Neuro clinics 21- stroke case discussion

Neuro-clinics 21 Dr Pratyush Chaudhuri Supported by Nirmal clinics & Mankind Pharmaceuticals

CASE DISCUSSION Acute Ischemic Stroke Intra-cerebral hemorrhage Dr Pratyush Chaudhuri

Case 1 ,[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object]

Stroke - clinical term ,[object Object],[object Object],[object Object],[object Object]

focal neurologic deficits sudden onset ,[object Object],[object Object],[object Object]

recognition of stroke ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Common signs of stroke ,[object Object],[object Object],[object Object],[object Object],[object Object]

Differential diagnosis ,[object Object]

Why is time important? ,[object Object],[object Object]

Emergency dept protocol for presumed stroke ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

early infarction signs on CT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],60% CT’s normal 31 % misinterpreted

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Loss of gray-white differentiation in the posterior aspect of the right frontal lobe

The scan exhibits subtle, hyperacute ischemic changes, including effacement of the insular ribbon and lentiform nucleus edema of the right hemisphere.

The hyperdense middle cerebral artery sign

[object Object],[object Object],[object Object]

MRI ,[object Object],[object Object]

MRI not easily available / need skilled interpretation ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],IV contrast (Gado) needed to determine age of infarct

Imaging developments for thrombolytic therapy in stroke magnetic resonance imaging ,[object Object],[object Object],[object Object],[object Object]

MRI – rule out ICH ?? ,[object Object],[object Object],[object Object],[object Object]

DW - MRI ,[object Object],[object Object],[object Object],[object Object],Returns to normal with time

DSA ,[object Object],[object Object],[object Object],[object Object]

This is the CT scan picture What now ??

Reperfusion strategies improve blood flow and limit size of infarct ,[object Object],[object Object],No benefit More deaths and bleeds Within 3 hrs -Class I recommendation by the American Stroke Association

Establishing time of onset is especially critical ,[object Object],[object Object],[object Object],3.40 pm in our pt Arrived at 5 pm

Inclusion criteria for IV rt-PA ,[object Object],[object Object],[object Object]

Exclusion criteria -- Medical history ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Exclusion criteria -- Clinical examination ,[object Object],[object Object],[object Object],[object Object]

Exclusion criteria -- CT / lab findings ,[object Object],[object Object],[object Object],[object Object]

Protocol for rt-PA administration ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Stroke onset>3hours— ( what we routinely see….. ) ,[object Object],[object Object],[object Object],[object Object],[object Object]

Candidate for thrombolysis - BP control ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

No thrombolysis - BP control ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Intensive care management ,[object Object],No autoregulation so cerebral blood flow dependant on MBP Reduction of BP can increase stroke size and severity Treat only if signs of HT emergencies – encephalopathy, retinal haemorrhage, cardiac ischemia, CHF, rapidly progressive renal dysfunction

Intensive care management ,[object Object],[object Object],[object Object]

Drugs to be avoided ,[object Object],[object Object],[object Object]

Drugs of choice ,[object Object],[object Object],[object Object]

Intensive care management ,[object Object],[object Object],Poor prognostic sign Beware hypotension and raised ICP during induction for intubation Keep pO2 ~100 and PCO2 ~ 35 PEEP as deemed

Intensive care management ,[object Object],[object Object],Raise head end 15 – 30 º Osmotherapy Induced coma No steroids

General medical management ,[object Object],[object Object],[object Object],[object Object]

Secondary prevention of stroke ,[object Object],[object Object],[object Object],[object Object],[object Object]

Secondary prevention of stroke ,[object Object],[object Object],[object Object]

Neuro clinics 21- stroke case discussion

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