1) A woman experienced sudden onset left-sided weakness, facial asymmetry, slurred speech and drooling while at a neighbor's house. She was brought by ambulance to the emergency department. 2) In the ED, her neurological examination found significant left-sided weakness. A CT scan showed a large right middle cerebral artery infarction. 3) Despite arriving within the time window, she was not eligible for thrombolysis due to the extensive area of brain injury seen on the CT scan. She was admitted for supportive care and monitoring.

2. 
 Known case of :
1) HPT
2) Dyslipidemia
3)Uterine fibroid
4) MDD

3.  Patient staying alone,
 Patient was at neighbor's house chit chatting while drinking
coffee
Suddenly had left sided body weakness ~10.15am
+ facial asymmetry
+ slurred speech
+ drooling saliva
+ patient complaint of headache left side
 Ambulance call by neighbors at 1020H, arrived in ED at
1130H (1H15min from onset)

4.  STROKE CODE was activated by EP at 1055H while patient
still in ambulance
 Stroke team arrived in ED at 1125H

5.  appears drowsy but obey command
 Neurological examination :
 Left UL 1/5, LL 2-3/5
 Right UL 5/5, LL 5/5 UMN 7th palsy
 forced right lateral gaze
 sensation intact BL
 dysarthria but no aphasia
 neglect +
 NIHSS score 15
 Pulse rate - irreguarly irregular
 BP 185/94 HR 98

6.  Called radiology team for stroke thrombolysis protocol, allowed
for CT brain + CTA cerebral and carotid urgent
 Pushed to CT room at 1155H, requiring low dose sedation in
view of patient restless

7.  CT brain plain : no ICB seen with sign of massive Right MCA
infarct
 Reviewed along with Radiologist – no ICB thus proceed with
CTA Cerebral and Carotid on the same setting
CTA results : Acute right MCA territorial infarction (ASPECT
score 4) secondary to long segment intra-arterial thrombus from
ipsilateral ICA extending to the MCA arterial distribution with
poor collateral supply (score 1).

10.  Despite patient arrived in ED within 4H from onset of
symptom, CT brain shows ASPECT Score of 4 (less than
minimum 7 required) thus not a suitable candidate for
thrombolysis
 Patient was admitted to ward for GCS monitoring, KIV for
neurosurgical referral if deteriorating

11.  Day 2 of stroke, patient still complaining of headache.
Repeated CT brain at 9h of stroke shows : Right MCA territory
infarct with worsening mass effect and leftward midline shift
associated with early hydrocephalus changes. No evidence of
hemorrhagic transformation.
 Family undecided regrading decompressive craniectomy in
case of deteriorating GCS and neurological function
 Family not keen for CPR/intubation in case of patient
deteriorating

12.  On day 3 of Stroke, GCS worsened from 15 to 12 (E3 V4 M5),
referred to neurosurgical team
 Family not keen for surgical intervention – opted for best
supportive therapy
 Started on IV mannitol 20% 100cc TDS

15.  Definition
 BEFAST
 Acute Stroke Assessment : NIHSS
 Thrombolysis IV : indication, dose and contraindications

16. “Stroke is a clinical syndrome characterized by rapidly
developing clinical symptoms and/or signs of focal, and at
times global, loss of cerebral function, with symptoms
lasting more than 24 hours or leading to death, with no
apparent cause other than that of vascular origin”.
Strokes may be classified and timed as:
I. Early hyperacute (a stroke that is 0–6 hours old)
II. Late hyperacute (6–24 hours)
III. Acute (24 hours to 7 days)
IV. Subacute (1–3 weeks)
V. Chronic (more than 3 weeks)

21. Four steps to making therapeutic decision
in Hyper Acute Stroke
DIAGNOSIS
EXCLUDE BLEEDING
ASSESS SEVERITY
IDENTIFY CONTRAINDICATIONS

22. DIAGNOSIS
EXCLUDE
BLEEDING
ASSESS
SEVERITY
IDENTIFY
CONTRAINDICATIONS
> 1/3 MCA
TERRITORY
– CT
NIHSS
ASPECTS
– CT
A variety of scores have been developed for assessing acute ischemic stroke severity
and outcome in the acute setting:

23. ASPECTS CAN HELP TO:
OPTIMIZE PATIENT SELECTION AND IMPROVE PATIENT
OUTCOME
REDUCE HOSPITALIZATION COSTS BY LIMITING
LENGTH OF STAY
INCREASE THE UPTAKE OF STROKE TREATMENTS
Pexman J. H. W et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for Assessing CT Scans in Patients with
Acute Stroke, AJNR Am J Neuroradiol 2001, 22:1534–1542; Mak H. K.F. et al. Hypodensity of >1⁄3 Middle Cerebral Artery
Territory Versus Alberta Stroke Programme Early CT Score (ASPECTS), Stroke 2003, 34:1194-1196
DIAGNOSIS
EXCLUDE
BLEEDING
ASSESS
SEVERITY
IDENTIFY
CONTRAINDICATIONS
The Alberta stroke program early CT score (ASPECTS) is a 10 point quantitative
topographic CT score

24. Pexman J. H. W et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for Assessing CT Scans in Patients
with Acute Stroke, AJNR Am J Neuroradiol 2001, 22:1534–1542; Mak H. K.F. et al. Hypodensity of >1⁄3 Middle Cerebral
Artery Territory Versus Alberta Stroke Programme Early CT Score (ASPECTS), Stroke 2003, 34:1194-1196
SEVEN AT THE LEVEL OF THE BASAL GANGLIA
C - HEAD OF CAUDATE NUCLEUS
I - INSULA
IC - INTERNAL CAPSULE
ASPECTS DIVIDES THE MCA-SUPPLIED CEREBRAL
TERRITORIES INTO TEN REGIONS
L - LENTIFORM NUCLEUS
(PUTAMEN + GLOBUS PALLIDUS)
CORTICAL REGIONS M1, M2 AND M3
M
1
M
2
M
3
L
I
C
I
C
DIAGNOSIS
EXCLUDE
BLEEDING
ASSESS
SEVERITY
IDENTIFY
CONTRAINDICATIO
NS

25. ASPECTS DIVIDES THE MCA-SUPPLIED CEREBRAL TERRITORIES
INTO TEN REGIONS
M
4
M
5
M
6
3 ABOVE THE LEVEL OF THE BASAL GANGLIA
CORTICAL REGIONS M4, M5 AND
M6
DIAGNOSIS
EXCLUDE
BLEEDING
ASSESS
SEVERITY
IDENTIFY
CONTRAINDICATIONS
A SCORE OF
ZERO INDICATES
DIFFUSE
ISCHAEMIC
DAMAGE
A SCORE OF 10
INDICATES A
NORMAL CT SCAN

26. 1.See http://brainomix.com
CLINICAL STUDIES1
HAVE
DEMONSTRATED
THAT PATIENTS WITH
AN ASPECTS SCORE
OF >7 WERE MOST
LIKELY TO BENEFIT
FROM TREATMENT
THOSE WITH
AN ASPECTS SCORE
OF <5 WERE UNLIKELY
TO SEE ANY IMPROVED
OUTCOME AND WERE
EXPOSED TO A
SIGNIFICANTLY
HIGHER RISK OF
HAEMORRHAGE
FOLLOWING
THROMBOLYSIS
>7
SCORE
<5
SCORE
DIAGNOSIS
EXCLUDE
BLEEDING
ASSESS
SEVERITY
IDENTIFY
CONTRAINDICATIO
NS

27. NCCT BRAIN + CTA CEREBRAL
ELIGIBLE FOR IVT
YES NO
RADIOLOGY TEAM
CONSENT TAKEN
(PATIENT
/GUARDIAN)
MEDICAL
THERAPY

28. CONTRAINDICATIONS
ABSOLUTE CONTRAINDICATION
• Systolic BP> 185 mmHg or Diastolic BP > 110
mmHg unresponsive to medical treatment
• Haemorrhage on CT Brain
• Major surgery within the past 14 days/ minor
surgery within the past 10 days (liver & kidney
biopsy, thoracocentesis)
• Active internal bleeding
• Intracranial / intraspinal surgery or severe head
trauma within 3 months

29. • Intracranial malignancy/ vascular malformations
• Platelet <100 000, INR >1.7, APTT >1.2x normal limit,
DOAC with last dose ingested within the last 48hrs.
rt-PA maybe started before PT/PTT and platelet count are known
if there is no history of alcohol abuse, not ESRF, no
heparin/warfarin use, no history of Antiphospholipid syndrome,
no Liver disease/haematological disease/ metastatic cancer, no
bleeding of any type within the last 1 month
• High pre-morbid dependency Modified Rankin score >3
• Arterial puncture at non-compressible site within 7 days
• Infective endocarditis
• Clinical presentation strongly suggests subarachnoid
haemorrhage even if the CT scan is normal.
• Blood sugar less than 2.8mmol

30. RELATIVE CONTRA-INDICATIONS
• Rapidly improving symptoms
• Significant trauma within 3 months (includes CPR with chest
compressions within past 10 days).
• Stroke within the past 3 months.
• History of intracranial hemorrhage; or symptoms suspicious for
subarachnoid haemorrhage.
• Pregnant (up to 14 days postpartum) or nursing woman. (case by case
risk decision with obstetric team)
• Seizure at onset (concern of diagnostic uncertainty)
• Acute MI within the last 3 months
• Previous history of intracranial bleed
• Treatment from 3 to 4.5 hours: Additional relative exclusions (where
the risk/benefit ratio is less clear) are Age > 80 years, oral
anticoagulant use regardless of INR, severe stroke (NIHSS > 25)
and/or a combination of both previous stroke and Diabetes mellitus.

31. IV ALTEPLASE DOSING AND INFUSION REGIME
GUIDE
1. Dose 0.9mg/kg ( maximum dose 90mg)
2. Reconstitute 50mg vial of rt-PA (Alteplase) with 50ml of sterile
water to make a solution of 1mg/ml
3. 10% of the dose given as a bolus over 1-2 min.
4. The remaining 90% of the dose draw into one or two 50ml syringe
and infuse over 60 minutes.

33. Infusion of alteplase should be given at red zone / closely monitored
area
Monitor pulse, BP and GCS

0-2 hours; every 15min

2-6 hours; every 30min

6-24 hours; hourly
STRICTLY Maintain BP <180/105mmHg with antihypertensive (if
needed)
1. If patient develops severe headache, acute hypertension, nausea,
vomiting or drop in GCS, to withhold Alteplase and repeat CT
brain
2. NIHSS assessed 1 hour after rt-PA infusion completed and 24
hours later.
3. No antiplatelet/ anticoagulant for 24 hours
4. Delay placement of nasogastric tubes, indwelling catheter or
arterial puncture.
5. No intramuscular injection or puncture of large artery/veins
within 24 hours.
6. Rest in bed for 24 hours post rt-PA infusion completion.
7. Repeat CT brain after 24 hours and start antiplatelet if no
contraindication

34. Prior to thrombolysis
⮚ Aim blood pressure <185/110mmHg
⮚ If high;
∙ IV Labetolol dilution: Mix 25mg/5ml ampoule Labetolol into 20 ml
D5% (so 1 ml = 1 mg Labetolol)
∙ IV labetolol 10 mg over 1-2 min. Repeat or double as necessary
every 10 min up to total dose of 150 mg
∙ Alternatively, start IV labetolol infusion at 20 mg/hour and titrate
upward to a maximum dose of 150mg/hour or
∙ Add five GTN 10mg/10mL ampoule to 450mL of D5% giving a final
concentration of 50mg / 500ml = 100micrograms/ml or
∙ One GTN 10mg/10ml ampoule to 90 ml of D5% giving a final
concentration of 10mg/100ml = 100micrograms/ml
NB: Concentration may be increased but must not exceed 400
micrograms/mL
∙ IV GTN infusion started at 5-10mcg /min and titrate accordingly
⮚ Monitor every 5min, if BP remains ≥185/110mmHg, DO NOT
administer rt-PA
⮚ To maintain BP < 180/105mmHg during thrombolysis until 72 hours
post therapy.

35. Suspect ICB if
∙ Drop in GCS ≥ 2
∙ Increase in NIHSS ≥4
∙ Sudden rise in BP
∙ Nausea and vomiting
∙ Stop iv rt-PA
∙ Urgent CT brain
Urgent FBC, coagulation,
fibrinogen level and GXM
HEMORRHAGE ON CT BRAIN
• IV Tranexamic acid 1g in 100 ml Normal saline over 10 min
• Obtain fibrinogen results, if fibrinogen result < 1.2 to give
cryoprecipitate
• Give cryoprecipitate 6-8 units and platelet 4 units
• Repeat fibrinogen level after 1 hour
• Consider IV Tranexamic acid infusion (1 g in 250 ml Normal
saline infusion over 8 hours)
• Consult Haematologist & Neurosurgeon
∙ Consider 2nd CT brain to assess progression of ICH

36.  BEFAST
 Time is Brain