03 - Management of Ischemic - Umair Ijaz.pdf

It inckudes the anesthesia pre evaluation intra operative management and post operative care of ischemic CVA patient

1. Anaesthetic
Management of
Ischemic CVA
PREPARED BY:DR.UMAIRIJAZ
UNDER KIND SUPERVISION OF PROFESSOR DR. MUDASSAR ASLAM
TUTOR: DR. ANUM ZEB

2. Objectives

Understand ischemic CVA and its implications

Goals of anaestheticmanagement

Preoperative, intraoperative, and postoperative considerations

Anaesthetictechniques and drugs

3. What is Ischemic CVA ??

Sudden loss of blood flow to part of the brain

Caused by thrombus or embolus

Leads to tissue ischemia and infarction

Time = Brain

4. Pathophysiology
1.Arterial Occlusion
–Due to thrombus (local clot) or embolus (from heart/carotid)
2. ↓ Cerebral Blood Flow (CBF)
–<20 mL/100g/min → reversible dysfunction
–<10 mL/100g/min → infarction (cell death)
3.Ischemic Cascade
•↓ Oxygen & glucose → ↓ ATP
•Na ⁺/K⁺pump failure → cytotoxic edema
•Excess glutamate → excitotoxicity
•↑ Intracellular Ca²⁺→ activates enzymes → cell damage
•Free radicals → oxidative damage
4.Penumbra
–Zone of reversible ischemia around the infarct
–Target for thrombolysis and perfusion therapies

5. AnaestheticGoals

Maintain cerebral perfusion pressure (CPP)

Avoid secondary brain injury

Optimize oxygenation and ventilation

Provide hemodynamic stability

Avoid hyperglycemia, hypoxia, hypotension

6. Preoperative Considerations

Assess neurological status (GCS, NIHSS)

CT/MRI to confirm ischemic stroke

Labs: Coagulation, glucose, electrolytes

Continue antihypertensives (except ACEi/ARBs)

Control blood pressure, glucose

Antiplatelet therapy—assess bleeding risk

7. Glasgow Coma Scale (GCS)

8. 0 = No stroke
1–4 = Minor stroke
5–15 = Moderate stroke
16–20 = Moderate to severe stroke
21–42 = Severe stroke

9. Intraoperative Monitoring

Standard ASA monitors

Invasive BP monitoring (ART line)

ETCO₂(target 35–40 mmHg)

Temperature control

Urine output (optional)

+/-EEG or NIRS (in selected cases)

10. Choice of Anaesthesia
General Anaesthesia (GA)
a) Preferred in uncooperative patients or airway risk
b) Controlled ventilation
c) Propofol, sevoflurane, remifentanil, or fentanyl
d) Short-acting agents preferred
Regional Anaesthesia
a) For minor procedures
b)Avoid in altered mental status or uncooperative patient

11. Intraoperative Management

BP: Maintain MAP > 70–80 mmHg

Ventilation: Avoid hypo/hypercapnia

O₂: Maintain normoxia

Fluids: Isotonic crystalloids; avoid glucose-containing fluids

Blood sugar: Target <180 mg/dL

Temperature: Avoid hyperthermia

Avoid: Hypotension, hypoventilation, high ICP

12. Post operative Care

Monitor for neurological deterioration

ICU or high-dependency unit

Control BP, glucose

Early physiotherapy

Avoid sedation overdose

Assess for complications: aspiration, edema, seizures

13. Special Situations

Thrombolysis or thrombectomy: Done before or during anaesthesia?

Anticoagulation: Risk vs. Benefit

Increased ICP signs: Avoid hypercarbia, Trendelenburg, excessive fluids

Difficult airway: Consider awake intubation or regional if suitable

14. Summary

Goal: Protect the brain

Preop: Imaging, labs, BP, glucose

Intraop: Stable hemodynamic, normocapnia,normoxia

Postop: Neuro-monitoring, avoid complications

Multidisciplinary approach is vital

15. Thank You.