Emergency Emergency Treatment of Treatment of
StrokeStroke
Normal Brain PhysiologyNormal Brain Physiology
2-3% of body weight
15% of cardiac output
20% of all O2
25% of all glucose
Cerebral Ischaemia - ThresholdCerebral Ischaemia - Threshold
Normal flow, normal functionNormal flow, normal function
Synaptic transmission failure
Membrane pump failure
2020
5050
1010
00
Time in hoursTime in hours
CB
F (
ml/1
00g
brai
n)C
BF
(m
l/100
g br
ain)
Low flow, raised O2 extraction, normal function
11 22 33 44 55
Cerebral infarct <3hrsCerebral infarct <3hrs
Onset
Infarct
Ischaemic penumbra
Cerebral infarct 6hrsCerebral infarct 6hrs
Infarct
Ischaemic penumbra
Cerebral infarct 24hrsCerebral infarct 24hrs
Infarct
Ischaemic penumbra
NA, DopamineNA, Dopamine
Ca2+ i Ca2+ i
Ischaemic Brain InjuryIschaemic Brain InjuryIschaemia - 02 Ischaemia - 02 glucose glucose
Anoxic depolarisationAnoxic depolarisation
lactatelactate
GlutamateGlutamate
Hi Hi Free Free Fe2+ Fe2+
Free radicalsFree radicals
LipolysisLipolysis NO synthase NO synthase
ProteolysisProteolysis
Cerebral Arterial territoryCerebral Arterial territoryAnterior cerebralAnterior cerebral
Middle cerebralMiddle cerebral
Posterior cerebralPosterior cerebral
Anterior choroidalAnterior choroidal
Partial Ant. Cir. Syndrome (PACS)Partial Ant. Cir. Syndrome (PACS)
ANY ONE OF THESE:- Two out of three as TACI
Higher Dysfunction Dysphasia Visuospatial Homonymous
Hemianopia Motor / Sensory Deficit >2/3 Face / Arm / Leg
Higher Dysfunction Alone Limited Motor / Sensory
Deficit
Total Ant. Cir. SyndromeTotal Ant. Cir. Syndrome
ALL OF THESE:-
Higher Dysfunction Dysphasia
Visuospatial
Homonymous Hemianopia
Motor / Sensory Deficit >2/3 Face / Arm / Leg
Lacunar syndromes (LACS)
• ANY ONE OF THESE:-
Pure Motor Stroke (>2/3 Face/Arm/Leg)
Pure Sensory Stroke (>2/3 Face/Arm/Leg)
Sensorimotor Stroke (>2/3 Face/Arm/Leg)
Ataxic Hemiparesis
Lacunar Infarct Types
MUST HAVE NONE OF THESE:-
New Dysphasia
New Visuospatial Problem
Proprioceptive Sensory Loss only
No Vertebrobasilar features
Posterior Cir. syndrome (POC) ANY OF THESE FEATURES
Cranial Nerve Palsy AND Contralateral Motor/Sensory Deficit
Bilateral Motor OR Sensory Deficit
Conjugate Eye Movement problems
Cerebellar Dysfunction WITHOUT Ipsilateral Long Tract Signs
Isolated Homonymous Hemianopia
Stroke types Stroke types
Al 35-44 yrAl 35-44 yr
Infarct 80% 42% Athero-thrombo-embolism 50%
Intracranial small vessel 25%
Cardioembolic 20%
Rare 5%
PICH 10% 10%
SAH 5% 38%
Unknown 5% 10%
75%
Pre Hospital Care
1. Early recognition of Stroke warning signal by patient
2. Call ED if a person has symptoms of acute stroke.
3. Emergency transport and care
ED immediate care of Stroke
1. Check Vitals, general assessment
2. Stabilize: Respiration, circulation
3. Control Seizure
4. Reduce intracranial tension
5. Maintain blood sugar
6. Maintain temperature
Emergency tests
• Complete blood
count, PCV, TRBC,
platelet, smear for
MP,
• Blood sugar, blood
urea, serum
creatinine, serum
electrolyte,
• Blood gas,
• SGOT, SGPT,
• PT, PTT
• HIV, Hepatitis profile
• ECG / X-ray / CBC /
Stroke Emergency Imaging
• CT / CTA
• MRI / MRA/ / PI/ DI
• Echocardiography
• Carotid doppler,
• Transcranial doppler
• Cerebral Angiography
• SPECT
MRA & MRI in Stroke
When TIA is an emergency?
High risk TIA,S
1. A high grade vascular stenosis
2. An antiplatelet failure
3. A cardioembolic
4. Crescendo TIA.
Heparin-> warfarin if a long term anticoagulation is required
Aspirin if anticoagulant contraindicated
Carotid endarterectomy in TIA’s
• High grade ipsilateral carotid stenosis
with TIA has high risk (30%) of
stroke within first week
• CE reduces mortality in such cases
“Patients who have improved neurologically
but have a persistent neurologic deficit when
seen, should be managed as a recent stroke”
Aspirin in Acute Stroke
“In acute stroke aspirin is the only proven antiplatelet agent. It should be commenced as soon as the diagnosis of cerebral infarction has been made, using a starting dose of 150-300mg a day and continuing until decisions have been made about secondary prevention”
Anticoagulant in Acute Stroke
• Not shown to prevent progression
• LMH long term improved
• Hemorrhagic transformation is high
• Cardioembolic infarct
– Immediate for small infarct
– Delayed for large infarct
• Heparin - 1000 units/hr. PTT 1.5
• Heparinoid - 2500 to 3200 units SC BD
rTPA Inclusion criteria
• Clinical evidence for an ischemic stroke
• Age >18 years
• Signed consent, if possible
• Onset of stroke within 3 hours of initiation of therapy*
• Normal PT and PTT
If a patient has stroke on awakening from sleep or if the onset of symptoms is not known, then stroke onset is determined from time patient was last seen as "normal" (eg, when he or she went
to bed).
rTPA exclusion criteria
Historical – Stroke or serious head
trauma in past 3 months
– Major surgery or invasive procedure within past 14 days
– GI or urinary bleeding within past 21 days
– Puncture of noncompressible artery or biopsy of internal organ within past 7 days
– Ongoing alcohol or drug abuse
– Seizure preceding or during stroke
rTPA exclusion criteria
– History of intracranial hemorrhage (including subarachnoid bleeds) or known history of cerebral vascular malformations
– (including aneurysms or arteriovenous malformations)
– Pericarditis, endocarditis, septic emboli, recent pregnancy, or active inflammatory bowel disease
rTPA exclusion criteria
Clinical, radiologic, or laboratory – SBP >185 mm Hg or
DBP >110 mm Hg after repeated measurements
– Rapidly improving or minor symptoms
– Coma or stupor
– CT of brain indicative of tumor, blood, or early signs of cerebral edema
– Elevated PT and/or PTT
– Serum glucose <50 mg/dl or >400 mg/dL
– Platelet count <100,000/mm3
rTPA Protocol
• Obtain and review stat CT scan of the brain.
• Establish peripheral IV access (two separate sites).
• Obtain CBC, chemistry panel, PT & PTT, type and screen, and urinalysis.
• Review inclusion and exclusion criteria
• Determine patient's weight.
IV rTPA for Acute Ischaemic Stroke
• Administer TPA, 0.9 mg/kg (maximum, 90 mg) as a 10% bolus over 1 to 2 minutes, followed by the remaining 90% as a 1-hour infusion
• Monitor for bleeding and neurologic deterioration.
• Admit to ICU for 24 hours.
• Monitor BP
• Do not give antiplatelet or anticoagulant therapies for 24 hours.
• Do not perform arterial punctures, invasive procedures, or IM injections for 24 hours.
• Obtain CT scan of brain 24 hours postinfusion or sooner if neurologic deterioration occurs.
BP Control during thrombolysis
• Monitor BP every 15 minutes for 2 hours after start of infusion
• Then every 30 minutes for 6 hours
• Then every hour, from the 8th hour until 24 hours after the start of TPA
• Then per routine
• If after two readings 5-10 minutes apart:
• SBP = 180-230 mm Hg or DBP = 105-120 mm Hg
• Give labetalol 10 mg IV over 1-2 minutes. May repeat or double the dose every 10 minutes, up to maximum of 150 mg or iv infusion.
BP Control during thrombolysis
• SBP >230 mm Hg or DBP = 121-140 mm Hg
• Give labetalol 10-20 mg IV over 1-2 minutes. May repeat or double the dose every 10 minutes, up to maximum of 150 mg or infusion. .
• If response is inadequate,
start sodium nitroprusside
• DBP >140 mm Hg
• Give sodium nitroprusside
0.5-10 µg/kg/minute
Emergency CE in acute Stroke
1. Stroke in evolution with a minimal fixed neurologic deficit,
2. A moderately severe neurologic deficit of abrupt onset when the surgery can be completed within the first 3 hours after the onset of deficit, and
3. CT scan without evidence of hemorrhagic transformation of an infarct or edema.
“Role of Neuro-protection in Stroke is not clear and not
recommended routinely”
Subarachnoid hemorrhage
• Bed rest Analgesic• Blood pressure control• Oral nimodipine 60mg q6hx21 days• Angiography for localization of bleedingIf aneurysm • Immediate surgical clipping for
– Grade 1-3 patient without contraindication– Grade 4-5 with intracerebral clot and deterioration
Primary Intracerebral hemorrhage
• Small (<3cm) hematoma has good prognosis
• Large hematoma (>6cm) in comatose patient have poor prognosis.
• Surgical evacuation for 3-6cm superficial lobar hematoma in a conscious patient
• Cerebellar hematoma with deteriorating level of consciousness
• Control of BP
Thank You