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Clinical Stroke Neurology
&Protocols
Dr Sunanda Anand
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Stroke
Neurological deficit lasting for >24 hrs due to vascularpathology of brain.
Neuroimaging does not indicate different
etiology.
Includes Cerebral infarction, CVT,SAH and
intracerebral bleed.
24hrs criteria excluded if patient dies or undergoes
cerebrovascular surgery. Excludes strokes due to head injury or disorders
like leukemia.
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Stroke Programme
Acute stroke Intervention
Chronic Stroke management
TIAs/ministrokes Secondary Prevention
Rehabilitation
Maintain Data.
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24/7 Services
Emergency Medical services.
Imaging CT/MRI.
DSA Lab : Interventional Neuroradiology. Stroke unit/ICU & Step down units.
Trained Staff.
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Stroke
Arterial Strokes
Ischemic (80%)
Hemorrhagic(20%)
Venous Strokes:20% of young strokes
Non hemorrhagic Hemorrhagic
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How to Diagnose Stroke?
PARALYSIS = STROKE
Anterior circulation: Acute deficit in the Arm,
Leg, Face and Speech (Abb. NIHSS).
Posterior circulation: Vertigo, Altered sensorium
-Coma, Hemianopia, Motorsensory
deficit, Cerebellar signs etc.
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When to Thrombolyse?
NEUROLOGICAL DEFICIT : NIHSS >4
WINDOW PERIOD : 0-8HOURS
CT SCAN : No Hemorrhage No established
infarct.
i) Normal scan
ii) Dense MCA sign
iii) Hypodensity
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Normal scan Dense MCA sign
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What to Do? When to Do?
0-3 hrs: I/V thrombolysis
3-6 hrs: I/A thrombolysis/Mechanical
6-8 hrs: Mechanical devices
Others:
Rescue therapy (Drip &Ship)
Ultrasonic recanalization.
Neuroprotection
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When not to Thrombolyse?
More than 8 hrs for anterior circulation.
Mild or rapidly improving deficit.
Neurological deficit noticed on waking up from
sleep.
Hemorrhage or established acute infarct on CT.
Known CNS vascular malformation or tumor.
Bacterial endocarditis, Bleeding diathesis etc.
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IV Thrombolysis
NINDS, ECASS 2 & Meta analysis.
Agent to be used: rtPA
DOSE: 0.9mg/kg to max of 90 mgm.
10% as bolus over 2 min rest as an infusionover 1 hr.
Outcome: 30% improvement in functional &neurological outcome.
Symptomatic hemorrhage 6.6%.
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IA Thrombolysis
rtPA and Urokinase (PROACT I &II)
0-6 Hrs for anterior circulation
24 hrs for Posterior circulation or Fluctuating neurological status.
Recent surgery, trauma,other contraindications for IV thrombolysis .
Patient having (PTCA) & embolic stroke
40% improvement in outcome at 3mths.
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Mechanical Devices
Concentric(Phase1&II . ongoing PhaseIII)
Penumbra (Phase I. ongoing PhaseII)
0-8hrs.
1st line therapy(3-8hrs)
Postoperative
Anticoagulated(INR=3)
Failed IV/IA tPA or Contraindications.
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Drip & Ship Therapy
IV + IA
Is combination of I/V and I/A.
IMS Trial (Phase 1&II).
Ongoing Phase III (randomised with IV rtPA).
Mod Severe Strokes NIHSS>=10.
0.6mg/kg IV rtPA.
Followed by 0.3 mg /kg IA rtPA if the clot is
visualized.
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Ultrasound
Transcranial doppler increases lytic
activity of rtPA ( Phase II ).
EKOS MicroLySUS catheter which can
administer tPA + IA low energyUltrasound.(PhaseI&II).
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Neuroprotection
Brain tissue to be made more resistant to
ischemic injury.
Decrease functional deficit.
Prolong Revascularization window.
Pharmacological& Mechanical. Disappointing results.
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Multi Modality ApproachRecent+Future
IV+IA
I/V +Mechanical
IV+ IA +Mechanical IA+Mechanical
+
Neuroprotection Ultrasonic
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Patient comes to Casualty with
Acute Stroke
Confirm diagnosis &onset time
Perform NIHSS+-GCS
Secure 2 IV lines ( Avoid dextrose) Nasal Oxygen if Sat
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Casualty into Action
Patient fulfills inclusion& exclusion criteria.
Discuss Treatment options
Treat BP to required level(100,000.
Other Invg not to delay therapy if Clinical H/O is not
relevant.
If Foleys/Intubation/RT is required insert prior totreatment.
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0-2 Hrs
IV rtPA
0.9mg/Kg max 90mg
Dilute 1:1 with sterile water or NS
Do not agitate.
10% bolus and remainder infusion 1hr.
or
Combined therapy: 0.6mg/kg rtPA.
15% bolus and 85% over 30 min.
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3-5 hrs.
Alert Interventional Neuroradiology. IA rtPA 0.3mg/kg.(max40mg)
IA Urokinase 7.5 00,000 units.(1.2million)
Mechanical Devices.
Multimodality.
Along with First line Invg .
MR DW1and PW1 mismatch +MRA or
CT Perfusion+CTA (dec CBF,Inc MTT &Norm or IncCBV).
CT clinical mismatch.
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Large Artery occlusion
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Basilar Occlusion
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5-8 hrs
Mechanical Devices
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Special situations:
Monoplegia
Paresis: MRC >3, dysarthria ,facial
Visual loss
Aphasia
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Post Intervention management
24 hrs
Shift to ICU/Stroke unit
NPO/ Sat>95%/Cardiac Monitoring.
IV NS maintenance drip(50cc/hr)
NIHSS & BP checks every 15 min for 1st 2hrs
Then every 30min for next 6 hrs
Every Hr for next 16 hrs
Then every 4 hrs.
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ICU /Stroke unit in Action
Control BP (
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Watch for
Severe headaches, vomiting,
Acute Hypertension ,drowsiness
Worsening of neurological status.(NIHSS>=4pts)
DISCONTINUE INFUSION &ORDER BRAIN CT
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Is There ICH?
Discontinue rtPA.
Stat Blood Grouping +cross, PT, PTT,
Fibrinogen level.
Infuse 6 units of platelets + 6 units of FFP
(or 6 units of cryoprecipitate with Factor
VIII)
Neurosurgery consultation for Evacuation.
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Is there Angioedema?
On rtPA (1-2%)
Tongue examn for enlargement every 20
min after starting infusion
Breathlessness /Stridor
DISCONTINUE rtPA INFUSION
Treat accordingly with H1 ,H2blockers,Steriods Adrenalin, Intubation.
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Is there Raised ICP?
Suspect in large hemispheric and
cerebellar strokes
Peaks at 72 hrs.
Change IN LOC.
Agitation, Increase BP, Dec Pulse rate
Change In respiratory pattern Pupillary changes,Fundus, Decerebrate
Posturing.
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How to Manage ICP?
Monitoring ICP?
Raise Head by 30-45 Deg.
Treat agitation/cough with Propfol/Fentanyl
Neuromuscular paralysis if Pt is bucking onVentilator.
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Treatment of ICP
Mannitol 0.25 -1gm/kg . Max for 5 days
Hypertonic Saline
Hyperventilation.PCo2 to 25-30mm. Temporary
Hypothermia(32-33deg) cooling blankets and ice
packs.
Neurosurgery of Decompression craniectomy.
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Other Complications
Seizures
Aspiration Penumonia ( 15-25% of
deaths)
dysphagia: facial palsy,altered
sensorium,brainstem strokes
Mechanical ventilation
Immobility leading to atelectasis
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Complications
UTI (16%) indwelling catheters
Constipation ( Commonly forgottten)
Malnutrition delays recovery(S.Albumin) Establish nutrition by 48 - 72hrs.
Assess swallowing test for Oral feeding.
NG tube
Feeding gastrotomy (>6weeks)
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Complications
DVT and pulmonary embolism(10% ofdeaths. Incidence 20-50%)
EARLY MOBILIZATION
Non ambulatory within 24 hrs then:- TEDS: Thromboembolic stockings
Penumatic compression devices
Heparin 5000units S/C BD Low mol wt heparin
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TIAS/Mini Strokes
Transient neurological deficit lasting
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Risk with TIAS
25-30% of strokes are preceded by TIAS
10% chance of stroke in next 90 days
50% of these in next 2 daysHigh Risk:-
Age>60yrs
DM
TIAs >10 min
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How to prevent recurrence?
Secondary Prevention
Recurrent strokes 5-18%.
Strategies according to Causes:-
Cardioembolic (20%) Large vessel atherosclerosis(15%)
Small vessel disease(15%)
Others(hpercoaguablity,dissection) (5%)
Cryptogenic(45% R/O PFO)
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Essential Stroke workup
in all cases
Echocardiography (thoracic /TEE)
Doppler for Carotid and vertebral arteries
Or MRA/CTA for Neck& Cerebral arteries.
Fasting lipids & DM workup.
Hypercoaguable workup (young strokes)
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Large+Small vessel atherosclerosis
First Line drugs
Aspirin + Clopidogrel for 1 month.
Then Single drug for lifelong.
Only CVD prefer Aspirin. CVA+CAD+-PVD prefer clopidogrel.
Statins If CVA +IHD
Treat Etiology.
If Antiplatelets fails add Anticoagulation.
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Aspirin
Aspirin 300mg loading then150mg OD
(75mg-325mg)
Start at presentation
Acute intervention start >24 hrs.
Decreases recurrent stroke by 22%
annually.
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Clopidogrel
Clopidogrel 75mg 4 tabs loading then 1OD Preferred in cases with stroke +IHD+PVD
Additional dec of 8.7% in end points.
ASA-Dipyridamole
Dec risk of recurrence by 23%.
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Heparin & Coumadians
First line therapy in Cardioembolic strokes
Controversial in acute stroke(TOAST&IST)
Our Practice: low mol wt heparin If partial recanalization in Acute stroke
intervention>24hrs.
Ist 48hrs in Acute stroke & TIAS.(exceptlarge hemispheric strokes)
Fall back therapy if antiplatelets fail.
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Large vessel Atherosclerosis
Carotids: Advised Stenting
>70% stenosis.
50-69% stenosis: Male gender, Precedinghemispheric stroke,Contalateral occlusion.
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Intracranial Atherosclerosis.
Medical therapy
Antiplatelets
Statins
26% recurrent stroke(by2yrs) on optimummedical management. (WASID)
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Intracranial Stenting/EC-IC bypass
Recurrent symptoms
Hemodynamic dependent lesion
Basilar stenosis.
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Cardioembolic Stroke
IHD
Atrial fibrillation (long term anticoagulation)
Patent foramen ovale & ASD.
Aortic arch atheroscelosis.
Others: RHD, Prosthetic valves,atrial/ventricular
thrombus,infective endocarditis,maratic
endocarditis, intrcardiac tumors.
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Atrial fibrillation & Stroke
AF : Risk of stroke 12%.
Anticoagulation risk : 4%.
Aspirin : 10%.
AF with acute Ischemic stroke : Delay
anticoagulation from 1-2 weeks weighing
the risk of hemorrhagic conversion.
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Cardioembolic Strokes
Treatment with anticoagulation.
PFO :AC/Aspirin/AC/Endovascular closure
Ascending Aortic arch atheroma>4mm,ulcerated ,mobile.
Rx with AC/Aspirin
CHF with stroke Rx with AC.
A i Ri k f t
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Aggressive Risk factor
Management in all Strokes
Rx Hypertension : Control BP preferably to
120/80mm Hg
First line : ACE inhibitors /ARBs
Thiazide diuretics.
R Di b t M llit
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Rx Diabetes Mellitus
Fasting Glucose & HgbA1C
Goal Maintain HgbA1C
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Rx Hyperlipidemia
LDL
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Discharge Instructions:
Life style modifications
Quit Smoking/tobacco
Quit Alcohol
Weight management
30 min of mod intensity exercise/day
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Acute Rehabilitation
PT, OT & Speech therapy at the earliest.
For brain plasticity and improvement
Rehabilitation should be:
Task specific
Repetitive
Motivating to Pt.
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Acute Venous Strokes
Clinical presentation: varied
Headache ,Focal deficits, Seizures,
Altered sensorium , Raised ICP etc.
Encephalopathy on admission or
progressive deterioration in LOC are bad
prognostic features.
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Diagnostic Modalities
High Level of suspicion
CT +CT venogram
MRI+ MR venogram
DSA
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Management
Mild Clinical grade: Heparin
Severe Clinical grade: Localthrombolysis
Clinical grade 3: deteriorating onHeparin >24 hrs.
CLINICAL GRADING
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CLINICAL GRADING
(GCS)
Mild Clinical Grade
Status 1 No symptoms.
Status 2 Minor symptoms.
Status 3 Major neurological deficit.
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Severe Clinical grade
Status 4 Impaired state of alertness butcapable of protective & adaptive
response to noxious stimuli.
Status 5 Poorly responsive but with
stable vital signs
Status 6 Not responsive to shaking, No
adaptive response to noxious stimuliand progressive instability of vital
signs.
CT GRADING
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CT GRADING Grade 1 No parenchymal change.
Grade 2 Nonhemorrhagic venous infarct ,No
mass effect.
Grade 3 Nonhemorrhagic venous infarct withmass effect.
Grade 4 Hemorrhagic venous infarct.
( bleed < 3cm)
Grade 5 Hemorrhagic venous infarct with
mass effect. (bleed>3cm)
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DSA GRADING
Grade 1 Partial thrombosis/Recanalization.
Grade 2 Dural sinus occlusion with no
restriction of venous outflow.
Grade 3 Dural sinus occlusion with
restriction of venous outflow.
Grade 4 Deep venous system occlusion.
Grade 5 Deep and superficial system
occlusion.
When to Thrombolyse in Venous
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When to Thrombolyse in Venous
Stroke? Clinical Grade :Severe(4,5,6) on
admission
+
DSA: Dural venous sinus thrombosis withrestrictive venous outflow
Clinical grade : Mild (3) worsening onHeparin therapy
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Severe grade +DSA
Patient deteriorating on Heparin
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Patient deteriorating on Heparin
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Stop Thrombolysis
Clinical improvement ( LOC).
AND/ OR
Recanalization of sinus with antegrade
flow on Venogram.
Evidence of Systemic & Intracranialbleed. (exclude puncture site oozing)
EXCLUSION CRITERIA
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EXCLUSION CRITERIA
Clinical recovery since presentation.
Sinus recanalization with no restriction tovenous outflow on DSA.
G.I. or G.U. tract bleeding (less than 2weeks)
Intracranial Aneurysms / AVMs /
Neoplasms. Bleeding diathesis, INR > 1.7, Platelet
count < 100,000
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Post Thrombolysis.
Treatment with Heparin
Oral anticoagulation for 6 months
Adjunctive therapy.
Thrombophilia workup.
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Thrombophilia profile
Protein C 70140%
Protein S 80---130%
Antithrombin III 75---125%
Lupus anticoagulant
Activated protein C resistence ( Normalized ratio 0.75---1.10)
S.Homocysteine male 6---16 Umol/L Female 3.4---20.5
Anticardiolipin antibodies IgG
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Follow Up
Clinical
MR Venogram+ thrombophilia status at 3
months.
To decide Further anticoagulation.
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