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