This document discusses the management of acute ischemic stroke. It begins by outlining the magnitude of stroke as a problem in India and defines what constitutes a stroke. It then discusses the concepts of penumbra and the importance of short door-to-needle times for thrombolysis. The standard of care for acute ischemic stroke involves rapid evaluation, neuroimaging, ruling out contraindications to thrombolysis, and administration of IV alteplase within 4.5 hours of symptom onset. Barriers to effective stroke treatment in India include delays in recognition of symptoms, reaching care, and administering thrombolysis. Public education on stroke signs and rapid evaluation and treatment are needed to improve outcomes.

1. Dr Mohit Janakkumar Shah
M.D., D.M.(Neurology)
Consultant Neurologist
BARODA NEURO, VADODARA
PARUL SEVASHRAM HOSPITAL

2. Management of Acute Ischaemic
Stroke.

3. Stroke victim

4. REPERFUSION IN ISCHEMIC STROKE
STANDARD OF CARE

5. • STROKE
• Magnitude of problem
• Penumbra
• Window period
• Door to needle times
• Road blocks
• Stroke unit

6. What is Stroke?
• An abrupt onset of a neurological deficit that
is attributable to a focal vascular cause.

7. Actilyse® • Emergency Physician Slide Kit
Where are we now ?
• The stroke epidemic has arrived in India.
• While we were busy combating the scourge of
infections and deficiency diseases, non-communicable
diseases (NCDs) including stroke stealthily crept up on
us.

8. • Most common life-threatening neurologic disease
• Third most common cause of death globally
• Prevalence 500/ 1,00,000 per year
• Incidence 180/ 1,00,000 per year
• Incidence in India: 73/ 1,00,000 per year
• Burden likely to ↑ aging, smoking, dietary patterns
Stroke 1998;29:1730-36; Neurol India 2002;50:279-81
Epidemic

10. Stroke awareness in India
• Far from satisfactory.
• 1/4th of the urban and 1/3rd of rural
respondents who were unaffected had no
knowledge of any warning symptom of stroke.
• There is an urgent need for stepping up
awareness drive in our country.

11. Actilyse® • Emergency Physician Slide Kit
The "Five Sudden, Severe Symptoms" of stroke include
• Sudden numbness or weakness of the face,
arm, or leg on one side of the body.
• Sudden confusion, difficulty talking or
understanding.
• Sudden trouble seeing on one side.
• Sudden, severe difficulty walking, dizziness,
loss of coordination or balance.
• Sudden, severe headache for no known
reason.

12. Actilyse® • Emergency Physician Slide Kit
How to detect?
F.A.S.T

14. Call

15. Code Stroke
• Initial evaluation
• Stroke team intimation (activation)
• Urgent Neuro-imaging
• Interpretation of Neuro-imaging
• Ruling out C/I of thrombolysis
• Drug/Intervention

16. Initial evaluation
• In ER/ICU
• Symptoms criteria: FAST (BEFAST)
• Time criteria present
Activation of CODE STROKE

17. • Secure 2 large bore venous access
• Labs: BSL, CBC, Blood urea, creatinine, electrolytes, PT (INR),
aPTT
• 12 lead ECG (should not hold patient from going to CT scan)
• Neurological assessment and NIHSS assessment and
documentation
To be completed within 10 minutes of arrival
to hospital
Initial evaluation

18. Activation of code stroke
Urgent
Phone call (and whattsapp group message)
Neurologist, Radiologist,
Intensivist
Intimate radiology technician for neuroimaging
Intimate lab processing samples
Intimate pharmacy for actilyse
Stroke team to arrive within
15 minutes of arrival of patient

20. Code Stroke
• Initial evaluation
• Stroke team intimation (activation)
• Urgent Neuro-imaging
• Interpretation of Neuro-imaging
• Ruling out C/I of thrombolysis
• Drug/Intervention

23. Dense MCA Sign

24. Sulcal effacement

26. MRI Acute Stroke

27. PENUMBRA

28. Potential to Reverse Neurologic Impairment With Thrombolytic
Reperfusion when done in time
Saver. Stroke 2006;37:263-266.
González. Am J Neuroradiol 2006;27:728-735.
Donnan. Lancet Neurol 2002;1:417-425.
An untreated patient loses
approximately 1.9 million
neurons every minute in the
ischaemic area
Reperfusion offers the
potential to reduce the
extent of ischaemic injury
Ischaemic core
(brain tissue
destined to die)
Penumbra
(salvageable
brain area)

30. “Time is brain”
Saver. Stroke 2006;37:263-266.
Neurons Lost Synapses Lost Myelinated Fibres Lost Accelerated Aging
Per Stroke 1.2 billion 8.3 trillion 7140 km 36 y
Per Hour 120 million 830 billion 714 km 3.6 y
Per Minute 1.9 million 14 billion 12 km 3.1 wk
Per Second 32,000 230 million 200 m 8.7 h
Minutes Hours Days
Inflammation
Peri-infarct
depolarisations
Excitotoxicity
Impact
Apoptosis
Time

31. CT scan performed on the day after thrombolysis
showing no hemorrhagic change and no enlargement
of the ischemic area

32. Code Stroke
• Initial evaluation
• Stroke team intimation (activation)
• Urgent Neuro-imaging
• Interpretation of Neuro-imaging
• Ruling out C/I of thrombolysis
• Drug/Intervention

33. IV rt PA
• The only approved therapy for better clinical
outcome in stroke has its effects strongly
dependant on time
• Principle behind the time dependency of
thrombolysis is that of penumbrA.

34. IV Alteplase
• Improves functional outcome in 3-6 months
• More patients are sent home independent
• Near complete recovery- 38% Vs 21%
• 3 month mortality- Same for both groups
• Symptomatic ICH- 6.8% Vs 1.3%
• Fatal bleed- 2.7% Vs 0.4%
• Severe systemic bleed < 1%

35. rtPA for Acute Ischemic Stroke
Indication
• Clinical diagnosis of stroke
• Onset of symptoms to time of drug
administration ≤4.5 h
• CT scan showing no hemorrhage
• Age ≥ 18 years
• Consent by patient or surrogate

36. Contraindication
• Sustained BP >185/110 mmHg despite
treatment
• Glucose <50 or >400 mg/dL
• Use of heparin within 48 h and prolonged
PTT, or elevated INR>1.7
• Rapidly improving symptoms

37. Cont..
• Prior stroke or head injury within 3 months;
prior intracranial hemorrhage
• Major surgery in preceding 14 days
• Minor stroke symptoms
• Gastrointestinal bleeding in preceding 21 days
• Recent myocardial infarction
• Coma or stupor

38. Administration of rtPA
• Administer 0.9 mg/kg IV (maximum 90 mg) IV
as 10% of total dose by bolus, followed by
remainder of total dose over 1 h
• Frequent cuff blood pressure monitoring
• No other antithrombotic treatment for 24 h
• For decline in neurologic status or
uncontrolled blood pressure, stop infusion,
give cryoprecipitate, and reimage brain
emergently

39. Door To Needle Time

40. NIH-recommended Emergency Department Response
Times
NINDS NIH website. Stroke proceedings. Latest update 2008.
DTN ≤60 min: the “golden hour” for evaluating and treating acute stroke
T=0
Suspected
stroke patient
arrives at
stroke unit
≤10 min
Initial MD evaluation
(including patient
history, lab work
initiation, & NIHSS)
≤ 15 min
Stroke team
notified
(including
neurologic
expertise)
≤ 25 min
CT scan
initiated
≤ 45 min
CT & labs
interpreted
≤ 60 min
rt-PA
given if patient
is eligible
IDEALLY performed
prehospital

41. Thrombolysis: Number of Patients Needed to
Treat (NNT) to Achieve Excellent Recovery (mRS 0-1)
Lees et al. Lancet 2010;375:1695-1703.
3 - 4.5 h NNT=14
90 min - 3 h NNT=9
mRS, modified Rankin Scale
≤ 90 mins NNT=4 to 5

42. Barriers to stroke treatment - India
42
Reach
24 x 7 Diagnostic services
Confident Stroke physician
Fight vs . Time

43. Why Under-used?
Failure
to recognise
stroke symptoms
and act
appropriately
Prolonged
delays from
symptom onset
to FMC to treatment
Poor infrastructure
for on-going
monitoring and
evaluation of
patients post
rt-PA4
Inability to manage
potential post rt-PA
complications
(neurosurgery,
neuro-intensive
care)

44. Hospitalization and transportation
• Poor recognition of early stroke symptoms
• low perception of threat
• Only 1/4th arrive within 6 h.
• In a major urban centre, the median time to
casualty arrival was 7.66 h.
• A rural-based study, it was 34 ± 6 h.

45. Stroke Chain of Survival
• Recognition of stroke signs and symptoms
Detection
• Call Emergency Medical Services and dispatch
Dispatch
• Prompt transport and pre-hospital notification to hospital
Delivery
• Immediate ED triage
Door
• ED evaluation, prompt laboratory studies, and CT imaging
Data
• Diagnosis and decision about appropriate therapy
Decision
• Administration of appropriate drugs or other interventions
Drug
Disposition • Timely admission to stroke unit, intensive care unit, or transfer

46. Take Home Message
Remember: ACT Fast  Time is brain!
 Early recognition of stroke symptoms, by public, attendants, ambulance
service providers, and paramedics.
 Public education of 5 “Sudden”.
 Prioritisation and direct transfer to specialised stroke centres
or stroke units
 Management by multidisciplinary teams
 Act fast to initiate treatment with thrombolysis as early as possible
 Earlier the action, better the result.

47. THANK YOU