Management of stroke three to twenty four hours
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Management of stroke three to twenty four hours

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Management of stroke three to twenty four hours Management of stroke three to twenty four hours Presentation Transcript

  • The sign wasn’t placed there By the Big Printer in the sky Management of Stroke ( Three to Twenty Four Hours )Prof.A.V.Srinivasan , M D, DM, Ph.D, DSc,F.R.C.P.(London) F.A.A.N, F.I.A.N Emeritus Professor, The Tamilnadu Dr.M.G.R.Medical university Former Professor and Head , INSTITUTE OF NEUROLOGY Madras Medical Colege
  • OBJECTIVE Definition Stroke burden Types & Mechanisms Risk factors Clinical evaluation Investigations Treatment of ischaemic stroke Treatment of h hemorrhagic stroke & SAH Rehabilitation Newer developments – Interventions & neuroprotectives.
  • Stroke: WHO Definition Stroke is clinically defined as a neurologicsyndrome characterized by “Rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin”. CONCEPT OF “BRAIN ATTACK” In all of us, even in good men, there is a wild - beast nature which peers out in sleep
  • Burden of Stroke Most common life-threatening neurologic disease Third most common cause of death globally Incidence in India: 73/1,00,000 per year No formal registry available. Burden is likely to increase with risk factors like aging, smoking, adverse dietary patterns Most common cause of disability and dependence. 70% of stroke survivors remaining vocationally impaired 30% requiring assistance with daily activities The True Art of Memory is The Art of Attention - S.Johnson
  • Burden of Stroke  26 per lac per year  Ischaemic – 69%  Hemorragic –23%  SAH – 3%  Undetermined – 5%We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts R.B. Schmeck
  • Types & mechanisms  Ischaemic – Atherothrombotic Embolic Lacunar  Hemorrhagic – ICH SAH  Global hypoperfusion – Watershed infarcts.A true commitment is a heart felt promise to yourself from which you will not back down - D. Mcnally
  • Stroke: Classification Ischemic stroke: Account for 80%.  Results from occlusion in the blood vessel supplying the brain  Thrombotic: Occlusion due to atherothrombosis of small/large vessels supplying the brain  Embolic: Occlusion due to embolus arising either from heart (e.g. atrial fibrillation, valvular disease) or blood vesselSerious, sincere, systematic study surely secures supreme success
  • Classification (contd.)Hemorrhagic stroke: Account for 20%. Results from rupture of blood vessels leading to bleeding in brain Intracerebral: Bleeding within the brain due to rupture of small blood vessels. Occurs mainly due to high blood pressure Subarachnoid: Bleeding around the brain; commonest cause is rupture of aneurysm.Other causes: Head injuryHabit is either the best of servants or worst of masters
  • LACUNAR INFARCT <10mm in size. Absence of cortical sings. Super lacune >15mm. Syndromes- ataxic hemiparesis pure motor, pure sensory,sensory-motor dysarthria clumsy hand, pure dysarthria, hemichorea& unilateral asterixis.Success in life is a matter not so much of talent and opportunity as of concentration and perseverance - C.W. Wendte
  • LACUNAR INFARCT  Associated with Systemic hypertension, DM  Weight of the heart exceeds 400g.  Prognosis -no mortality,  lenticulo striate territory-good recovery  ant.cho.artery-poor recovery.Give us the GR ACE to acce pt with se re nity the thing s that canno t bechang e d the COUR AGE to chang e the thing s that sho uld be chang e d and the WISDOM to kno w the diffe re nce
  • Oxfordshire Community Stroke project (OCSP) Anterior circulation stroke – Total (TACS) Anterior circulation stroke – Partial (PACS) Posterior circulation stroke – PCS Lacunar Strokes.- (LS)“ He who cannot forgive others destroy the bridge over which he s him m pass” self ust - Annoy
  • Differentials Focal epilepsy. Migraine. Transient Global Amnesia. Tumor Metabolic Encephalopathy Multiple Sclerosis. The secret of walking on water is Knowing where the stones are
  • Transient Ischemic Attack (TIA) “Mini stroke” Stroke symptoms last for less than 24 hours (usually 10 to 15 mins) Result as a brief interruption in blood flow to brain Every TIA is an emergency TIA may be a warning sign of a larger stroke Patients with possible TIA should be evaluated If you think you can or you can’t You are always right
  • TIA- contd Few minutes to 24hrs (>85% within 30mts). 12% atherosclerotic infarct Predominantly negative symptoms. Weakness/numbness of UL/UL&LL,speech disturbance,mono ocular blindness, weakness of thumb&index the daughter of attention , Memory, finger. is the teeming mother of knowledge - Martin Tupper
  • Stroke: Predisposing factors Age (risk doubles for every decade after 55yrs) Gender (males>females) Family history of stroke/TIA Hypertension Diabetes Hyperlipidemia Hyperhomocysteinemia As long as you get there before It’s over you’re never late
  • Stroke: Predisposing factors Obesity Smoking Atrial fibrillation Sedentary lifestyle Drug abuse (e.g. cocaine use) Hormone replacement therapy Oral contraceptive Discipline Weighs ounces Regret weighs Tons
  • Genetics & stroke Single gene disorder Sickle cell disease Homocystinuria Marfans syndrome – dolichoectasia Fabry’s disease Vascular risk factors Genetic hypercoagulable disorders Metabolic disorders with vasculopathy Hereditary intracranial aneurysms Some people feel the rain; Others just get wet
  • Genetics & stroke CADASIL – Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and Leucoencephalopathy. Recurrent episodes of subcortical infarcts or TIAs Onset 30 – 50 years Stroke, dementia, pseudobulbar palsy, migraine MRI shows extensive leucoencephalopathy Opinion is ultimately determined by the feelings and not by the intellect
  • Genetics & stroke Multiple infarcts in the basal ganglia and in the periventricular regions . U- fibers are spared. Skin biopsy is diagnostic- granular, eosinophilic, electron dense material in the media of the arterial wall. Familial clusters with hemiplegic migraine- CADASIL - M Experience can be defined as yesterday’s answer to today’s problems
  • Stroke: Symptoms Onset of stroke symptoms varies as per type of stroke  Thrombotic stroke: Develop more gradually  Embolic stroke: Hits suddenly  Hemorrhagic stroke: Hits suddenly and continues to worsen It is the province of the knowledge to speak and it is the privilege of the wisdomto listen - Hodly’s
  • Stroke: Symptoms (contd.) Dizziness Confusion Loss of balance/coordination Nausea/vomiting Numbness/weakness on one side of the body Seizure Severe headache M ovement disorder/speech disorder/blindness etc (depending on the area of brain affected) Additional symptoms for hemorrhagic stroke Pain upon looking at or into light Painful stiff neck
  • “SILENT STROKES” A silent stroke is a stroke which causes brain damage, but does not exhibit classicsymptoms of stroke. They are detected only when a person undergoes a brain scan. – Multi infarct state. The meek shall inherit the earth - but not its mineral rights
  • Stroke management“TIME IS BRAIN” Our best thoughts come from others
  • Stroke management Detection Dispatch Door Data 6 Ds Decision Drug It’s not over until it’s over
  • DETECTION Success is a prize to be won. Action is the road to it.Chance is what may lurk in the shadows at the road side. - O. Henry
  • Stroke management - Detection Cincinatti stroke Score - Facial droop - Arm drift - Slurred speech1 out of 3 - > 72% probability of stroke.Thinking is the hardest work there is, which is probable reason why so few engage in it. - Henry Ford
  • Stroke management - Detection Los Angeles Probable stroke Score. (LAPSS) Includes arm drift, facial droop, slurring of spech, age , presence of risk factors like hypertension, DM, previous TIAs, Little cumbersome. No better than Cincinatti Score. People of mediocre ability often achieve success because they don’t know enough to quit - Bernard Baruch
  • DISPATCH TO HOSPITAL EMR Whatever the Mind can conceive and Believe, the mind can Achieve Napoleon Hill
  • Stroke management – to Door On suspicion of stroke the person should be dispatched to the Emergency Medical Room as early as possible.( Within minutes) Maintain vitals and arrange for transport. No Aspirin or heparin to be administered. “ Social Isolation is in itself a pathogenic Factor for disease production”
  •  DATA EMERGENCY IMAGING – CT/ MRI BIOCHEMICAL PROFILE Possible investigations.Science is below the mind; Spirituality is beyond the mind
  • Stroke management – Door to data Physical examination: Vitals,Neurologic Brain imaging (cranial CT and/or MRI): discriminate between ischemic and hemorrhagic Stroke Doppler ultrasonography/Angiography: Detect large vessel atherosclerosis ECG/Echocardiography: Detect cardiac embolism Exclusion of conditions mimicking stroke (hypoglycemia, migraine, seizure) Speak obligingly even if you cannot oblige
  • Ischemic stroke diagnostic algorithmAcute focal brain deficit Excluded hypoglycemia, migraine with aura, post-seizure deficit < 1 hour TIA (if CT/MR brain imaging Head CT without ischemic lesion) Ischemic Stroke Lacunar syndrome Cortical syndrome Doppler MRI Vasculopathy CRYPTOGENIC MRA CT Coagulopathy STROKE ECG Angiogram Echo CARDIAC LARGE ARTERY SMALL OTHER DETERMINED EMBOLISM ATHEROSCLEROSIS VESSEL DISEASE CAUSE A woman’s desire for revenge outlasts all her other emotions
  • General management ABC Fluids & electrolytes Dysphagia, aspiration Urinary dysfunction Venous thromboembolism Seizures Skin care Depression Maintaining the right attitude is easier than regaining the right mental attitude
  • Management of acute ischemic stroke Systemic thrombolysis: Intravenous recombinant tissue plasminogen activator (rt-PA) Within 3 hrs of onset of stroke. Dose 0.9 mg/kg, max 90 mg. Intra arterial thrombolysis is being tried.- time window is upto 6 hrs. – technically demanding.No Aspirin or heparin for 24 hrs. following thrombolysisWhen they tell you to grow up, they mean stop growing
  • Management of acute ischemic stroke (contd..) Anticoagulants: Heparin/LMWH NOT recommended in acute ischemic stroke routinely. Recommended in setting of atrial fibrillation, acute MI risk, prosthetic valves, coagulopathies and for prevention of DVT. Intra-arterial thrombolytics: An option for treatment of selected patients with major stroke of < 6 hrs duration due to large vessel occlusion. Why should I question the monkey when I can question the organ grinder?
  • Management of acute ischemic stroke (contd)- hypertension BP Should be kept within higher normal limits since low BP could precipitate perfusion failure. Reduction of BP in acute stroke phase is controversial. Reduce BP if there is severe end organ damage like pulmonary edema, encephalopathy, uremia. Markedly elevated BP (>220/110mmHg) managed with nitroglycerin, clonidine, labetalol, sodium nitroprusside. More aggressive approach is taken if thrombolytic therapy is instituted He is free who knows how to keep in his own hands the power to decide
  • Management of acute ischemic stroke Glucose & pyrexia Blood glucose Should be kept within physiological levels using oral or IV glucose (in case of hypoglycemia) insulin (in case of hyperglycemia) RBS >300 mg Avoid routine glucose infusions Elevated body temperature management: Antipyretics and use of cooling device can improve the prognosis To get to the promised land you have to negotiate your way through the wilderness
  • Specific therapy - Ischaemic Thrombolytic therapy- r- tPA Time window – 3 hrs. 0.9 mg/kg max. 90mg. 10% bolus & 90% as infusion in 1 hour. Risk of hemorrage – 6%It is a great misfortune not to possess sufficient wit to speak well nor sufficient judgment to keep silent La Broyers character
  • Ancrod  Venom of Malaysian pit viper.  ↓Fibrinogen & viscosity  ↓ RBC aggregation  Endogenous tPA upregulation  Vasodilatation  Anticoagulant activity.We possess by nature the factors out of which personality can be made, and to organize them into effective personal life is every man’s primary responsibility - Harry Emerson Fosdick
  • Hemorrheologic therapy Hemodilution Pentoxyfylline Ancrod – Malaysian pit viper venom. Mind is the great level of all things; human thought is the process by which human ends are ultimately answered
  • Thrombolytic drugs t NK- Tenectoplase – derived from t PA. Desmoteplase Alteplase r- pro UK Gp IIIa Iib receptor blockers. Lys- plasminogen “ Social Isolation is in itself a pathogenic Factor for disease production”
  • Secondary prevention of stroke Recurrence: Annual risk is 4.5 to 6%. Five year recurrence rates range from 24 to 42% one-third occur within first 30 days, hence high priority should be given to secondary prevention. Patients with TIA or stroke have an increased risk of MI or vascular event. Management of hypertension (goal <140/85 mm Hg) A bad teacher complains; A good teacher explains; The best teacher inspires;
  • Secondary prevention of stroke Diabetes control (goal<126 mg/dL) Lipid management: Statins (goal cholesterol<200 mg/dL, LDL<100 mg/dL) Anticoagulants: Warfarin (target INR 2 to 3); esp. recommended in patients with cardioembolic stroke Appropriate life style modification (cessation of smoking, exercise, diet etc) Knowledge without action is useless; Action without knowledge is foolish
  • Secondary prevention of stroke Antiplatelet agents: Aspirin (50-325 mg), clopidogrel (75 mg). Ticlopidine 200mg bid Aspirin + ER Dipyridamole Sulfinpyrazone Suloctidil A combination of the two drug may also be usedReputation is made in a moment; character is built in a life time
  • Complications of stroke Cerebral edema – 30% of patients worsen after stroke due to cerebral edema. 24 – 96 hrs after acute stroke. Initially cytotoxic(gray matter),later vasogenic (white matter) Excitatory amino acids (EAA) – produces neurotoxic edema – Vedanta admits realization accelarates apoptosis. But defies verbal definition
  • Complications of ischaemic stroke Hemorrhagic transformation occurs in about 40%. Occurs in first 2 weeks. 10% of patients worsen. Increased risk with antithrombotics, anticoagulants, and thrombolytic therapy. Size (>1/3 rd) of the vascular territory and elderly are more prone for hemorrhagic transformation. Pure love ever gives; Never seeks
  • Management of Acute hemorrhagic stroke Analgesics/Antianxiety agents: To relieve headache. Analgesics having sedative properties are beneficial Hyperosmotic agents (e.g. mannitol, glycerol, furosemide): To reduce cerebral edema, and raised intracranial pressure. Adequate hydration is necessary Surgical intervention may occasionally be life saving What is mind no matter What is matter never mind
  • Surgical interventions Balloon angioplasty/stenting Carotid endarterectomy/Bypass Decompressive craniectomy Stem cell therapy. Every thing should be made as simple as possible; but not simpler
  • Carotid endarterectomy & stenting CEA in symptomatic patients provides protection against stroke. ( >70% stenosis) In 50 –69% stenosis the benefit is marginal compared to medical therapy. The stroke reduction is realized early after surgery and persisted for extended periods. In TIA CEA has to be performed as early as possible if there is significant stenosis ECST and NASCET trials have proved the benefit. Hate screeches, fear squeals; conceits trumpets but love since lullabies
  • Carotid stenting & angioplasty “ FROM KNIFE TO STENT” In patients having a increased surgical risk. CCF, severe COPD, unstable angina, past radiation therapy, local tumor mass etc.,. SAPPHIRE study has shown benefit in a group of patients. Angioguardadapt, adjust and accommodate device is Learn to emboli protection used. to give, not to take and learn to serve not to rule Learn
  • Sub arachnoid hemorrhage (SAH) Aneurysmal or non aneurysmal. Vasospasm is a critical factor. Autoregulation impaired with vasospasm. Hunt and Hess grading – Clinical Fisher grading – CT scan Lumbar puncture may be necessary.Teachers are reservoirs from which, through the process of education, the students draw the water of life
  • SAH - TRIPLE - H Therapy Hypertension Hypervolemia Hemodilution Nimodipine – used to treat vasospasm.Love is selfishness and selfishness is lovelessness
  • SAH - Surgical Aneurysmal clipping within 48 – 72 hours Prevents early rebleeding Permits aggressive therapy for vasospasm Endovascular therapy – coiling with GDC coils or thrombogenic platinum coils Asymptomatic one who thinks to his> 6mm Expert is aneurysms - chosen mode of ignorance
  • GUIDELINES
  • History And Examination Guide: 1 & 2a. Stroke clerking Performa (1994) R.C.P.1. Improved patient Assessment2. Improved Management & outcome- not clearb. Examination1. Secure Diagnosis of Stroke2. Specify Impairment3. Identify sub type of Ischemic an audience God is a comedian performing before stroke that is afraid to laugh
  • Guide: 3 (B) - CPR – Impaired consciousness in stroke is common in posterior circulation strokes. – Impaired Consciousness - From Stroke Resuscitation is rarely successful - Schneider 1993“Prediction is always difficult – especially when it concerns the future” – Oscar Wilde
  • Guide: 4 - CXRChest x-ray abnormal in 16%– Only 4% change clinical management– Order x-ray chest if WT Loss or chest symptoms present- Not recommended in routine stroke management.If I were to choose between pain and nothing… I would choose pain -- William Faulkner
  • Guide: 5 - ECG Detection of cerebrogenic cardiovascular disturbance. Acute ST- T changes,rhythm abnormalities are common (upto 40%) Insular cortex involvement is an independent risk factor Rt. Sided lesions, age ,HT/DM/IHD are other factors Cardiac cause of Death (30 days) ALL STROKE PATIENTS TO HAVE ECG Pain is god’s greatest gift to mankind - Paul Brand.
  • Guide: 6 - ECHO To identify stroke mechanism. LV clot, Patent Foramen Ovale (PFO), Infective endocarditis, AF,Silent lesions Detects silent cardiac lesions Lesions of aorta TEE is more useful than TTE. High yield in ischaemic lesions. RECOMMENDED IN SETTINGS WHERE AVAILABLE and im oralityare two of the greatest inhibitors of The Truth is fear m Performance to progress
  • Guide: 7 - CT scan brain ABSOLUTE INTEGRAL PART IN STROKE Differentiates between ischaemia, hemorrhage, SAH Early signs are useful in deciding about thrombolytic therapy. (Hyperdense MCA sign,insular ribbon sign,sulcal effacement) Helical and CT Angio are useful. MUST IN ALL STROKES Develop the heart; art comes automatically
  • Guide 8: M.R.I. Not Routine in Acute Stroke Diffusion & perfusion weighted images are very useful in the acute phase in ischaemic infarction Along with MRA gives valuable information NOT ROUTINELY INDICATED “ My opinions are founded on knowledge but modified by experience”
  • Guide 9: - Doppler studies B-mode, Duplex, continuous wave and pulsed doppler systems, Color doppler flow imaging, TCD Shows changes in flow patterns near plaques. Gives idea about the vulnerability of the plaque. Useful in assessing the Vasospasm, collateral circulation, hemodynamic effects, reserve capacity To plan carotid endarterectomy. IUSEFUL peripheral neuritis– it interferes with work don’t like IN APPROPRIATE CLINICAL
  • Guide 10: (B) - FEVER Fever (Worst Prog.) – 1 * C increases the metabolic need by 7% . Treatment of fever has consistently produced good results. Hypothermia theoretically useful. – not proved TEMPERATURE REDUCTION IS INDICATED.In any field, find the strangest thing and explore it
  • Guide 11: (B) - OXYGENATION Hypoxia ( Moroney 1996) – Exacerbated by seizures Pneumonia and Arrhythmias - Worst outcome Oxygenation bas been Consistently useful. Hyperbaric O2 ineffective (Nighoghossaln 1995) OXYGEN ADMINISTRATION IS USEFUL AND RECOMMENDED. He can’t walk and chew gum at the same time
  • Hyperglycemia DM & hyperglycemia are associated with larger infarcts and fasting hypoglycemia with smaller infarcts. Worsening in hyperglycemia is due to lactic acidosis Optimal blood glucose is less than 130 mg% Treat hyperglycemia with insulin. Take time to think; it is the source of power Take time to read; it is the foundation of wisdom Take time to work; it is the price of success
  • Guide: 12- Anti edema measures. Steroids are ineffective in stroke Mannitol, Glycerol, Hypertonic saline is useful in some cases. Loop diuretics are useful. Albumin can also be used – not proved in major trials Hyperventilation – useful for short periods, rebound edema is common- not recommended routinely. Thought is the labour of the intellect Reverie is its pleasure
  • Guide 13: (B) - OTHERS Haemodilution- Plasm Expanders TRIPLE – H therapy useful in SAH. Mean Arterial Pressure – 120-130 mm Hg CVP – 10-12 mm Hg PCWP –14-18mm Hg Hematocrit 30-33% Check ABG only if Hypoxia suspected.
  • Guide: 14 - OTHERS Barbiturate coma and propofol to reduce the elevated intracranial pressure have been useful in large ischaemic strokes. They produce hypotension and hence may be detrimental in some patients. Judicious use is advised. Indomethacin 50mg I.v. has been used in stroke to lower ICP – may reduce CBF- only case reports are available
  • Guide: 14 - OTHERS Sedation, pain control and neuromuscular blockade may be necessary in patients with altered sensorium as pain and irritation impede cerebral venous return Sedation reduces sympathetic overactivity, increases co operation for procedures and nursing care. Helpful in reducing the cerebral metabolism.
  • Guide 12: (B) - Blood Pressure Defer - acute reduction of BP - 10 days unless HT Encephalopathy or aortic dissection present Increase in BP - falls in 10 days (Moris 1997) HT - Prim. stroke prevention ACE- I are very useful in managing HTA diuretic may also be combined. NO DEFINITE LOWER LEVEL BP
  • Guide 13: (A/B) - AF AF / LV clot - warfarin after 48 Hrs – start along with heparin Aspirin for others EAFT 1995 Prothrombin time- Less than 2 - No effect PT- > 5 - Bleeding (SPAF 1996 )
  • Guide 15: Cholesterol Dietary and pharmacologic measures in reducing cholesterol are very effective Proven in large controlled trials Statins are very useful Start all patients with stroke on Statins. At twenty the will rules At thirty the intellect At forty the Judgment
  • Guide 16: Deep vein thrombosis 50% stroke Pts –develop DVT 10 days (Kalra 1995 Pulmonary embolism in 6-16% only (Sandercock 1993 ) Heparin 5000IU QID or 12500IU twice daily - Hemorrage greater Gradual stocking is of value -Use with caution - if peripheral artery insufficiency is present HEPARIN IS USEFUL IN PREVENTING DVT.
  • Guide 18: (A) –Antithrombotic drugs Aspirin 75 - 150 /Day 3 yrs 40% reduces of vascular events in 1000 pts (APTC - 1994) Stroke sub type value ? (TACI, PACI, LACI, POCI) synergy possible with clopidogrel ,ticlopidine etc.
  • Anti CoagulationWarfarin - AF In sinus rhythm - uncertain Spirit 1997 low dose aspirin + Warfarin in TIA & Minorstorke Heparin (IST 1997) - Signif. reduction in early death (12 fewor in 1000) not better than aspirin So avoid Heparin (A)
  • Guide 20: (I) Hemorrhage Supra tentorial evacuation for ICH is controversial - Avoid (Hankey and Hon 1997) Infra tentorial hematomas- early evacuation Main Indication - Deteriorating or depressed consciousness
  • Other measures. Nutritional maintenance especially if dysphagiais present Prevention of pulmonary complications Prevention/treatment of UTI Prevention of decubiti Treatment of depression Physiotherapy and rehabilitation
  • GOALS ACHIEVED ? Prevent first stroke Facilitate recovery improve neurological function
  • Dedicated to my family formaking everything worthwhile
  • READ not to contradict or confute Nor to Believe and Take for Granted but TO WEIGH AND CONSIDER THANK YOUMy sincere thanks to Mr. G. Kakuthan, for his meticulous computer work
  • DECISION TO USE THROMBOLYTIC NATURE, TIME AND PATIENCE are the 3 great physicians
  • DRUG - r tPA  Before administering thrombolytic therapy the following investigations have to be carried out apart from the MANDATORY CT SCAN BRAIN which rules out hemorrhage.  Routine blood biochemistry.  Coagulation profile – PT,PTT  Doppler studies.The world shall perish not for lack of wonders but lack of wonder
  • Multimodal monitoring CBF monitoring – Xenon enhanced CT scanning laser doppler flowmetry (qualitative) Thermal diffusion ( quantitative) Brain tissue oxygenation tissue partial pressure of oxygen (Ptio2) Directly measured with electrodes. Through Action You Create your Own Education - D.B. ELLIS
  • Intracerebral microdialysis Monitor the chemistry of the extracellular space in living tissues. Physiological salt solution is slowly pumped through the microdialysis probe, the solution equilibrates with the surrounding extracellular tissue fluid. The microdialysate is then extracted and analysed for lactate and glutamate “Knowledge can be communicated but not Wisdom” etc.., - Hermann Hesse
  • Emergency Medical Care for Neurologic Emergencies • Provide reassurance. • Ensure proper airway and breathing. • Place the patient in a position of comfort. • Assess and care for any injuries if you suspect any type of trauma.Many Ideas grow better when transplanted into another mind than in the one where they sprang UP O.W. Holmos
  • General management ABC Fluids & electrolytes Dysphagia, aspiration Urinary dysfunction Venous thromboembolism Seizures Skin care Depression Maintaining the right attitude is easier than regaining the right mental attitude
  • Management of acute ischemic stroke Systemic thrombolysis: Intravenous recombinant tissue plasminogen activator (rt-PA) Within 3 hrs of onset of stroke. Dose 0.9 mg/kg, max 90 mg. Intra arterial thrombolysis is being tried.- time window is upto 6 hrs. – technically demanding.No Aspirin or heparin for 24 hrs. following thrombolysisWhen they tell you to grow up, they mean stop growing
  • Management of acute ischemic stroke (contd..) Anticoagulants: Heparin/LMWH NOT recommended in acute ischemic stroke routinely. Recommended in setting of atrial fibrillation, acute MI risk, prosthetic valves, coagulopathies and for prevention of DVT. Intra-arterial thrombolytics: An option for treatment of selected patients with major stroke of < 6 hrs duration due to large vessel occlusion. Why should I question the monkey when I can question the organ grinder?
  • Management of acute ischemic stroke (contd)- hypertension BP Should be kept within higher normal limits since low BP could precipitate perfusion failure. Reduction of BP in acute stroke phase is controversial. Reduce BP if there is severe end organ damage like pulmonary edema, encephalopathy, uremia. Markedly elevated BP (>220/110mmHg) managed with nitroglycerin, clonidine, labetalol, sodium nitroprusside. More aggressive approach is taken if thrombolytic therapy is instituted He is free who knows how to keep in his own hands the power to decide
  • Management of acute ischemic stroke Glucose & pyrexia Blood glucose Should be kept within physiological levels using oral or IV glucose (in case of hypoglycemia) insulin (in case of hyperglycemia) RBS >300 mg Avoid routine glucose infusions Elevated body temperature management: Antipyretics and use of cooling device can improve the prognosis To get to the promised land you have to negotiate your way through the wilderness
  • Specific therapy - Ischaemic Thrombolytic therapy- r- tPA Time window – 3 hrs. 0.9 mg/kg max. 90mg. 10% bolus & 90% as infusion in 1 hour. Risk of hemorrage – 6%It is a great misfortune not to possess sufficient wit to speak well nor sufficient judgment to keep silent La Broyers character
  • Ancrod  Venom of Malaysian pit viper.  ↓Fibrinogen & viscosity  ↓ RBC aggregation  Endogenous tPA upregulation  Vasodilatation  Anticoagulant activity.We possess by nature the factors out of which personality can be made, and to organize them into effective personal life is every man’s primary responsibility - Harry Emerson Fosdick
  • Hemorrheologic therapy Hemodilution Pentoxyfylline Ancrod – Malaysian pit viper venom. Mind is the great level of all things; human thought is the process by which human ends are ultimately answered
  • Thrombolytic drugs t NK- Tenectoplase – derived from t PA. Desmoteplase Alteplase r- pro UK Gp IIIa Iib receptor blockers. Lys- plasminogen “ Social Isolation is in itself a pathogenic Factor for disease production”
  • Secondary prevention of stroke Recurrence: Annual risk is 4.5 to 6%. Five year recurrence rates range from 24 to 42% one-third occur within first 30 days, hence high priority should be given to secondary prevention. Patients with TIA or stroke have an increased risk of MI or vascular event. Management of hypertension (goal <140/85 mm Hg) A bad teacher complains; A good teacher explains; The best teacher inspires;
  • Secondary prevention of stroke Diabetes control (goal<126 mg/dL) Lipid management: Statins (goal cholesterol<200 mg/dL, LDL<100 mg/dL) Anticoagulants: Warfarin (target INR 2 to 3); esp. recommended in patients with cardioembolic stroke Appropriate life style modification (cessation of smoking, exercise, diet etc) Knowledge without action is useless; Action without knowledge is foolish
  • Secondary prevention of stroke Antiplatelet agents: Aspirin (50-325 mg), clopidogrel (75 mg). Ticlopidine 200mg bid Aspirin + ER Dipyridamole Sulfinpyrazone Suloctidil A combination of the two drug may also be usedReputation is made in a moment; character is built in a life time
  • Complications of stroke Cerebral edema – 30% of patients worsen after stroke due to cerebral edema. 24 – 96 hrs after acute stroke. Initially cytotoxic(gray matter),later vasogenic (white matter) Excitatory amino acids (EAA) – produces neurotoxic edema – Vedanta admits realization accelarates apoptosis. But defies verbal definition
  • Complications of ischaemic stroke Hemorrhagic transformation occurs in about 40%. Occurs in first 2 weeks. 10% of patients worsen. Increased risk with antithrombotics, anticoagulants, and thrombolytic therapy. Size (>1/3 rd) of the vascular territory and elderly are more prone for hemorrhagic transformation. Pure love ever gives; Never seeks
  • Management of Acute hemorrhagic stroke Analgesics/Antianxiety agents: To relieve headache. Analgesics having sedative properties are beneficial Hyperosmotic agents (e.g. mannitol, glycerol, furosemide): To reduce cerebral edema, and raised intracranial pressure. Adequate hydration is necessary Surgical intervention may occasionally be life saving What is mind no matter What is matter never mind
  • Surgical interventions Balloon angioplasty/stenting Carotid endarterectomy/Bypass Decompressive craniectomy Stem cell therapy. Every thing should be made as simple as possible; but not simpler
  • Carotid endarterectomy & stenting CEA in symptomatic patients provides protection against stroke. ( >70% stenosis) In 50 –69% stenosis the benefit is marginal compared to medical therapy. The stroke reduction is realized early after surgery and persisted for extended periods. In TIA CEA has to be performed as early as possible if there is significant stenosis ECST and NASCET trials have proved the benefit. Hate screeches, fear squeals; conceits trumpets but love since lullabies
  • Carotid stenting & angioplasty “ FROM KNIFE TO STENT” In patients having a increased surgical risk. CCF, severe COPD, unstable angina, past radiation therapy, local tumor mass etc.,. SAPPHIRE study has shown benefit in a group of patients. Angioguardadapt, adjust and accommodate device is Learn to emboli protection used. to give, not to take and learn to serve not to rule Learn
  • Sub arachnoid hemorrhage (SAH) Aneurysmal or non aneurysmal. Vasospasm is a critical factor. Autoregulation impaired with vasospasm. Hunt and Hess grading – Clinical Fisher grading – CT scan Lumbar puncture may be necessary.Teachers are reservoirs from which, through the process of education, the students draw the water of life
  • SAH - TRIPLE - H Therapy Hypertension Hypervolemia Hemodilution Nimodipine – used to treat vasospasm.Love is selfishness and selfishness is lovelessness
  • SAH - Surgical Aneurysmal clipping within 48 – 72 hours Prevents early rebleeding Permits aggressive therapy for vasospasm Endovascular therapy – coiling with GDC coils or thrombogenic platinum coils Asymptomatic one who thinks to his> 6mm Expert is aneurysms - chosen mode of ignorance
  • Number of events, fatal and nonfatal strokes and fatal and nonfatalmyocardial infarctions (MI) reported in recent prospective hypertension trials Trial Average Patients Strokes MI (n) age randomized (n) (years) (n)STOP-I 76 1627 82 53SHEP 72 4736 269 165STONE 67 1632 52 4Syst-Eur 70 4695 124 78Syst-China 67 2394 104 16HOT 61 18790 294 209CAPPP 53 10985 340 327STOP-2 76 6614 452 293NICS 70 414 20 4NORDIL 60 1088 355 340INSIGHT 67 6575 1141 138
  • MODIFIABLE RISK FACTORWell documented risk factors Hypertension Cardiac diseases  Atrial fibrillation  Infective endocarditis  Mitral stenosis  Recent extensive myocardial infarction Cigarette smoking Transient ischemic attack Asymptomatic carotid stenosis Diabetes mellitus Hyperhomocystinemia Left ventricular hypertrohy
  • Less well documented risk factors Elevated blood cholesterol and  Spontaneous lipids echocardiographic Cardiac disease contrast  Cardiomyopathy  Segmental well motion abnormalities  Bacterial endocarditis  Aortic stenosis  Mitral annular calcification  Patent foramen ovale  Mitral valve prolapse  Atrial septum aneurysm  Valve strands A good teacher is a perpetual learner
  •  Use of oral contraceptives  Hypercoagulability and inflammation Consumption of alcohol  Fibrin formation and fibrinolysis Use of illicit drugs  Fibrinogen Physical inactivity  Anticardiolipin antibodies Obesity  Genetic and acquired causes Migraine  Subclinical diseases Elevated hematocrit  Carotid intima-media thickness Dietary factors  Aortic atheroma Hyperinsulinemia and insulin  MRI evidence of infarct like resistance lesions Acute triggers (stress)  Socio economic features “ He who cannot forgive others destroy the bridge over s which he him m pass”- Annoy self ust
  • Non modifiable risk factors Age Gender Hereditary / familial factors Race / ethnicity Geographic location It is not your position that makes you happy or unhappy It is your disposition
  • Stroke incidence compared between antihypertensive drug trials Drug treatment Relative risk P (95% CI)β-Blockers and/or diuretics vs 0.64 (0.41 – 0.90) <0.01placeboACEIs vs placebo 0.70 (0.57 – 0.85) <0.01Calcium antagonists vs placebo 0.61 (0.44 – 0.85) <0.01ACEIs vs β-blockers and/or 1.05 (0.92 – 1.19) NSdiureticsCalcium antagonists vs β- 0.86 (0.76 – 0.98) NSblockers and/or diureticsACEIs vs calcium antagonists 1.02 (0.85 – 1.21) NS
  • Control of risk factors Smoking cessation Reduction of alcohol consumption Physical exercise Dietary control Medical interventions Antihypertensive drug treatment Antithrombotic therapy Hypocholesterolemic drug treatment Antibiabetic and lipid-lowering treatment Let the wave of memory, the storm of desire, a fire of emotion pass through without affecting your equanimity
  • Stroke subtypes and risk factor associations Risk factorStroke Age HT Smoking Diabete AF CHOsubtypes s LIschemic +++ ++ ++ ++ ++ +Intracerebral +++ +++ - - - -hemorrhageSubarachnoid ++ ++ - - - -hemorrhage Learn to adapt, adjust and accommodate Learn to give, not to take and learn to serve not to rule
  • Ischemic stroke subtypes and risk factor associations Risk factorIschemic Age HT Smoking Diabete AF CHOStroke s LsubtypesArtery-to- +++ ++ ++ ++ - +arteryLacunar +++ +++ +++ ++ - ±Cardioembolic +++ ++ ++ ++ +++ +Aortic arch +++ ++ ++ ++ - +Border zone +++ ++ ++ ++ ± +
  • Risk of thromboembolism in patients with atrial fibrillation Clinical risk group Thromboembolism rate per year (95% CI) No risk factors 2.5 (1.3 – 5.0) One risk factor 7.2 (4.8 – 10.8) Two or more risk factors 17.6 (10.5 – 29.9)Character gets y out of bed; com itm m ou m ent oves y to action faith, hope and ou Discipline follow through to completion
  • Recommendations for pre clinical evaluation of neuroprotectants in experimntal brain ischemiaDrug dose Generate dose-response curves in several species; assess likelihood of drug penetration of tissue at riskTherapeutic Assess carefully the time interval after thetime window onset of ischemia or reperfusion when the drug can be successfully administeredAnimal Study permanent and transient ischemiamodels models initially in rats/mice, the possibly in cats or primates in a radomized and blinded fashion; results should be replicated by independent laboratories; consider influence of sex
  • Physiological Monitor blood pressure, blood gases,monitoring hemoglobin, glucose, brain temperature and cerebral blood flow for as long as possibleOutcome Evaluate acute and long-term outcomemeasures (typically reduced infarct volume). Assess functional recovery in multiple animal speciesTarget It is uncertain if benefit in young, healthypopulations animals can be extrapolated to elderly, sick humansCombination Consider using agents that affect multipletherapy mechanisms of neuronal injury after ischemia, simultaneously or in successions (the “cocktail” approach
  • Studies of moderate hypothermia after cardiac arrest Study Method Favourable outcome (OR, 95 CI)N Engl J Med 2002; N=77; 330C<2 hrs 5.25 (1.47-18.76)346:549-556 after the return of spontaneous P = 0.011 circulation for 12 hrsN Engl J Med 2002; N=27; 320C-340C for 1.4 (1.08-1.81)346:557-563 24 hrs; median interval between P = 0.009 restoration of circulation and initiation of cooling; 105 min
  • GUIDELINES
  • History And Examination Guide: 1 & 2a. Stroke clerking Performa (1994) R.C.P.1. Improved patient Assessment2. Improved Management & outcome- not clearb. Examination1. Secure Diagnosis of Stroke2. Specify Impairment3. Identify sub type of Ischemic an audience God is a comedian performing before stroke that is afraid to laugh
  • Guide: 3 (B) - CPR – Impaired consciousness in stroke is common in posterior circulation strokes. – Impaired Consciousness - From Stroke Resuscitation is rarely successful - Schneider 1993“Prediction is always difficult – especially when it concerns the future” – Oscar Wilde
  • Guide: 4 - CXRChest x-ray abnormal in 16%– Only 4% change clinical management– Order x-ray chest if WT Loss or chest symptoms present- Not recommended in routine stroke management.If I were to choose between pain and nothing… I would choose pain -- William Faulkner
  • Guide: 5 - ECG Detection of cerebrogenic cardiovascular disturbance. Acute ST- T changes,rhythm abnormalities are common (upto 40%) Insular cortex involvement is an independent risk factor Rt. Sided lesions, age ,HT/DM/IHD are other factors Cardiac cause of Death (30 days) ALL STROKE PATIENTS TO HAVE ECG Pain is god’s greatest gift to mankind - Paul Brand.
  • Guide: 6 - ECHO To identify stroke mechanism. LV clot, Patent Foramen Ovale (PFO), Infective endocarditis, AF,Silent lesions Detects silent cardiac lesions Lesions of aorta TEE is more useful than TTE. High yield in ischaemic lesions. RECOMMENDED IN SETTINGS WHERE AVAILABLE and im oralityare two of the greatest inhibitors of The Truth is fear m Performance to progress
  • Guide: 7 - CT scan brain ABSOLUTE INTEGRAL PART IN STROKE Differentiates between ischaemia, hemorrhage, SAH Early signs are useful in deciding about thrombolytic therapy. (Hyperdense MCA sign,insular ribbon sign,sulcal effacement) Helical and CT Angio are useful. MUST IN ALL STROKES Develop the heart; art comes automatically
  • Guide 8: M.R.I. Not Routine in Acute Stroke Diffusion & perfusion weighted images are very useful in the acute phase in ischaemic infarction Along with MRA gives valuable information NOT ROUTINELY INDICATED “ My opinions are founded on knowledge but modified by experience”
  • Guide 9: - Doppler studies B-mode, Duplex, continuous wave and pulsed doppler systems, Color doppler flow imaging, TCD Shows changes in flow patterns near plaques. Gives idea about the vulnerability of the plaque. Useful in assessing the Vasospasm, collateral circulation, hemodynamic effects, reserve capacity To plan carotid endarterectomy. IUSEFUL peripheral neuritis– it interferes with work don’t like IN APPROPRIATE CLINICAL
  • Guide 10: (B) - FEVER Fever (Worst Prog.) – 1 * C increases the metabolic need by 7% . Treatment of fever has consistently produced good results. Hypothermia theoretically useful. – not proved TEMPERATURE REDUCTION IS INDICATED.In any field, find the strangest thing and explore it
  • Guide 11: (B) - OXYGENATION Hypoxia ( Moroney 1996) – Exacerbated by seizures Pneumonia and Arrhythmias - Worst outcome Oxygenation bas been Consistently useful. Hyperbaric O2 ineffective (Nighoghossaln 1995) OXYGEN ADMINISTRATION IS USEFUL AND RECOMMENDED. He can’t walk and chew gum at the same time
  • Hyperglycemia DM & hyperglycemia are associated with larger infarcts and fasting hypoglycemia with smaller infarcts. Worsening in hyperglycemia is due to lactic acidosis Optimal blood glucose is less than 130 mg% Treat hyperglycemia with insulin. Take time to think; it is the source of power Take time to read; it is the foundation of wisdom Take time to work; it is the price of success
  • Guide: 12- Anti edema measures. Steroids are ineffective in stroke Mannitol, Glycerol, Hypertonic saline is useful in some cases. Loop diuretics are useful. Albumin can also be used – not proved in major trials Hyperventilation – useful for short periods, rebound edema is common- not recommended routinely. Thought is the labour of the intellect Reverie is its pleasure
  • Guide 13: (B) - OTHERS Haemodilution- Plasm Expanders TRIPLE – H therapy useful in SAH. Mean Arterial Pressure – 120-130 mm Hg CVP – 10-12 mm Hg PCWP –14-18mm Hg Hematocrit 30-33% Check ABG only if Hypoxia suspected.
  • Guide: 14 - OTHERS Barbiturate coma and propofol to reduce the elevated intracranial pressure have been useful in large ischaemic strokes. They produce hypotension and hence may be detrimental in some patients. Judicious use is advised. Indomethacin 50mg I.v. has been used in stroke to lower ICP – may reduce CBF- only case reports are available
  • Guide: 14 - OTHERS Sedation, pain control and neuromuscular blockade may be necessary in patients with altered sensorium as pain and irritation impede cerebral venous return Sedation reduces sympathetic overactivity, increases co operation for procedures and nursing care. Helpful in reducing the cerebral metabolism.
  • Guide 12: (B) - Blood Pressure Defer - acute reduction of BP - 10 days unless HT Encephalopathy or aortic dissection present Increase in BP - falls in 10 days (Moris 1997) HT - Prim. stroke prevention ACE- I are very useful in managing HTA diuretic may also be combined. NO DEFINITE LOWER LEVEL BP
  • Guide 13: (A/B) - AF AF / LV clot - warfarin after 48 Hrs – start along with heparin Aspirin for others EAFT 1995 Prothrombin time- Less than 2 - No effect PT- > 5 - Bleeding (SPAF 1996 )
  • Guide 15: Cholesterol Dietary and pharmacologic measures in reducing cholesterol are very effective Proven in large controlled trials Statins are very useful Start all patients with stroke on Statins. At twenty the will rules At thirty the intellect At forty the Judgment
  • Guide 16: Deep vein thrombosis 50% stroke Pts –develop DVT 10 days (Kalra 1995 Pulmonary embolism in 6-16% only (Sandercock 1993 ) Heparin 5000IU QID or 12500IU twice daily - Hemorrage greater Gradual stocking is of value -Use with caution - if peripheral artery insufficiency is present HEPARIN IS USEFUL IN PREVENTING DVT.
  • Guide 18: (A) –Antithrombotic drugs Aspirin 75 - 150 /Day 3 yrs 40% reduces of vascular events in 1000 pts (APTC - 1994) Stroke sub type value ? (TACI, PACI, LACI, POCI) synergy possible with clopidogrel ,ticlopidine etc.
  • Anti CoagulationWarfarin - AF In sinus rhythm - uncertain Spirit 1997 low dose aspirin + Warfarin in TIA & Minorstorke Heparin (IST 1997) - Signif. reduction in early death (12 fewor in 1000) not better than aspirin So avoid Heparin (A)
  • Guide 20: (I) Hemorrhage Supra tentorial evacuation for ICH is controversial - Avoid (Hankey and Hon 1997) Infra tentorial hematomas- early evacuation Main Indication - Deteriorating or depressed consciousness
  • Other measures. Nutritional maintenance especially if dysphagiais present Prevention of pulmonary complications Prevention/treatment of UTI Prevention of decubiti Treatment of depression Physiotherapy and rehabilitation
  • GOALS ACHIEVED ? Prevent first stroke Facilitate recovery improve neurological function
  • Dedicated to my family formaking everything worthwhile
  • READ not to contradict or confute Nor to Believe and Take for Granted but TO WEIGH AND CONSIDER THANK YOUMy sincere thanks to Mr. G. Kakuthan, for his meticulous computer work