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1. MANAGEMENT OF CVA Dr Meghana B S Assistant Professor ESIMC& PGIMSR

2. COMPETENCIES: IM 18.10 : Choose and interpret the appropriate diagnostic testing in young patients with a cerebrovascular accident (CVA) IM 18.11: Describe the initial supportive management of a patient presenting with a CVA IM 18.12: Enumerate the indications for and describe acute therapy of non hemorrhagic stroke including the use of thrombolytic agents IM 18.13: Enumerate the indications for and describe the role of anti platelet agents in non hemorrhagic stroke

3. INVESTIGATING A PATIENT WITH STROKE IN YOUNG

4. Stroke in Young: Age criteria : Less than 45 years

5. Causes of Stroke in Young: Cardiac causes : Mitral stenosis with atrial fibrillation, PFO, VSD, TOF, Infective endocarditis Antiphospholipid syndrome SLE Hematological disease —sickle cell anemia , polycythemia rubra vera. Inherited deficiency of naturally occurring anti-coagulant deficiency (protein C, protein S, antithrombin III, factor V Leiden). Vasculitis : Behcet’s disease, Takayasu, Temporal arteritis Vascular malformation —AVM, berry aneurysm causing SAH

6. Arterial dissection In female —oral contraceptive pill, eclampsia Homocystinemia MELAS Fibromuscular dysplasia Syphilis Familial hyperlipidemia Drugs like amphetamine, cocaine. Inherited stroke syndromes: CADASIL, CARASIL (Cerebral Autosomal dominant/ recessive arteriopathy with subcortical infarcts and leukoencephalopathy) Moya- moya disease: ‘Puff of smoke appearance’

7. CBC FLP FBS, PPBS, HBA1C TSH Homocysteine Hypercoagulability workup: Protein C, Protein S, AT III, Factor V Leiden mutation Autoimmune workup: P ANCA , C ANCA, ANA Profile ECG , 2D ECHO HIV , VDRL What investigations should be done in a young patient with stroke?

8. MANAGEMENT OF CVA:

9. 1. General measures: ABC, treat hypo or hyperglycemia, treat Fever Oropharyngeal suction DVT Prophylaxis Nasogastric tube feeding Maintenance of nutritional status Regular change of posture (2 hourly) Care of bowel and bladder (catheterization) Care of mouth (to prevent fungal infection) Care of eyes (CMC drops or taping of the affected eye shut).

10. 2. Control of risk factors or cause: Control of hypertension Control of diabetes mellitus Control of hyperlipidemia Other treatment according to the cause.

11. MANAGEMENT OF HTN IN CVA:

12. 3. Specific treatment according to the type of stroke (after CT scan): Cerebral infarction: When ischemic stroke occurs, the immediate goal is to optimize cerebral perfusion in the surrounding ischemic penumbra. IV thrombolysis Endovascular revascularization Antithrombotic treatment Cerebral hemorrhage : For massive hemorrhage : neurosurgical intervention may be required. Antiedema measures: Glycerol and mannitol.

13. IV thrombolysis

14. TIME OF STROKE ONSET: It is defined as the time the patient’s symptoms were witnessed to begin or the time the patient was last seen as normal. Patients who awaken with stroke have the onset defined as when they went to bed.

15. THROMBOLYSIS:

16. COMMON THROBOLYTICS USED: Tenecteplase (0.25 mg/kg IV bolus over 5 s)

17. ENDOVASCULAR REVASCULARIZATION Ischemic stroke from large-vessel intracranial occlusion results in high rates of mortality and morbidity. Occlusions in such large vessels (middle cerebral artery [MCA], intracranial internal carotid artery, and the basilar artery) generally involve a large clot volume and often fail to open with IV rtPA alone. Endovascular mechanical thrombectomy.

18. ANTITHROMBOTIC TREATMENT Platelet Inhibition: Aspirin is the only antiplatelet agent that has been proven to be effective. Dosage : 150mg OD Anticoagulants are not indicated (Prophylactic dose may be considered for prevention of DVT) Statins therapy

19. Indications for dual antiplatelets in stroke : Minor Stroke (NIHSS > 3) High risk TIA (ABCD score more than 4)

20. Hemorrhagic stroke: Putamen, globus pallidus, thalamus, cerebellar hemisphere, pons

21. 4. MANAGEMENT OF COMPLICATIONS:

22. 5. Rehabilitation: Physiotherapy Speech therapy Occupational therapy.