1. Regional stroke centers should be established to provide thrombolysis and transport to endovascular treatment centers. Every hospital should have a stroke team and protocols for emergency evaluation.
2. Patients should receive IV alteplase as quickly as possible if eligible. Mechanical thrombectomy is recommended for large vessel occlusions within 6-24 hours of onset depending on criteria.
3. In-hospital prevention includes antiplatelet therapy, vascular imaging, and lipid management with statins to reduce cardiovascular risk.
This document discusses encephalitis, which is inflammation of the brain caused by viral infection. It notes that herpes simplex virus is a common cause. There are two main types: primary encephalitis results from direct viral infection of the brain, while secondary encephalitis results from an immune system response to infection elsewhere in the body. Symptoms can range from mild headaches and sensitivity to light to confusion, slower movements, hallucinations, and coma. Diagnosis involves tests such as PCR, virus culture, and ELISA to detect viral antigens in the brain or antibodies in the blood. Treatment options for herpes simplex encephalitis include antiviral drugs like aciclovir.
This document provides an overview of coma, including its anatomical and physiological bases, definition, causes, evaluation, and management. Coma requires dysfunction of the pontine reticular activating system and/or bilateral cerebral hemispheres. Common causes include drug overdose, metabolic derangements, head trauma, anoxia, and stroke. Evaluation involves assessing ABCs, looking for signs of increased intracranial pressure, and performing tests to identify potential causes. Management priorities are supporting ABCs, treating potentially reversible causes like hypoglycemia, and controlling intracranial pressure if elevated.
1. Regional stroke centers should be established to provide thrombolysis and transport to endovascular treatment centers. Every hospital should have a stroke team and protocols for emergency evaluation.
2. Patients should receive IV alteplase as quickly as possible if eligible. Mechanical thrombectomy is recommended for large vessel occlusions within 6-24 hours of onset depending on criteria.
3. In-hospital prevention includes antiplatelet therapy, vascular imaging, and lipid management with statins to reduce cardiovascular risk.
This document discusses encephalitis, which is inflammation of the brain caused by viral infection. It notes that herpes simplex virus is a common cause. There are two main types: primary encephalitis results from direct viral infection of the brain, while secondary encephalitis results from an immune system response to infection elsewhere in the body. Symptoms can range from mild headaches and sensitivity to light to confusion, slower movements, hallucinations, and coma. Diagnosis involves tests such as PCR, virus culture, and ELISA to detect viral antigens in the brain or antibodies in the blood. Treatment options for herpes simplex encephalitis include antiviral drugs like aciclovir.
This document provides an overview of coma, including its anatomical and physiological bases, definition, causes, evaluation, and management. Coma requires dysfunction of the pontine reticular activating system and/or bilateral cerebral hemispheres. Common causes include drug overdose, metabolic derangements, head trauma, anoxia, and stroke. Evaluation involves assessing ABCs, looking for signs of increased intracranial pressure, and performing tests to identify potential causes. Management priorities are supporting ABCs, treating potentially reversible causes like hypoglycemia, and controlling intracranial pressure if elevated.
This document provides information on consciousness and coma:
- Consciousness has two components - arousal from the reticular activating system and awareness from the cerebral cortex. Stimulation of the RAS produces arousal while its destruction causes coma.
- The Glasgow Coma Scale and newer scales like FOUR are used to evaluate patients in comatose or reduced states of consciousness. The FOUR scale assesses eye, motor, brainstem, and respiratory responses.
- Causes of coma can be structural/focal brain injuries or non-structural/diffuse issues like hypoxia, infections, or toxic exposures. An approach is outlined to initially stabilize an unconscious patient and guide further examination and investigations.
Stich ii trial for supratentorial intra cerebral bleedgarry07
This document summarizes the STICH II trial which compared early surgery versus initial conservative treatment for spontaneous supratentorial lobar intracerebral haemorrhages between 10-100mL. The trial involved 601 patients randomized to either early surgery within 12 hours or initial conservative treatment with delayed surgery if needed. The primary outcome of death or severe disability at 6 months showed no significant difference between the groups. Secondary outcomes of mortality, functional scales also showed no significant differences, indicating that early surgery did not improve outcomes over initial conservative treatment for these types of hemorrhages.
2018 AHA ASA guideline - guidelines for the early management of patients with...Vinh Pham Nguyen
The document provides guidelines for the early management of acute ischemic stroke, covering prehospital stroke management and systems of care, emergency evaluation and treatment, and in-hospital supportive care. It recommends public education on stroke signs and calling 911, designating stroke centers and teams, and using telemedicine to expand access to stroke expertise. The goal is to optimize early management through improved systems and rapid treatment to increase utilization of therapies like IV alteplase and endovascular procedures.
This document summarizes the management of acute ischemic stroke patients. It discusses the types of strokes, prehospital identification and scales used to identify strokes, the evaluation process in the emergency department, differential diagnosis, and management strategies. The key points are:
1) Prehospital scales like the Los Angeles Prehospital Stroke Screen and Cincinnati Prehospital Stroke Scale are used by EMS to rapidly identify acute strokes.
2) In the emergency department, patients receive an evaluation including vital signs, glucose testing, neurological exam using the NIH Stroke Scale, and non-contrast head CT to identify the type and location of stroke.
3) Differential diagnosis for acute neurological symptoms includes conditions like seizures, intrac
This document discusses encephalopathy and summarizes key points about its causes, features on EEG, and types. Encephalopathy is defined as altered brain function resulting in impaired consciousness. It can be caused by metabolic, toxic, infectious, hepatic or other issues. On EEG, encephalopathy typically shows generalized slowing and reduced reactivity. Specific patterns like triphasic waves indicate metabolic encephalopathy. The document outlines different types of encephalopathy and their associated EEG findings to help evaluate severity and guide treatment.
Anesthesiology And Intraoperative Neurophysiological Monitoring Anurag Tewari MD
Anesthesiologists play a central role in optimizing IONM.
Intraoperative neuromonitoring (IONM) offers a near-real-time assessment of the functional integrity of the neuronal pathways during surgery. Evoked Potential signals may thus be regarded as surrogate markers of neuronal function and can be thought of as a repeated but limited neurological examination under general anesthesia. Optimization of anesthetic management contributes to the successful integration of IONM into perioperative care
The document is a presentation on the Yale Insulin Infusion Protocol, which is used to manage blood glucose levels in hospitalized patients receiving intravenous insulin therapy. It discusses the characteristics of an ideal insulin infusion protocol, outlines the steps of the Yale Protocol including initiating insulin infusion rates and adjusting rates based on blood glucose monitoring, and provides examples of applying the protocol. It also shows that using the Yale Protocol results in better glucose control and fewer episodes of hypoglycemia compared to historical controls.
This document provides information on consciousness and coma:
- Consciousness has two components - arousal from the reticular activating system and awareness from the cerebral cortex. Stimulation of the RAS produces arousal while its destruction causes coma.
- The Glasgow Coma Scale and newer scales like FOUR are used to evaluate patients in comatose or reduced states of consciousness. The FOUR scale assesses eye, motor, brainstem, and respiratory responses.
- Causes of coma can be structural/focal brain injuries or non-structural/diffuse issues like hypoxia, infections, or toxic exposures. An approach is outlined to initially stabilize an unconscious patient and guide further examination and investigations.
Stich ii trial for supratentorial intra cerebral bleedgarry07
This document summarizes the STICH II trial which compared early surgery versus initial conservative treatment for spontaneous supratentorial lobar intracerebral haemorrhages between 10-100mL. The trial involved 601 patients randomized to either early surgery within 12 hours or initial conservative treatment with delayed surgery if needed. The primary outcome of death or severe disability at 6 months showed no significant difference between the groups. Secondary outcomes of mortality, functional scales also showed no significant differences, indicating that early surgery did not improve outcomes over initial conservative treatment for these types of hemorrhages.
2018 AHA ASA guideline - guidelines for the early management of patients with...Vinh Pham Nguyen
The document provides guidelines for the early management of acute ischemic stroke, covering prehospital stroke management and systems of care, emergency evaluation and treatment, and in-hospital supportive care. It recommends public education on stroke signs and calling 911, designating stroke centers and teams, and using telemedicine to expand access to stroke expertise. The goal is to optimize early management through improved systems and rapid treatment to increase utilization of therapies like IV alteplase and endovascular procedures.
This document summarizes the management of acute ischemic stroke patients. It discusses the types of strokes, prehospital identification and scales used to identify strokes, the evaluation process in the emergency department, differential diagnosis, and management strategies. The key points are:
1) Prehospital scales like the Los Angeles Prehospital Stroke Screen and Cincinnati Prehospital Stroke Scale are used by EMS to rapidly identify acute strokes.
2) In the emergency department, patients receive an evaluation including vital signs, glucose testing, neurological exam using the NIH Stroke Scale, and non-contrast head CT to identify the type and location of stroke.
3) Differential diagnosis for acute neurological symptoms includes conditions like seizures, intrac
This document discusses encephalopathy and summarizes key points about its causes, features on EEG, and types. Encephalopathy is defined as altered brain function resulting in impaired consciousness. It can be caused by metabolic, toxic, infectious, hepatic or other issues. On EEG, encephalopathy typically shows generalized slowing and reduced reactivity. Specific patterns like triphasic waves indicate metabolic encephalopathy. The document outlines different types of encephalopathy and their associated EEG findings to help evaluate severity and guide treatment.
Anesthesiology And Intraoperative Neurophysiological Monitoring Anurag Tewari MD
Anesthesiologists play a central role in optimizing IONM.
Intraoperative neuromonitoring (IONM) offers a near-real-time assessment of the functional integrity of the neuronal pathways during surgery. Evoked Potential signals may thus be regarded as surrogate markers of neuronal function and can be thought of as a repeated but limited neurological examination under general anesthesia. Optimization of anesthetic management contributes to the successful integration of IONM into perioperative care
The document is a presentation on the Yale Insulin Infusion Protocol, which is used to manage blood glucose levels in hospitalized patients receiving intravenous insulin therapy. It discusses the characteristics of an ideal insulin infusion protocol, outlines the steps of the Yale Protocol including initiating insulin infusion rates and adjusting rates based on blood glucose monitoring, and provides examples of applying the protocol. It also shows that using the Yale Protocol results in better glucose control and fewer episodes of hypoglycemia compared to historical controls.
4. Hakan AY. Curr Neurol Neurosci Rep. 2010;10:14–20;
Andersen KK, et al. Stroke 2009;40:2068–2072
Lancet Neurol . 2014 Apr;13(4):429-38.
National Institutes of Health. National Heart Lung and Blood Institute. Stroke types. October 2015;
Stroke
Hemorrhagic
(<20% of all strokes)
Intracerebral
Ischemic
(>80% of all strokes)
Subarachnoid
Cardio-
embolic
Small
vessel
Specific
cause
Crypto-
genic
Large
artery
5. Stroke Subtype in Taiwan
Taiwan Stroke Registration
Ischemic stroke (81%)Hemorrhagic stroke
(19%)
Atherothrombotic
disease (28%)
Cardiac Embolism (11%)
Lacunar small vessel
disease (38%)
Cryptogenic (22%)
Intracerebral
hemorrhage (16.2%)
SAH (2.8%)
Specific causes(1.5%)Hsieh, F. I., & Chiou, H. Y. (2014) J Stroke, 16(2),
59-64. doi:10.5853/jos.2014.16.2.59
5
7. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
7
19. Lees et al. Lancet 2010;375:1695-1703.
5
60 120 150 210 240 300 330
0
1
2
3
4
Odds ratio (OR)
Oddsratioand95%CI
OR
2.55
OR
1.64
OR
1.34
270 36018090
NNT, Number needed to treat
OTT, Time from stroke onset to start of treatment
mRS, modified Rankin Scale
OTT (min)
NNT
4-5
NNT
9
NNT
14
23. MRI-Guided Thrombolysis for Stroke with Unknown
Time of Onset (WAKE-UP study):
◦ 時間窗: 睡醒時發現中風、不知道或無法告知中風時間,
從最近仍呈現正常時間點起算到評估時間差 >4.5 小時
◦ Advanced neuroimage:
MRI: diffusion-weighted image(DWI) and FLAIR mismatch
◦ Result:
Good outcome (mRS 0-1, 90 days): 53.3% vs 41.8% (OR 1.61)
Symptomatic ICH: 2% vs 0.4% (p 0.15)
Mortality: 4.1% vs 1.2% (p 0.07)
24
24. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
25
34. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
35
37. 中風後多久可進行EVT ?
MR CLEAN ESCAPE EXTEND-IA
SWIFT
PRIME
REVASCAT
Population AIS with LVO AIS with LVO AIS with LVO AIS with LVO AIS with LVO
Design
Standard vs
S+EV
Standard vs
S+EV
IV tPA vs
IVtPA+Solitare
IV tPA vs
IVtPA+Solitare
Standard vs
S+Solitare
NIHSS >2 ≧6 No limits 8-29 ≧6
ASPECT score No ≧6 No ≧6 ≧6, ≧7, ≧8
Ischemic
core, ml
<70
Penumbra V V
Collateral cir. >50% MCA
Time (hr.) 6
12
(84% <6 h)
6 6
8
(90% <6h) 38
38. 中風臨床嚴重度(NIHSS分數)
MR CLEAN ESCAPE EXTEND-IA
SWIFT
PRIME
REVASCAT
Population AIS with LVO AIS with LVO AIS with LVO AIS with LVO AIS with LVO
Design
Standard vs
S+EV
Standard vs
S+EV
IV tPA vs
IVtPA+Solitare
IV tPA vs
IVtPA+Solitare
Standard vs
S+Solitare
NIHSS >2 ≧6 No limits 8-29 ≧6
ASPECT score No ≧6 No ≧6 ≧6, ≧7, ≧8
Ischemic
core, ml
<70
Penumbra V V
Collateral cir. >50% MCA
Time (hr.) 6
12
(84% <6 h)
6 6
8
(90% <6h) 39
39. 中風後,Infarction core
MR CLEAN ESCAPE EXTEND-IA
SWIFT
PRIME
REVASCAT
Population AIS with LVO AIS with LVO AIS with LVO AIS with LVO AIS with LVO
Design
Standard vs
S+EV
Standard vs
S+EV
IV tPA vs
IVtPA+Solitare
IV tPA vs
IVtPA+Solitare
Standard vs
S+Solitare
NIHSS >2 ≧6 No limits 8-29 ≧6
ASPECT score No ≧6 No ≧6 ≧6, ≧7, ≧8
Ischemic
core, ml
<70
Penumbra V V
Collateral cir. >50% MCA
Time (hr.) 6
12
(84% <6 h)
6 6
8
(90% <6h) 40
42. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
43
43. AHA/ASA 2018 Guideline建議 (Class I, Level A)
◦ (1) Causative occlusion of ICA or MCA segment 1
(M1)
◦ (2) Prestroke mRS score:0-1
◦ (3) Age ≥18 years
◦ (4) Treatment within 6 hours of symptom onset.
(groin puncture)
◦ (5) NIHSS score ≥6
◦ (6) (Brain CT) ASPECTS ≥6
44
47. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
48
59. Airway, Breathing and Oxygenation
Airway support and ventilatory assistance are recommended
for the treatment of patients with acute stroke who have
decreased consciousness or who have bulbar dysfunction
that causes compromise of the airway. (class I, level C-EO)
Supplemental oxygen is not recommended in nonhypoxic
patients with AIS. (class III: no benefit, level B-R)
Supplemental oxygen should be provided to maintain oxygen
saturation >94%. (class I, level C-LD)
60
62. Blood sugar(血糖)
Hypoglycermia:
• Hypoglycemia (blood glucose <60 mg/dL) should be treated in
patients with AIS. (class I, level C-LD)
Hyperglycerima:
• 40-70%急性中風患者會出現血糖上升的情況(>110mg/dl),此
現象可能是糖尿病(已知或先前未被診斷)或是急性中風之壓
力所引起。
• 不論先前是否有糖尿病,急性期血糖的上升可能導致較差的
預後,增加中風後的死亡率,且 對於日後的功能恢復也較差。
64
63. Blood sugar(血糖)
Hyperglycerima:
• 2014年Cochrane整合分析研究發現無法證明以靜脈注射胰島
素嚴格控制血糖可帶來較好的預後,反而有較高風險出現低
血糖事件。
• It is reasonable to treat hyperglycemia to achieve blood glucose
levels in a range of 140 to 180 mg/dL and to closely monitor to
prevent hypoglycemia. (class IIa, Level C-LD)
Cochrane Database Syst Rev. 2014 Jan 23
• 2019 SHINE study: Intense iv glucose control does
not improve functional stroke outcomes.
• 80-130mg/dl(intensive) vs 80-179mg/dl(standard)
• Good outcome: 20.5% vs 21.6%
• Severe Hypoglycermia: 15 vs 0
65
66. 結論及建議:
◦ Ticagrelor is not recommended (over aspirin) in the
acute ischemic stroke. (Class III, no benefit)
SOCRATES trial(2016):
Ticagrelor vs Aspirin within 24 hr after minor stroke(NIHSS <4) or TIA
Primary endpoint (Recurrent stroke, MI, Death to 90 days):
HR, 0.89; 95% CI, 0.78–1.01; P=0.07
◦ IV IIb/IIIa inhibitor:
Tirofiban and Eptifibatide: not well established (Class IIb,
Level B)
Abciximab: harm (Class III)
68
N Engl J Med. 2016 Oct 6;375(14):1395.
Mono antiplatelet therapy
72. Ticagrelor + Aspirin vs Aspirin (n.11016)
RCT study involving patients with NIHSS
<=5 or TIA (ABCD2=6) who were not
undergoing tPA or EVT
Onset <24 hours recruitment
A composite of stroke or death within 30 d
Ticagrelor+Apirin vs Aspirin (5.5 vs 6.6%)
Severe bleeding (0.5 vs 0.1%)
74
THALES
HR 0.83
HR 3.99
76. Lancet Neurol . 2014 Apr;13(4):429-38.;
- 1/4 patients with ischemic stroke have no probable cause found after
standard workup.
- Most cryptogenic ischemic strokes are embolic in origin, arising from
proximal arterial sources, the heart, or venous sources (with right-to-left
shunts).
N Engl J Med 2016 May 26;374(21):2065-74.Covert Atrial Fibrillation
77. N Engl J Med 2014;370:2467e77.
Detection: 16.1% vs. 3.2% 6 mon. Detection: 8.9% vs. 1.4%
N Engl J Med 2014;370:2478e86.
78. 結論及建議:
◦ Urgent anticoagulation, with the goal of preventing
early recurrent stroke, halting neurological worsening,
or improving outcomes after AIS, is not recommended。
(Class III: no benefit, Level A)
80Stroke. 2013; 44: 870-947
1. No evidence that early anticoagulation
reduced the odds of dead or dependent.
(OR 0.99; 95% CI 0.93 to 1.04)
2. Although early anticoagulant therapy was
associated with fewer recurrent ischaemic
strokes (OR 0.76; 95% CI 0.65 to 0.88),
it was also associated with an increase in
symptomatic intracranial haemorrhages
(OR 2.55; 95% CI 1.95 to 3.33).
2015
79. 結論及建議:
◦ Dabigatran, argatroban or other thrombin inhibitors for the
treatment of patients with AIS is not well established。
(Class IIb, Level B-R)
◦ Factor Xa inhibitors in the treatment of AIS are not well
established. (Class IIb, Level B-R)
81Stroke. 2013; 44: 870-947
80. 結論及建議:
◦ For most patients with AIS and atrial fibrillation, it is
reasonable to initiate oral anticoagulation within 4 to 14
days after the onset of neurological symptoms.
(Class IIb, Level B-R)
82Stroke. 2013; 44: 870-947
81. From: Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K
antagonist anticoagulants in patients with non-valvular atrial fibrillation: Executive summary
Flowchart for the initiation or re-initiation of anticoagulation after transient ischaemic attack (TIA)/stroke or intracerebral
haemorrhage. Europace 2015;17:1467-507.
83