1. Emergency Treatment of Stroke

2. Normal Brain Physiology 2-3% of body weight 15% of cardiac output 20% of all O2 25% of all glucose

3. Cerebral Ischaemia - Threshold Normal flow, normal function Synaptic transmission failure Membrane pump failure 20 50 10 0 Time in hours CBF (ml/100g brain) Low flow, raised O2 extraction, normal function 1 2 3 4 5

4. Cerebral auto regulation 60 160 Mean systemic BP

5. Falling cerebral perfusion Cerebral perfusion pressure Cerebral blood volume O 2 extraction fraction Cerebral blood flow Cerebral metabolic rate of O 2 Autoregulation, no symptoms Exhausted reserve Ischaemic symptoms

6. Cerebral infarct <3hrs Onset Infarct Ischaemic penumbra

7. Cerebral infarct 6hrs Infarct Ischaemic penumbra

8. Cerebral infarct 24hrs Infarct Ischaemic penumbra

9. NA, Dopamine Ca2+ i  Ischaemic Brain Injury Ischaemia - 02  glucose  Anoxic depolarisation  lactate Glutamate Hi  Free Fe2+ Free radicals Lipolysis NO synthase Proteolysis

10. Cerebral Arterial territory Anterior cerebral Middle cerebral Posterior cerebral Anterior choroidal

15. Stroke types Al 35-44 yr Infarct 80% 42% Athero-thrombo-embolism 50% Intracranial small vessel 25% Cardioembolic 20% Rare 5% PICH 10% 10% SAH 5% 38% Unknown 5% 10% 75%

20. Platelet aggregation Platelet aggregation Thrombus in lumen ADP platelet membrane receptor Clopidrogel Aspirin Thromboxane Dipyridamole Increase Cyclic AMP and GMP

27. Early sign CT - Infarction

28. MRA & MRI in Stroke

32. “ Patients who have improved neurologically but have a persistent neurologic deficit when seen, should be managed as a recent stroke ”

33. “ Role of Neuro-protection in Stroke is not clear and not recommended routinely ”

36. Thrombolytic Therapy of Acute Ischemic stroke

41. Thrombolysis in acute stroke Within 3 hour of Stroke Small Vessel Medium Vessel IV rTPA/URK Large Vessel IA rTPA/URK Stop

43. Route of Administration 21 6 15 URK 35 10 25 Total 5 2 3 rTPA 9 2 7 STK Total IA IV Drug

45. Age Sex Distribution 13 2 11 60-80 35 7 28 Total 17 5 12 40-59 5 - 5 20-39 Total Female Male Age

46. Arterial Territory and Severity 35 17 18 Total 9 7 2 PCA 26 10 16 ACA Total Unconscious Conscious Artery

47. Outcome and Agent used 35 5 21 9 Total 9 2 4 3 Death 7 1 4 2 Dependent 19 2 13 4 Independent Total rTPA URK STK Recovery

48. Outcome and Arterial Territory Unc Con Unc Con 35 7 2 10 16 Total 9 2 - 6 1 Death 7 1 - 3 3 Dep 19 4 2 1 12 Ind Total PCA ACA Recovery

49. Outcome and Timing of Treatment 35 21 5 9 Total 9 6 - 3 Death 7 6 1 - Dep 19 9 4 6 Ind Total 3-6h 1-3h <1h Outcome

50. Outcome and CT scan 32 6 26 Total 9 3 6 Death 7 2 5 Dependent 16 1 15 Independent Total Early Normal Outcome

51. Complication of therapy 8 2 5 2 Toxic edema 1 - 1 - IC bleed 1 - 1 - IC spasm 1 - - 1 Hem trans 1 - 1 - Urinary bleed 3 - 1 2 Gastric bleed 2 1 1 - Gum bleed 2 1 1 - Anaphylaxis 2 1 1 - Bronchospasm 1 - 1 - Skin Rash Total rTPA URK STK Complication

52. Left Coronary angiogram showing severe atherosclerosis

53. Right middle cerebral artery block following coronary angiogram

54. Right middle cerebral artery reperfusion (AP) following IA Urokinase

57. Dec 31 st 1999 Jan 21 st 2000 Feb 11 th 2000 Emergency Carotid Endarterectomy DOA 5 th Feb 00

58. Thank You