hematoma Volume Modified Kothari Method A x B x C / 2 Select the CT slice with the largest area of hemorrhage A B Hemorrhage > 75% of the largest area = 1 slice Hemorrhage > 25 – 75% of the largest area = 0.5 slice Hemorrhage < 25% of the largest area - 0
    29. 30. Interpretation of Hematoma Volume for Supratentorial Hemorrhages <ul><li>< 30cc small medical </li></ul><ul><li>30 – 50cc moderate </li></ul><ul><li>> 50cc large surgical </li></ul>* Factor in age, neurologic status, concomitant medical conditions
    31. 32. Advantages of Cranial MRI DIAGNOSING STROKE: Other Neuroimaging Techniques <ul><li>More sensitive in detecting </li></ul><ul><ul><li>small lesions / lacunar infarcts </li></ul></ul><ul><ul><li>early infarction </li></ul></ul><ul><ul><li>brainstem / post fossa lesions </li></ul></ul><ul><li>Can detect lesions as early as 6 hours from onset of stroke (as early as 90 mins. for Diffusion MRI) </li></ul>
    32. 33. Early signs of infarction on MRI Slow flow (absence of normal flow void) in involved artery Parenchymal signal changes (hypointense on T1) T1 DWI: acute infarct appears bright Parenchymal signal changes (hyperintense on T2) T2
    33. 34. R medullary Infarction T1 T2 MAGNETIC RESONANCE IMAGING in BRAINSTEM INFARCTION R Pontine Infarction
    34. 35. Limitations of Cranial MRI DIAGNOSING STROKE: Other Neuroimaging Techniques <ul><li>More expensive & less widely available </li></ul><ul><li>Longer acquisition time compared to CT </li></ul><ul><li>(difficult in uncooperative patients) </li></ul><ul><li>Contraindicated in patients with metallic implants (e.g. pacemaker) </li></ul><ul><li>Not sensitive in detecting acute hemorrhage </li></ul>
    35. 36. MRI is not sensitive in detecting ACUTE HEMORRHAGE Cranial MRI Cranial CT scan Pontine Hemorrhage
    36. 37. NEUROVASCULAR EVALUATION <ul><li>Ultrasound Techniques </li></ul><ul><li>Catheter Angiography </li></ul><ul><li>CT Angiography </li></ul><ul><li>MR Angiography </li></ul>
    37. 38. RATIONALE for NEUROVASCULAR EVALUATION <ul><li>Identifying occlusive arterial disease (Is there blockage ?) </li></ul><ul><li>Localizing the occlusion </li></ul><ul><li>(Where ?, carotid ?, intracranial ?) </li></ul><ul><li>Quantifying the degree of stenosis (How severe ?) </li></ul><ul><li>Determining the pathology (Athero ?, dissection ?, others ?) </li></ul><ul><li>Identifying other vascular lesions </li></ul>
    38. 39. Recommendations for Neurovascular Imaging in Patients with Stroke <ul><li>A non-invasive screening technique is indicated as an initial diagnostic test </li></ul><ul><li>Conventional radiographic angiography may be indicated based on findings of non-invasive screening procedures (i.e. severe stenosis, occlusion) </li></ul><ul><li>Cerebral arteriography may also be required when a diagnosis of vasculitis, dissection, vascular malformation needs confirmation or exclusion </li></ul>
    39. 40. Transcranial Doppler (TCD) Carotid/vertebral Duplex VASCULAR ULTRASOUND “ NEUROSONOLOGY ”
    40. 41. CAROTID DUPLEX <ul><li>Established technique to identify </li></ul><ul><li>extracranial carotid / vertebral </li></ul><ul><li>artery disease </li></ul><ul><li>Advantages: non-invasive, bedside </li></ul><ul><li>availability, low cost </li></ul><ul><li>Disadvantages: operator </li></ul><ul><li>dependent, unable to differentiate </li></ul><ul><li>occlusion from near occlusion </li></ul>
    41. 42. TRANSCRANIAL DOPPLER <ul><li>Established technique to evaluate basal intracranial </li></ul><ul><li>arteries </li></ul><ul><li>Established utility in stroke (e.g. stenosis, vasospasm,  ICP, vasomotor reactivity) </li></ul><ul><li>Advantages: non-invasive, bedside availability, low cost, allows serial monitoring, detects micro emboli </li></ul><ul><li>Disadvantages: operator dependent, poor temporal window, circle of Willis variation </li></ul>
    42. 43. <ul><li>Stenosis / occlusion </li></ul><ul><li>Emboli detection </li></ul><ul><li>Collateralization </li></ul><ul><li>Vasospasm </li></ul><ul><li>Increased ICP / Brain death </li></ul><ul><li>Cerebral Autoregulation </li></ul>TCD APPLICATION in STROKE
    43. 44. MAGNETIC RESONANCE ANGIOGRAPHY CT ANGIOGRAPHY Other Non-Invasive Neurovascular Imaging Procedures
    44. 45. Severe Carotid Stenosis CATHETER ANGIOGRAPHY Vertebral Artery Stenosis MCA Stenosis “ Gold standard”
    45. 46. AV Malformation CATHETER ANGIOGRAPHY Venous angioma Aneurysm <ul><li>Cost, availability, invasive procedure </li></ul><ul><li>Risks (vascular damage, stroke, ionizing radiation, reaction to contrast) </li></ul><ul><li>Exclusion: poor renal function, absent </li></ul><ul><li>femoral pulses, coagulopathy </li></ul><ul><li> </li></ul>
    46. 47. CARDIAC EVALUATION Holter Monitoring 2 D Echocardiography
    47. 48. Recommendations for Echocardiography in Patients with Stroke … <ul><li>Clinical evidence of heart disease </li></ul><ul><li>Less than or equal 45 years of age </li></ul><ul><li>Older patients, without evidence of extra or intracranial occlusive disease or other obvious cause </li></ul><ul><li>Abrupt occlusion of major peripheral or visceral artery </li></ul><ul><li>Suspect embolic disease (non-lacunar syndrome, multiple arterial territory involvement) </li></ul><ul><li>Clinical therapeutic decision will depend on results of echocardiography </li></ul>
    48. 49. <ul><li>LV thrombus </li></ul><ul><ul><li>LV dyskinesia </li></ul></ul><ul><ul><li>Mitral stenosis </li></ul></ul><ul><ul><li>Mitral annular calcification </li></ul></ul><ul><ul><li>Mitral valve prolapse </li></ul></ul><ul><ul><li>Atrial thrombus </li></ul></ul><ul><ul><li>Atrial appendage thrombus </li></ul></ul><ul><ul><li>Atrial septal aneurysm </li></ul></ul><ul><ul><li>Patent foramen ovale </li></ul></ul><ul><ul><li>Aortic arch athero / dissection </li></ul></ul>Transthoracic vs Transesophageal Echocardiography TTE Preferred TEE Preferred
    49. 50. Proper use of diagnostic examinations in stroke requires an understanding of: <ul><li>Underlying disease process </li></ul><ul><li>Principles of test involved </li></ul><ul><li>Advantages & limitations of each procedure </li></ul><ul><li>How each investigation influences patient management </li></ul>
    50. 51. SUMMARY <ul><li>Rule out stroke mimickers </li></ul><ul><li>History, PE & NE should be done immediately on patients with stroke </li></ul><ul><li>Do emergent diagnostic tests to determine patient’s eligibility for rTPA </li></ul>
    51. 52. SUMMARY <ul><li>CT scan remains to be the most important brain imaging test. Cranial MRI is not recommended for routine evaluation of acute stroke patients </li></ul><ul><li>Differentiation of ischemic & hemorrhagic stroke is important because of marked difference in the management </li></ul><ul><li>Second line diagnostic tests need not be done in the ER setting and should not delay treatment </li></ul>
    52. 53. GUIDELINES FOR TIA AND MILD STROKE <ul><li>MANAGEMENT PRIORITIES </li></ul><ul><li>Ascertain clinical diagnosis of stroke or TIA </li></ul><ul><li>Exclude common stroke mimickers </li></ul><ul><li>Monitor and manage blood pressure </li></ul><ul><ul><li>SBP = 220 or DBP= 120 </li></ul></ul><ul><li>MAP= 130 </li></ul><ul><li>Avoid precipitous drop in BP> 20% of baseline MAP </li></ul><ul><li>No rapid-acting sublingual agents </li></ul><ul><li>Use oral or easily titratable IV antihypertensive </li></ul><ul><li>Ensure appropriate hydration. No hypotonic IV fluids </li></ul>
    53. 54. GUIDELINES FOR TIA AND MILD STROKE <ul><li>EMERGENT diagnostics </li></ul><ul><ul><li>Complete Blood count (CBC) </li></ul></ul><ul><ul><li>Blood sugar (CBG, HGT, or RBS) </li></ul></ul><ul><ul><li>Electrocardiogram (ECG) </li></ul></ul><ul><ul><li>PT/PTT (Atrial Fibrillation or possible cardioembolic source) </li></ul></ul><ul><ul><li>Plain CT Scan Of brain as soon as possible </li></ul></ul>
    54. 55. GUIDELINES FOR TIA AND MILD STROKE <ul><li>EARLY SPECIFIC TREATMENT FOR THROMBOTIC OR LACUNAR STROKE </li></ul><ul><li>(CTSCAN CONFIRMED ) </li></ul><ul><ul><li>Aspirin 160-325 mg start as early as possible for 14 days </li></ul></ul><ul><ul><li>Neuroprotection </li></ul></ul><ul><ul><li>Early rehabilitation within 72 hours </li></ul></ul>
    55. 56. GUIDELINES FOR TIA AND MILD STROKE <ul><li>EARLY SPECIFIC TREATMENT FOR CARDIOEMBOLIC </li></ul><ul><li>(CTSCAN CONFIRMED) </li></ul><ul><li>Anticoagulation with IV heparin or subcutaneous LMWH </li></ul><ul><li>Or Aspirin 160-325 mg/day (If anticoagulation not available) </li></ul><ul><li>Neuroprotection </li></ul><ul><li>Early rehabilitation within 72 hours </li></ul><ul><li>If infective endocarditis is suspected, give antibiotics and do not anticoagulate. </li></ul>
    56. 57. GUIDELINES FOR TIA AND MILD STROKE <ul><li>EARLY SPECIFIC TREATMENT FOR HEMORRHAGIC </li></ul><ul><li>If there is suspicion of nonhypertensive cause for ICH (e.g. AVM, aneurysm), REFER to neurosurgeon. </li></ul><ul><li>Neuroprotection </li></ul><ul><li>Early rehabilitation with in 72 hrs </li></ul>
    57. 58. GUIDELINES FOR TIA AND MILD STROKE <ul><li>EARLY SPECIFIC TREATMENT FOR T.I.A. </li></ul><ul><li>Aspirin 160-325 mg/ day </li></ul><ul><li>If crescendo T I A (multiple events within hours, Increasing severity and duration of deficits), </li></ul><ul><li>consider ANTICOAGULATION with intravenous heparin </li></ul>
    58. 59. GUIDELINES FOR TIA AND MILD STROKE <ul><li>CT SCAN NOT AVAILABLE </li></ul><ul><li>No specific emergent drug treatment recommended </li></ul><ul><li>Neuroprotection </li></ul><ul><li>Consult a neurologist or neurosurgeon </li></ul><ul><li>Early supportive rehabilitation </li></ul>
    59. 60. GUIDELINES FOR TIA AND MILD STROKE <ul><li>PLACE OF TREATMENT </li></ul><ul><li>Admit to Hospital (Stroke Unit) </li></ul><ul><ul><ul><li>1. Stroke onset within 48 hours </li></ul></ul></ul><ul><ul><ul><li>2. Patients requiring specific active intervention for any of the following: </li></ul></ul></ul><ul><li>a. BP control, monitoring, and stabilization </li></ul><ul><li>b. Cardiac stabilization, incl. Atrial fibrillation, CHF, acute MI </li></ul><ul><li>c. Hydration </li></ul><ul><li>d. Anticoagulation, if ICH ruled out by CT </li></ul>
    60. 61. GUIDELINES FOR TIA AND MILD STROKE <ul><ul><ul><ul><ul><li>PLACE OF TREATMENT </li></ul></ul></ul></ul></ul><ul><ul><li>Admit to Hospital (Stroke Unit) </li></ul></ul><ul><ul><li>3. Rapidly worsening deficits </li></ul></ul><ul><ul><li>4. >4 TIA’s in 2 weeks prior to consult </li></ul></ul><ul><ul><li>5. 1-4 TIA’s in 2 weeks but high risk (multiple events within hours, increasing severity and duration of deficits </li></ul></ul>
    61. 62. GUIDELINES FOR TIA AND MILD STROKE <ul><li>PLACE OF TREATMENT </li></ul><ul><li>URGENT OUTPATIENT WORK-UP </li></ul><ul><li>1. S ingle TIA more than 2 weeks ago </li></ul><ul><li>2. 1-4 TIA’s in 2 weeks, but not high risk (no change in severity and duration of deficit, cardiac arrhythmia, carotid bruit) </li></ul><ul><li>3. Transient monocular blindness alone </li></ul><ul><li>4. Stable mild strokes occurring > 48 hrs not requiring specific active intervention </li></ul><ul><li>*Advise immediate re-consult if there is worsening of deficit . </li></ul>
    62. 63. GUIDELINES FOR MODERATE STROKE <ul><li>MANAGEMENT PRIORITIES </li></ul><ul><li>1. Basic emergent supportive care (ABC of resuscitation) </li></ul><ul><li>2. Monitor and manage blood pressure. Treat if SBP>220; DBP>120; MAP= >130 </li></ul><ul><li>Precautions: Avoid precipitous drop in BP >20% MAP </li></ul><ul><li>No Sublingual agents </li></ul><ul><li>3. Exclude stroke mimickers </li></ul><ul><li>4. Identify co-morbidities (cardiac dis. Gastric ulcer, etc) </li></ul><ul><li>5. Recognize and treat early signs of increased ICP </li></ul>
    63. 64. GUIDELINES FOR MODERATE STROKE <ul><li>EMERGENT DIAGNOSTICS </li></ul><ul><li>Complete Blood Count </li></ul><ul><li>Blood sugar (CBG, HGT, RBS) </li></ul><ul><li>PT/PTT </li></ul><ul><li>Serum Na and K+ </li></ul><ul><li>Electrocardiogram (ECG) </li></ul><ul><li>Plain CT Scan of brain ASAP </li></ul>
    64. 65. GUIDELINES FOR MODERATE STROKE <ul><li>EARLY SPECIFIC TREATMENT </li></ul><ul><li>(CTSCAN CONFIRMED) </li></ul><ul><li>Ischemic- Noncardioembolic (Thrombotic/ Lacunar ) </li></ul><ul><li>- If within 3 hours of stroke onset, consider rtPA treatment and refer to specialist </li></ul><ul><li>- Aspirin 160-325 mg/day start as early as possible </li></ul><ul><li>- Neuroprotection </li></ul><ul><li>- Early supportive rehabilitation </li></ul>
    65. 66. GUIDELINES FOR MODERATE STROKE <ul><li>EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED ) </li></ul><ul><li>CARDIOEMBOLIC </li></ul><ul><li>- If within 3 hours of stroke onset consider rtPA </li></ul><ul><li>` treatment and refer to specialist </li></ul><ul><li>- Aspirin 150- 325 mg/day start as early as pos. </li></ul><ul><li>- Early anticoagulation if source of embolism can be demonstrated </li></ul><ul><li>- Neuroprotection </li></ul><ul><li>- Early supportive rehabilitation </li></ul><ul><li>* If infective endocarditis is suspected, give antibiotics and DO NOT anticoagulate </li></ul><ul><li> </li></ul>
    66. 67. GUIDELINES FOR MODERATE STROKE <ul><li>EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED ) </li></ul><ul><li>HEMORRHAGIC </li></ul><ul><li>- Supportive treatment: </li></ul><ul><li>1. Mannitol 20% 0.5 mg/kg BW q 6 h </li></ul><ul><li>for 2- 5 days </li></ul><ul><li>2. Neuroprotection </li></ul><ul><li>- Neurosurgery consult for hematomas distorting or displacing 4 th ventricle </li></ul><ul><li>- Within 12-24 h, recommended surgery for hematoma: </li></ul><ul><li>1. size 10-30 cc (non-dominant subcortical frontal/temporal) </li></ul><ul><li>2. size >30 cc (subcortical, putaminal, cerebellar) </li></ul><ul><li>- Early supportive rehabilitation </li></ul>
    67. 68. GUIDELINES FOR MODERATE STROKE <ul><li>CT SCAN NOT AVAILABLE </li></ul><ul><li>= USE SCORING SYSTEM </li></ul>Likely Ischemic Likely Hemorrhagic No specific emergent drug Tx. Neuroprotection Refer to Specialist Early Supportive Rehabilitation Refer to Neurologist/ Neurosurgeon further Dx workups and/or subsequent surgery Neuroprotection Early supportive rehabilitation
    68. 69. GUIDELINES FOR SEVERE STROKE <ul><li>Management Priorities </li></ul><ul><li>Basic Emergent supportive care (ABC of Resus.) </li></ul><ul><li>Neurovital signs: BP; PR, CR, RR, Temp, Pupils. </li></ul><ul><li>Glasgow Coma scale, </li></ul><ul><li>Recognize and Treat early signs of increased ICP </li></ul><ul><li>Monitor and manage blood pressure. Treat if SBP is </li></ul><ul><li>220 or DBP of 120 or MAP of 130. Precautions: </li></ul><ul><li>*Avoid precipitous drop in BP >20% of MAP </li></ul><ul><li>*Do not use sublingual agents </li></ul><ul><li>Ascertain clinical Dx; exclude stroke mimickers </li></ul><ul><li>Identify co-morbidities (cardiac dis. Gastric ulcer, etc) </li></ul>
    69. 70. GUIDELINES FOR SEVERE STROKE <ul><ul><ul><ul><ul><li>EMERGENT DIAGNOSTICS: </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Complete blood count, </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Blood Sugar, </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>PT/PTT, </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Serum Na, K </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Electrocardiogram, </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Plain CTscan of the brain </li></ul></ul></ul></ul></ul>
    70. 71. GUIDELINES FOR SEVERE STROKE <ul><li>EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED) </li></ul><ul><li>Non-cardioembolic (Thrombotic/Lacunar) </li></ul><ul><li>- May give aspirin 160-325mg/day </li></ul><ul><li>- Neuroprotection </li></ul><ul><li>- If cerebellar infarct, consult neurosurgeon ASAP </li></ul><ul><li>- Early supportive rehabilitation </li></ul><ul><li>Place of Treatment: Hospital, Intensive Care Unit or </li></ul><ul><li>Acute Stroke Unit </li></ul>
    71. 72. GUIDELINES FOR SEVERE STROKE <ul><li>EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED) </li></ul><ul><li>HEMORRHAGIC </li></ul><ul><li>- Supportive Treatment: </li></ul><ul><li>1. Mannitol 20% 0.5 mg/kg q 6h for 2-5 days </li></ul><ul><li>2. Neuroprotection </li></ul><ul><li>- Neurosurgery consult if: </li></ul><ul><li>1. Patient not herniated, hematoma in putamen, subcortical, cerebellum and goal is to reduce mortality’ </li></ul><ul><li>2. Herniated patient but family is willing </li></ul><ul><li>3. ICP monitoring contemplated and salvage surgery is considered </li></ul><ul><li>Place of Tx.: Intensive Care Unit </li></ul>
    72. 73. BRING HOME MESSAGE <ul><ul><ul><li>STROKE IS BRAIN ATTACK! </li></ul></ul></ul><ul><ul><ul><li>STROKE IS AN EMERGENCY! </li></ul></ul></ul><ul><ul><ul><li>STROKE IS TREATABLE! </li></ul></ul></ul><ul><ul><ul><li>STROKE IS PREVENTABLE! </li></ul></ul></ul>