Management of ischaemic stroke pathogenesis of stroke difference between ischaemisc and haemorrhagic stroke investigations imaging rTPA trreatment thrombectomy strike rehabilitation

1. Mx OF
ISCHAEMIC STROKE
DR.ANUSREE.K
KANNUR MEDICAL
COLLEGE

3. ABRUPT ONSET OF NON CONVULSIVE
FOCAL NEUROLOGICAL DEFICIT

4. ISCHAEMIC STROKE

5. PATHOGENESIS
ISCHAEMIA
NECROSIS
NO ATP
NON
FUNCTIONING
PUMPS
DEPOLARIZATION CALCIUM MEMBRANE DAMAGE FREE RADICALS

6. ISCHAEMIC PENUMBRA
ISCHAEMIA
NORMAL BLOOD VOLUME

7. AETIOLOGY
1.CARDIAC(EMBOLIC)
AF
IE
MI
MYXOMA(LA)
DILATED CARDIOMYOPATHY
PARADOXICAL EMBOLI:TOF

8. 2.CONNECTIVE TISSUE DISORDERS(VASCULITIS)
SLE
RA
SCLERODERMA
TAKAYASU ARTERITIS
SYPHILIS

9. 3.HAEMATOLOGICAL(HYPERCOAGULABLE STATES)
POLYCYTHEMIA VERA
ESSENTIAL THROMBOCYTOSIS
MULTIPLE MYELOMA
PROTEIN C AND S DEFICIENCY
PNH
APLA
SICKLE CELL ANAEMIA

10. 4.MISCELLANEOUS
PREGNANCY
OCP:CORTICAL VEIN THROMBOSIS
DRUGS:COCAINE
INFECTION:TB-VASCULITIS

11. YOUNG STROKE
TRANSIENT CEREBRAL ARTERIOPATHY
MOYAMOYA DISEASE
TAKAYASU DISEASE
MIGRAINIOUS INFARCTION
SICKLE CELL ANAEMIA
IRON DEFICIENCY ANAEMIA

12. MANAGEMENT

13. TIME IS BRAIN!!

14. STROKE IS AN EMERGENCY!!

15. RISK FACTORS
HYPERTENSION
TIA
PRIOR STROKE
CAROTID STENOSIS
DM
DYSLIPIDAEMIA
HEART FAILURE
CIGARETTE SMOKING
ALCOHOL
OCP
OBESITY
GENETICS

16. ABCD2 SCORE
A
B
C
D
D
AGE>60
SBP>140 and/ DBP>90
U/L WEAKNESS
ONLY SPEECH DISTURBANCE
10-59 MINUTES
>60 MINUTES
DM
1
1
1
2
2
1
1
7

17. HISTORY
TIME OF ONSET WHEN THE PATIENT WAS LAST SEEN NORMAL
DURATION
PROGRESSION OR FLUCTUATION
PRIOR TIA SYMPTOMS
CARDIAC ARRHYTHMIAS
ATHEROSCLEROTIC RISK FACTORS
CVST FEATURES POSITIONAL HEADACHE WITH DIURNAL VARIABILITY
B/L 6N PALSY
BLURRED VISION
TRANSIENT MONOCULAR LOSS OF VISION
APHASIA,DYSARTHRIA
PARESIS
SENSORY DISTURBANCE

18. PHYSICAL
EXAMINATION

19. HAEMORRHAGIC ISCHAEMIC
• MORE DEPRESSED LEVEL OF CONSCIOUSNESS
• HIGHER INITIAL BP
• WORSENING SYMPTOMS AFTER ONSET
DEFICIT MAXIMUM AT ONSET
OR REMITS

20. L
ANTERIOR CEREBRAL ARTERY

21. PARALYSIS OF OPPOSITE FOOT AND LEG
CORTICAL SENSORY LOSS OVER C/L FOOT AND LEG
URINARY INCONTINANCE PARACENTRAL LOBULE
ABULIA
FRANK CONFUSION
AREA FOR SOCIAL BEHAVIOUR
AND PERSONALITY

22. MIDDLE CEREBRAL ARTERY
A
H

23. HEMIPLEGIA:PARALYSIS OF C/L FACE,ARM,LEG ARM>LEG
SENSORY LOSS OF FACE,ARM,LEG ARM>LEG
DOMINANT HEMISPHERE
 BROCAS:MOTOR APHASIA
 WERNICKES:SENSORY APHASIA

24. GERSTMANN SYNDROME
HEMINEGLECT,DRESSING APRAXIA
DOMINANT PARIETAL
NON-DOMINANT PARIETAL
HOMONYMOUS HEMI ANOPIA OPTIC RADIATIONS
PARALYSIS OF CONJUGATE GAZE TO OPPOSITE SIDE
UPPER I/3 rd OF FACE SPARED

25. C
H
E
S
A
N
G
C/L PARESIS AND SENSORY LOSS
HOMONYMOUS HEMI ANOPIA
APHASIA
NEGLECT
GAZE PREFERENCE
TOWARDS THE
SIDE OF LESION

26. POSTERIOR CEREBRAL ARTERY
 CEREBELLUM
 MIDBRAIN
 PONS
 MEDULLA
 SUBTHALAMUS
 THALAMUS

27. D
D
D
D
DYSPHAGIA
DIPLOPIA
DIZZINESS
DYSARTHRIA

28. INVESTIGATIONS

29. ESR
VDRL
ANA
PROTEIN C
PROTEIN S
APLA
FACTOR V LEIDEN MUTATION

30.  ECG/HOLTER
 ECHO
 CAROTID DOPPLER
MRI-MOST ACCURATE
CEREBRAL ANGIOGRAPHY
USG

31. CEREBRAL ANGIOGRAPHY
 ANEURYSM
 VASOSPASM
 INTRALUMINAL THROMBI
 FIBROMUSCULAR DYSPLASIA
 A-V FISTULA
 VASCULITIS
 COLLATERAL CHANNELS OF BLOOD FLOW
 BLEEDING SITE

32. USG
DOPPLER ULTRASOUND ASSESSMENT OF
FLOW VELOCITY
TRANSCRANIAL DOPPLER ASSESSMENT OF
MIDDLE ANTERIOR AND POSTERIOR
CEREBRAL ARTERY AND VERTEBROBASILAR
FLOW

33. 4 Ps OF IMAGING
P
P
P
P
PARENCHYMA
PERFUSION
PIPE
PENUMBRA
NCCT
CTA-LVO
CTP

34. CT

35. MRI

37. ISCHAEMIC STROKE
<4.5 hours >4.5 hours
NCCT+CTA NCCT+CTA
THROMBOLYSIS
CTA/CTP
MECHANICAL
THROMBECTOMY
MECHANICAL
THROMBECTOMY
4.5-6 hours >6 hours
NCCT+CTA NCCT+CTA
+
CTP

38. CORE PENUMBRA
CEREBRAL BLOOD FLOW
CEREBRAL BLOOD VOLUME
MEAN TRANSIT TIME
CBV/CBF
N/
PERFUSION CT

39. TREATMENT

40. FIRST GOAL:PREVENT/REVERSE BRAIN INJURY
AIRWAY
BREATHING
CIRCULATION
Tt HYPO/HYPER GLYCAEMIA
EMERGENCY NON CONTRAST CT
ISCHAEMIA

41. • MEDICAL SUPPORT
• IV THROMBOLYSIS
• ENDOVASCULAR REVASCULARISATION
• ANTI THROMBOTIC TREATMENT
• NEUROPROTECTION
• STROKE CENTRES AND REHABILITATION

42. OXYGEN SATURATION
RBS
STATIN
MEDICAL
DVT PROPHYLAXIS
 PHYSIOTHERAPY
 PNEUMATIC COMPRESSOR
 LMWH
PREVENTION OF INFECTIONS
 PNEUMONIA
 UTI
 SKIN

43. INDICATION FOR LOWERING BP
>220/110 >185/110
• MALIGNANT HTN
• CONCOMITANT MI
THROMBOLYTIC
THERAPY IS
ANTICIPATED
BP SHOULD BE MAINTAINED
GOAL:15% DURING FIRST 24 HOURS

44. FEVER
• ANTIPYRETICS
• SURFACE COOLING
SERUM GLUCOSE
<10 mmol/L (180mg/dL)

45. CEREBRAL OEDEMA
• WITHIN 3 DAYS
• LARGER THE INFARCT MORE THE OEDEMA
• WATER RESTRICTION
• IV MANNITOL
• AVOID HYPOVOLAEMIA
HEMICRANIOTOMY BASED ON DW MRI

46. CEREBELLAR INFARCTION
SPECIAL VIGILANCE
• MIMICS LABYRINTHITIS
• VERTIGO AND VOMITING
EMERGENCY SURGICAL DECOMPRESSION
SUB OCCIPITAL DECOMPRESSION
CEREBELLAR OEDEMA
DIRECTLY PRESS ON BRAIN STEM
COMA AND RESPIRATORY ARREST
^ICP BY OBSTRUCTING CSF
CEREBELLAR INFARCTION

47. THROMBOLYSIS
RECOMBINANT TISSUE PLASMINOGEN ACTIVATORS

48. TIME OF ONSET < 6 HOURS
BP
ISCHAEMIC SROKE
NCCT
>185/110
IV LABETALOL/NICARDIPINE
>140/90

49. rtPA
0.9mg/kg MAX.90mg
10% 90%
Bolus over 1 min. OVER 1 HOUR

50. 24 HOURS
CT
NO HAEMORRHAGE
ASPIRIN 325 mg DAILY ORALLY

52.  RECEIVING WARFARIN EVEN WITH NORMAL PT/INR
 HISTORY OF CNS DAMAGE
 HEMORRHAGIC RETINOPATHY
 SEVERE STROKE ASSESSED CLINICALLY OR BY IMAGING

53. ANTI THROMBOTIC TREATMENT
ANTI COAGULATION
NO BENEFIT
INCREASE RISK OF BRAIN AND
SYSTEMIC HAEMORRHAGE
ASPIRIN(BEST)
DIPYRIDAMOLE
CLOPIDOGREL
ANTI PLATELETS

54. ENDOVASCULAR
REVASCULARISATION
• INELIGIBLE FOR IV THROMBOLYSIS
• C/I TO THROMBOLYTICS
• FAILED TO ACHIEVE VASCULAR RECANALIZATION
WITH IV THROMBOLYSIS

55. MECHANICAL THROMBECTOMY

56. CAROTID ARTERY STENOSIS
 FREQUENT CAUSE OF EMBOLI TO BRAIN
 CAROTID DUPLEX USG
 BRUIT= ISCHAEMIATO BRAIN
 SYMPTOMATIC:ENARTERECTOMY>CAROTID ANGIOGRAPHY
ENTARTERECTOMY
 <50% BLOCK:NO ROLE
 50-70:DOUBTFULL
 >70:BEST
 100%:NO ROLE

57. NEUROPROTECTIVE AGENTS
HYPOTHERMIA
REDUCES ISCHAEMIC INJURY TO BRAIN
DRUGS THAT BLOCK THE EXCITATORY AMINO ACID PATHWAYS
CITICOLINE(STROCIT):PHOSPHATIDYLCHOLINE

58. STROKE CENTRES AND REHABILITATION
STROKE CENTRE
TEAMS: a/c MEDICAL MANAGEMENT AND CONSIDERATION OF
THROMBOLYSIS/ENDOVASCULAR Rx
PASSIVE FOLLOWED BY ACTIVE MOVEMENTS:PREVENT CONTRACTURE
EARLY MOBILIZATION AND ACTIVE REHABILITATION
ELEVATION OF HEAD END TO PREVENT ASPIRATION
OCCUPATIONAL THERAPY
SPEECH THERAPY
AVOID URINARY CATHETERS
REHABILITATION

62. THANK YOU..

63. REFERRENCE
HARRISON 20th EDITION
WASHINGTON MANUAL OF MEDICAL THERAPEUTICS 35th EDITION
CMDT 2019
NELSON PAEDIATRICS
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