Acute Ischemic Stroke - Etiopathogenesis, Clinical features, Advances in Management

Acute Ischemic Stroke - Etiopathogenesis, Clinical features, Advances in Management

1. CHAIR PERSON – DR. KALINGA.B.E STUDENT – DR. MAMATARANI MANAGEMENT OF ACUTE ISCHEMIC STROKE

2. WHO DEFINITION OF STROKE A NEUROLOGICAL DEFICIT OF Sudden onset With focal rather than global dysfunction In which, after adequate investigations, symptoms are presumed to be of non-traumatic vascular origin and last for >24 hours

3. BLOOD SUPPLY OF BRAIN

4. TYPES OF STROKE 85% I s c he m i c 15 % Hemorrhagic

5. Principles of acute stroke care (1) achieve timely recanalization of the occluded artery and reperfusion of the ischemic tissue, (2) optimize collateral flow, and (3) avoid secondary brain injury .

6. Stroke Risk Factors Non-modifiable AGE Gender - male Race – Blacks > Asians or Hispanics> Whites Family History. Coagulation Disorders Cardiac Disease

7. Stroke Risk Factors Modifiable Hypertension Diabetes mellitus Hypercholesterolemia Elevated LDL or Low HDL Elevated homocystein Smoking Alcohol Abuse Oral Contraceptive Pregnancy Obesity Sleep apnea Carotid stenosis

8. Stroke chain of survival Detection Recognition of stroke signs/symptoms D is p a t ch Call 119 and priority EMS dispatch Delivery Prompt transport and prehospital notification to Hospital Door Immediate ED triage Data ED evaluation, prompt laboratory studies, and CT Imaging Decision Diagnosis and decision about appropriate therapy Drug Administration of appropriate drugs or other intervention

9. EMERGENCY EVALUATION OF ACUTE ISCHEMIC STROKE Assess ABCs, vital signs Provide oxygen by nasal cannula wherever necessary Obtain IV access; obtain blood samples (CBC, ’ lytes , coagulation studies) Obtain 12-lead ECG, check rhythm, place on monitor Check blood sugar; treat if indicated

10. NIHSS

11. MEDICAL MANAGEMENT Supportive treatment IV thrombolysis Endovascular revascularization Anti thrombotic tretment Neuroprotection Stroke centers and Rehabilitation

12. SURGICAL MANAGEMENT Endovascular intervention 1.angioplasty and stenting 2. Mechanical clot disruption 3. clot extraction Carotid end artrectomy

13. MANAGEMENT OF COMPLICATION Cerebral edema Hemorrhagic transformation seizures

14. SUPPORTIVE TREATMENT Airway, Breathing and Circulation. Temperature Blood pressure Blood glucose

15. When to lower B lood pressure the hypertension is extreme (systolic blood pressure >220 mmHg or diastolic blood pressure >120 mmHg) Acute myocardial infarction Aortic dissection Hypertensive encephalopathy Acute renal failure

16. THROMBOLYSIS FOR AIS

17. IV rtPA Dose - 0.9mg/kg to a 90mg maximun dose.. Before IV rtPA ensure that blood pressure is not More than 185/110 mmhg Door to needle time should be within 60min.

18. INTRA ARTERIAL THROMBOLYSIS

19. MECHANICAL / ENDOVASCULAR METHODS CRITERIA FOR MECHANICAL THROMBECTOMY 1.prestroke mRS score of 0-1 2.occlusion of the internal carotid artery or MCA segment 1 3.age >18yr 4.NIHSS score> 6 5.ASPECT score of >6 6. treatment can be initiated (groin puncture) within 6 hours of sypmtom onset

20. ANTIPLATELETS. The oral administration of aspirin in AIS is recommended within 24 -48 hrs of symptoms onset. For those treated with IV alteplase , aspirin administration is generally delayed until 24 hours later

21. ROLE OF DUAL ANTIPLATELETS???

22. ANTICOAGULANTS

23. NEUROPROTECTION

24. CLINICAL SCENARIO A 70-year-old, right-handed man has been known to have previous history of poorly controlled hypertension, diabetes, and cardiac arrhythmia. He developed abrupt onset of left-sided weakness after dinner at 7 pm What should you do?

25. He brought to a medical center ER by the EMS at 8:30 pm On initial ER arrival, his consciousness was awake, blood pressure was 210/120 mmHg, pulse rate was 120/min irregularly, respiratory rate was 20/min, body temperature was 37°C and blood sugar was 320 mg/ dL

26. Neurologically, he had flaccid hemiplegia and right- sided gaze preference with dense left-sided hemineglect . The NIHSS score was 17. Head CT scan revealed effacement of cortical sulcal marking in the right middle cerebral artery territory and hyperdense MCA sign. What is your diagnosis of the stroke ? What are the next you will do ?

27. POOR PREDICTORS OF THROMBOLYIS Marked hyperglycemia CT >1/3 MCA Increasing stroke severity Low platelet counts Higher NIHSS score Longer time to recanalization Lower platelet counts Higher glucose level at admission

28. SUMMARY CT within 20 minutes Door-to-needle time within 60 minutes . EVT, ECG, troponin should not delay IV t-PA. Only the assessment of blood glucose must precede the initiation of IV t-PA Receive IV t-PA: BP <185/110 mmHg IV t-PA for AIS < 3 hr

29. SUMMARY IV t-PA for AIS < 3 – 4.5 Class I for pts ≤80 y without both DM and stroke , NIHSS ≤25, not taking any OACs, <1/3 MCA territory by CT or MRI

30. SUMMARY Class IIa for pts >80 y Class IIb Taking OACs and INR ≤1.7 and/or PT <15 s with both DM and stroke history

31. SUMMARY Endovascular Therapy Class I AIS < 6 hr AIS < 6-16 hr: DAWN or DEFUSE 3 criteria Class IIa AIS < 6-24 hr: DAWN criteria

32. REFERENSES Harrison’s principles of internal medicine 20 th edition Adam’s and victors principles of neurology 10 th edition 2018 ACC/AHA guidelines for management of acute ischemic stroke.

33. THANK YOU