Approach A Patient With STROKE for beginnerspptx

approach A Patient With STROKE for beginners

1. Approach To A Patient With STROKE Dr . Siadul Islam Soikot

2. Blood Supply of Brain

3. STROKE Acute onset of neurological deficit due to non-traumatic vascular cause, lasting more than 24 hours According to WHO, 1970

4. TYPES OF STROKE Due to occlusion of cerebral artety Due to rupture of vessels of brain

5. Risk Factors :

6. Clinical Features

7. FAST Symptoms

8. Nervous System Examination Level of consciousness: GCS Scoring Jerks : Exaggerated in contralateral side Planter : Extensor in contralateral side

9. Extensor Planter Reflex Behind sign 1. Dorsiflexion of great toe 2. Fanning out of other toes

10. INVESTIGATIONS Routine : 01.CT Scan of brain 02.CBC with ESR 03.RBS 04.S. Electrolytes 05.CXR P/A View 06.ECG

11. INVESTIGATIONS FOR UNDERLYING CAUSES : 01.Echocardiograph (any embolism from heart) 02.LP ( whether SAH) 03.Digital Subtraction Angiography (To find out AVM) 04. For Hypercoagulable state : a.Protien-c b.protien-s c.AT-lll 05.For collagen Vascular Disease - Anticardiolipin Antibody

12. Keep In Mind In patients with a clinical diagnosis of an acute stroke, a CT scan that shows no intracerebral haemorrhage makes an ischaemic stroke the likelier diagnosis.

13. TREATMENT General Treatment Specific Treatment

14. General Treatment

15. Specific Treatment For Ischemic Stroke

16. TPA

17. Specific Treatment For Hemorrhagic stroke CCB : If Ventricular Extension or Midline shifting

18. MANAGEMENT HYPERTENSION in ICH Current guidelines for managing elevated blood pressure in aecute spontancous ICH are asfollows: a. For patients with SBP >200 mmHg or MAP >150 mmHg, consider aggressive reduction of blood pressure with continuous intravenous infusion of medication accompanied by frequient (every five minules) blood pressure monitoring b. For patients with SBP >180 mmHg or MAP >130 mmHg and evidence or suspicion of elevated ICP,consider monitoring ICP' and reducing blood pressure using intermittent or continuous intravenous medication to keep cerebral perfusion pressure in the rangeof 6l to 80 mmHg c. For patients with SBP >180 mmHg or MAP >130 mmHg and no evidence or suspicion of elevated ICP, consider a modest reduction of blood pressure (eg,target MAP of 110 mmHg or target blood pressure of 160/90 mmHg)using intermittent or continuous intravenous medication, and clinically reexamine the patient every 15 minutes Labetalol,nicardipine, esmolol,enalapril,hydralazine, nitroprusside,and nitroglycerin are useful intravenous agents for controlling blood,pressure.

19. Management of hypertension in subarachnoid Hemorrhage 1. Patients with SAH often develop increased intracranial pressure (ICP). With increased ICP,cerebral perfusion may be impaired. Cerebral perfusion pressure (CPP) equals the mean arterial pressure (MAP) minus the ICP. 2.Thus,increases in MAP may be the only means to maintain CPP at a level necessary tomaintain perfusion. Target cerebral perfusion pressure is 60-70 mmHg. 3. On the other hand, elevated blood pressure can worsen a SAH. 4. While lowering blood pressure may decrease the risk of rebleeding, this benefit may be offset by an increased risk of infarction. 5.Ventriculostomy is placed in appropriate patients; this allows direct measurement of intracranial pressure and often drops systemic blood pressure into the normal range. 6. In the absence of ICP measurement, antihypertensive therapy is often withheld unless there is a severe elevation in blood pressure because of concern about cerebral ischemia and the frequent compensatory nature of acute hypertension.

20. 7. The patient's cognitive status may be a useful guide a. If the patient is alert, then CPP is adequate, and lowering the blood pressure may decrease the risk of rerupture. It is reasonable to lower the SBP to below 160 mmHg. b. In contrast, antihypertensive therapyis generally withheld in those with a severely impaired level of consciousness since the impairment may be due to a reduced CPP. 8. When blood pressure controI is necessary, the use of vasodilators such as nitroprusside or nitroglycerin should be avoided because of their propensity to increase cerebral blood volume and therefore intracranial pressure. 9. Preferred antihypertensive drug are labetalol, esmolol or nicardipine.

21. Complications :