Stroke

14. Pathophysiology of TIA and Ischemic
stroke

19. • Initial Evaluation of TIA
o Need urgent evaluation
o High risk of stroke
o Early treatment prevent strokes

20. • TIA differential diangosis
o Transient Neurological deficit
o Seizure
o Migraine
o Syncope
o Peripheral nerve disease (less frequent)

21. ABCD score

22. ABCD score

23. Recommendations (National Stroke Association)
•The National Stroke Association recommends that hospitalization be
considered for patients with a first TIA within the past 24 to 48 hours, and
is generally recommended for patients with the following conditions:
•Duration of symptoms >1 hour
•Symptomatic internal carotid artery stenosis >50 percent
•Known cardiac source of embolus such as atrial fibrillation
•Known hypercoagulable state
•High risk of early stroke after TIA (ABCD2 score)

24. • Patients who need urgent evaluation and are
not hospitalized should have rapid access to
the following studies:
–Brain imaging with head CT and/or MRI
–Neurovascular studies such as CT angiography (CTA),
MR angiography (MRA), and/or ultrasound
–Electrocardiogram (ECG)

25. Signs and symptoms

27. • Emergency Evaluation and Treatment
Stroke Scales
- The National Institute of Health Stroke Scale
(NIHSS) is the preferred stroke assessment
tool.

30. • Head and Neck Imaging
-CT Brain
-MRI Brain diffusion
-CT cerebral angiography or MRA

31. • IV Alteplase Eligibility
• Mechanical Thrombectomy Eligibility: Vessel
Imaging
• Mechanical Thrombectomy Eligibility:
Multimodal Imaging

32. • Other Diagnostic Tests
-Blood glucose
- ECG

33. General Supportive Care and
Emergency Treatment
• Airway, Breathing, and Oxygenation
• Blood Pressure
• Temperature
• Blood Glucose Level

34. - Saturation
>94%
- Blood Pressure
> 220/120
-15% in 24h
- 140/90
< 180/105
-TPA
-Mechanical thrombectomy
-co morbid hypertensive dse

35. • Tempressure
- normothermia
- Hypothermai
- hyperthermia
• Blood Glucose
-140-180 vs <110

36. • IV Alteplase
- Time Window
- Dose
- Mild Stroke
- Bleeding Risk
- Post Alteplase Treatment
- Contraindications

37. • Time window
3 h all patients
3-4.5 h all patients excluding
->80 Y
-Stroke & DM
-on anticoagulants
>4.5 h
No signal change on FLAIR DW-MRI images, and
whose lesion is less than 1/3 of middle cerebral
artery (MCA) territory IN diffusion Image.

38. • Dose
IV alteplase 0.9 mg/kg (maximum dose of 90
mg) over 60 minutes, giving the initial 10% of
the dose as a bolus over 1 minute

42. • Mechanical Thrombectomy
o Pre-stroke modified Rankin Scale (mRS) score of 0 to 1.
o Causative occlusion of the internal carotid artery (ICA) or
MCA segment 1 (M1),
o Age 18 or older
o NIHSS score of 6 or higher
o ASPECTS of 6 or higher, and o Treatment can be initiated
within 6 hours of symptom onset

46. • Antiplatelet Treatment
o For a patient with AIS, aspirin (ASA) within 24 to 48
hours after symptom onset is recommended.
o in most cases, ASA is held for the first 24 hours after
IV alteplase administration.
o The team must determine the need for ASA within
the first 24 hours after IV alteplase administration for
a patient with a concomitant condition in which the
addition of ASA would be beneficial.

47. o Dual antiplatelet therapy (aspirin and clopidogrel)
started within 24 hours of a minor stroke and
continued for 21 days can be beneficial for early
secondary stroke prevention for up to 90 days after
symptom onset.
o In a patient with a minor stroke, the use of ticagrelor
over ASA is not beneficial as an acute treatment, and
it is not recommended.

48. o Aspirin is not recommended as a substitute for
acute stroke treatment in a patient who is
eligible for IV alteplase administration or
mechanical thrombectomy.
o The efficacy of IV tirofiban and eptifibatide in
treating AIS is not well established.

49. • Anticoagulants
• For a patient with severe carotid stenosis on the ipsilateral side from
the ischemic stroke, the efficacy of urgent anticoagulation is
unproven.
• Further studies are needed on the use of argatroban, dabigatran,
other thrombin inhibitors, and factor Xa inhibitors to treat AIS.
• For AIS, anticoagulant therapy started emergently offers no benefit
in terms of preventing recurrence, diminishing the worsening of
symptoms, or improving outcomes. It is not recommended.

50. • Dysphagia Screening
• Nutrition
• Deep Vein Thrombosis Prophylaxis
• Depression Screening
• Rehabilitation

51. • Treatment of Acute Complications
o Brain Swelling
--Medical
- Osmotic therapy
- Hyperventilation
- Barbiturate & Hypothermia XX
- steroids xx

52. --Surgical
A decompressive craniectomy with dural expansion is suggested
for patients age 60 or younger with a unilateral MCA infarction
who, despite medical management, exhibit a worsening
neurologic status in the first 48 hours after the event. Treatment
for patients over the age of 60 may be considered.
o Seizures

53. • Prevention of secondary stroke
o Antithrombotic Treatment
Noncardioembolic Stroke
Atrial Fibrillation

55. o Treatment of Hyperlipidemia
Statins
Ezetimeb
PCK-9 inhibitors.
o Smoking session