Acute Ischemic Stroke - Etiopathogenesis, Clinical features, Advances in Management

1. CHAIR PERSON – DR. KALINGA.B.E
STUDENT – DR. MAMATARANI
MANAGEMENT OF ACUTE ISCHEMIC
STROKE

2. WHO DEFINITION OF STROKE
A NEUROLOGICAL DEFICIT OF
• Sudden onset
• With focal rather than global dysfunction
• In which, after adequate investigations, symptoms are
presumed to be of non-traumatic vascular origin and
• last for >24 hours

3. BLOOD SUPPLY OF BRAIN

6. TYPES OF STROKE
85%
Ischemic
15 %
Hemorrhagic

8. Principles of acute stroke care
(1) achieve timely recanalization of the occluded artery and
reperfusion of the ischemic tissue,
(2) optimize collateral flow, and
(3) avoid secondary brain injury.

10. Stroke Risk Factors Non-
modifiable
 AGE
 Gender - male
 Race – Blacks > Asians or Hispanics> Whites
 Family History.
 Coagulation Disorders
 Cardiac Disease

11. Stroke Risk Factors Modifiable
 Hypertension
 Diabetes mellitus
 Hypercholesterolemia
 Elevated LDL or Low HDL
 Elevated homocystein
 Smoking
• Alcohol Abuse
•OralContraceptive
• Pregnancy
•Obesity
•Sleep apnea
•Carotid stenosis

12. Stroke chain of survival
 Detection Recognition of stroke signs/symptoms
 Dispatch Call 119 and priority EMS dispatch
 Delivery Prompt transport and prehospital notification to Hospital
 Door Immediate ED triage
 Data ED evaluation, prompt laboratory studies, and
CT Imaging
 Decision Diagnosis and decision about appropriate therapy
 Drug Administration of appropriate drugs or other intervention

13. EMERGENCY EVALUATION OF ACUTE
ISCHEMIC STROKE
 Assess ABCs, vital signs
 Provide oxygen by nasal cannula wherever necessary
 Obtain IV access; obtain blood samples (CBC, ’lytes,
coagulation studies)
 Obtain 12-lead ECG, check rhythm, place on monitor
 Check blood sugar; treat if indicated

15. NIHSS

20. MEDICAL MANAGEMENT
 Supportive treatment
 IV thrombolysis
 Endovascular revascularization
 Anti thrombotic tretment
 Neuroprotection
 Stroke centers and Rehabilitation

21. SURGICAL MANAGEMENT
 Endovascular intervention
1.angioplasty and stenting
2. Mechanical clot disruption
3. clot extraction
• Carotid end artrectomy

22. MANAGEMENT OF COMPLICATION
 Cerebral edema
 Hemorrhagic transformation
 seizures

23. SUPPORTIVE TREATMENT
 Airway, Breathing and Circulation.
 Temperature
 Blood pressure
 Blood glucose

24. When to lower Blood pressure
 the hypertension is extreme (systolic blood pressure >220
mmHg or diastolic blood pressure >120 mmHg)
 Acute myocardial infarction
 Aortic dissection
 Hypertensive encephalopathy
 Acute renal failure

25. THROMBOLYSIS FOR AIS

27.  IV rtPA Dose - 0.9mg/kg to a 90mg maximun dose..
 Before IV rtPA ensure that blood pressure is not More
than 185/110 mmhg
 Door to needle time should be within 60min.

30. INTRAARTERIAL THROMBOLYSIS

31. MECHANICAL / ENDOVASCULAR
METHODS
 CRITERIA FOR MECHANICAL
THROMBECTOMY
1.prestroke mRS score of 0-1
2.occlusion of the internal carotid artery or MCA segment
1
3.age >18yr
4.NIHSS score> 6
5.ASPECT score of >6
6. treatment can be initiated (groin puncture) within 6
hours of sypmtom onset

35. ANTIPLATELETS.
 The oral administration of aspirin in AIS is
recommended within 24 -48 hrs of symptoms
onset.
 For those treated with IV alteplase, aspirin
administration is generally delayed until 24 hours
later

36. ROLE OF DUALANTIPLATELETS???

37. ANTICOAGULANTS

38. NEUROPROTECTION

39. CLINICAL SCENARIO
 A 70-year-old, right-handed man has been known to have previous
historyofpoorlycontrolledhypertension, diabetes,andcardiacarrhythmia.
Hedevelopedabrupt onsetofleft-sidedweaknessafterdinnerat7 pm
What should you do?

40. • Hebrought to a medicalcenterERbytheEMSat 8:30
pm
• OninitialERarrival,hisconsciousnesswasawake,
• blood pressure was 210/120 mmHg, pulse rate was
120/min irregularly, respiratory rate was 20/min, body
temperaturewas37°Candbloodsugarwas320mg/dL

41.  Neurologically,hehadflaccidhemiplegiaandright- sidedgazepreferencewithdenseleft-
sidedhemineglect. TheNIHSSscorewas17.HeadCTscanrevealed effacementofcortical
sulcalmarkingintherightmiddlecerebralarteryterritoryandhyperdenseMCAsign.
 What is your diagnosis of the
stroke ?
 What are the next you will do ?

42. POOR PREDICTORS OF
THROMBOLYIS
 Marked hyperglycemia
 CT >1/3 MCA
 Increasing stroke
severity
 Low platelet counts
•Higher NIHSS score
•Longer time to
recanalization
•Lower platelet counts
•Higher glucose level at
admission

43. SUMMARY
• CT within 20 minutes
• Door-to-needle time within 60 minutes .
• EVT, ECG, troponin should not delay IV t-PA.
• Only the assessment of blood glucose must precede the
initiation of IV t-PA
• Receive IV t-PA: BP <185/110 mmHg
• IV t-PAfor AIS < 3hr

44. SUMMARY
IV t-PA for AIS < 3 – 4.5
 Class I
 for pts ≤80 y
 without both DM and stroke ,
 NIHSS ≤25,
 not taking any OACs,
 <1/3 MCA territory by CT or MRI

45. SUMMARY
 Class IIa
 for pts >80 y
 Class IIb
 Taking OACs and INR ≤1.7 and/or PT <15 s
 with both DM and stroke history

46. SUMMARY
Endovascular Therapy
 Class I
 AIS < 6 hr
 AIS < 6-16 hr: DAWN or DEFUSE 3 criteria
 Class IIa
 AIS < 6-24 hr: DAWN criteria

47. REFERENSES
 Harrison’s principles of internal medicine 20th edition
 Adam’s and victors principles of neurology 10th edition
 2018 ACC/AHA guidelines for management of acute
ischemic stroke.

48. THANK YOU