MANAGEMENT OF STROKE

1. MANAGEMENT OF STROKE
ILA SINGH
MBBS 2014 BATCH

2. 60yrs old male patient k/c/o systemic HT had missed
dose of antihypertensive since last 7 days presented in
casualty with sudden onset loss of consciousness 3 hrs
back.
O/e- patient stupors
BP-160/100
Responds to deep painful stimuli by moving left upper
limb and lower limb
Spasticity right UL & LL
DTR +++on RT UL & LL
Planter RT. ↑
What is your diagnosis ?
& How will you manage ?

3. Diagnosis- STROKE.
Investigations
Diagnostic question Investigation
Is it a vascular lesion ? CT/MRI
Is it ischaemic or haemorrhage? CT/MRI
Is there any cardiac source of embolism? ECG, Echocardiogram
What is the underlying vascular disease? Duplex ultrasound , MRA, CT angiography
What are the risk factors ? Full blood count, Cholesterol, Blood
glucose
Is there an unusual cause ? ESR, Serum protein electrophoresis,
Clotting/ Thrombophilia screen

4. Management
1. General measures
• Airway- maintain adequate airway with periodic clearance of
secretion and keep patient nil by mouth if swallowing unsafe
or aspiration occurs.
• Breathing- administer oxygen if oxygen saturation <95%.
• Circulation- check peripheral perfusion, pulse and BP and
treat abnormalities with fluid replacement , anti-arrhythmics
and inotropic drugs as appropriate.
• Hydration- if signs of dehydration, give fluids parenterally or
by nasogastric tube.
• Nutrition-assess nutritional status and provide nutritional
supplements if necessary. If dysphagia persists for >48hrs ,
start feeding via nasogastric tube.

5. • Blood pressure- unless there is heart or renal failure ,
evidence of hypertensive encephalopathy or aortic dissection
, do not lower BP in 1st week as it may reduce cerebral
perfusion.
• Blood glucose- check blood glucose, treat hypoglycemia with
50% dextrose, treat hyperglycemia by insulin infusion or
glucose/potassium/insulin(GKI).
• Temperature- investigate and control with antipyretics, as
raised brain temperature may increase infarct volume.
• Pressure areas- turn immobile patients regularly to prevent
bed sore.
• Incontinence- bladder catheterisation if incontinence or
retention has occurred.
• Mobilisation – passive movements of limbs to prevent
contractures, edema of the limbs, venous stasis and
pulmonary embolism.

6. 2. Specific measures
• Thrombolysis- i.v recombinant tissue plasminogen
activator (rTPA) has been shown to be beneficial when
initiated within the first 3-4.5 hrs. However, it increases the
risk of haemorrhagic transformation of the cerebral infarct
with potentially fatal results.
Indication-
i. Clinical diagnosis of stroke
ii. Onset of symptoms to time of drug administration <4.5 hrs
iii. CT scan showing no hemorrhage or edema of >1/3 of the
MCA territory
iv. Age ≥ 18 yrs
v. Consent by patient or surrogate

7. Contraindication
i. Sustained BP>185/110mmHg despite treatment
ii. Platelets<100,000, HCT<25%, glucose <50 or >400mg/dl
iii. Use of heparin within 48h & prolonged PTT or elevated INR
iv. Rapidly improving symptoms
v. Prior stroke or head injury within 3mo , prior intracranial
hemorrhage
vi. Major surgery in preceding 14 days
vii. Minor stroke symptoms
viii. GI bleeding in preceding 21 days
ix. Recent myocardial infarction
x. Coma or stupor
Administration- administer 0.9mg/kg IV (max 90mg)IV as
10% of total dose by bolus followed by remainder of total dose
over 1hr. No other antithrombotic t/t for 24hr.

8. • Platelet inhibition- In the absence of C/I , Aspirin
(300mg daily) should be started immediately after an
ischaemic stroke unless rTPA has been given , in which case it
should be withheld for at least 24h. Aspirin reduces risk of
early recurrence and has a small but clinically worthwile
effect on long term outcome.
• Anticoagulation- role of heparin in acute stage is
controversial and at present not recommended.
• Carotid endarterectomy & angioplasty- if a
carotid territory ischaemic stroke or TIA is diagnosed, such
patients have greater than average risk of stroke recurrence .
For those without major residual disability , removal of
stenosis has been shown to reduce the overall risk of
recurrence. Surgery is most effective in pts with more severe
stenosis(70-99%)and in those it is performed within first
couple of wks after stroke or TIA. Carotid angioplasty and
stenting are not as effective as endarterectomy.

9. Secondary prevention

10. THANK YOU