Stroke emergency treatment

1. Emergency Treatment of Emergency Treatment of
StrokeStroke

2. Normal Brain Physiology
2-3% of body weight
15% of cardiac output
20% of all O2
25% of all glucose

3. Cerebral Ischaemia - Threshold
Normal flow, normal functionNormal flow, normal function
Synaptic transmission
failure
Membrane pump failure
2020
5050
1010
00
Time in hoursTime in hours
CBF (ml/100g brain) CBF (ml/100g brain)
Low flow, raised O2 extraction, normal
function
11 22 33 44 55

4. Cerebral infarct <3hrs
Onset
Infarct
Ischaemic
penumbra

5. Cerebral infarct 6hrs
Infarct
Ischaemic
penumbra

6. Cerebral infarct 24hrs
Infarct
Ischaemic
penumbra

7. NA, DopamineNA, Dopamine
Ca2+ i Ca2+ i 
Ischaemic Brain Injury
Ischaemia - 02 Ischaemia - 02  glucose glucose 
Anoxic depolarisationAnoxic depolarisation
 lactatelactate
GlutamateGlutamate
Hi Hi
Free Free
Fe2+ Fe2+
Free radicalsFree radicals
LipolysisLipolysis NO synthase NO synthase
ProteolysisProteolysis

8. Cerebral Arterial territory
Anterior cerebralAnterior cerebral
Middle cerebralMiddle cerebral
Posterior cerebralPosterior cerebral
Anterior choroidalAnterior choroidal

9. Partial Ant. Cir. Syndrome (PACS)
·ANY ONE OF THESE:-
·Two out of three as TACI
·Higher Dysfunction
·Dysphasia
·Visuospatial
·Homonymous
Hemianopia
·Motor / Sensory Deficit
·>2/3 Face / Arm / Leg
·Higher Dysfunction Alone
·Limited Motor / Sensory
Deficit

10. Total Ant. Cir. Syndrome
·ALL OF THESE:-
·Higher Dysfunction
·Dysphasia
·Visuospatial
·Homonymous Hemianopia
·Motor / Sensory Deficit
·>2/3 Face / Arm / Leg

11. Lacunar syndromes (LACS)
•ANY ONE OF
THESE:-
·Pure Motor Stroke
(>2/3 Face/Arm/Leg)
·Pure Sensory Stroke
(>2/3 Face/Arm/Leg)
·Sensorimotor Stroke
(>2/3 Face/Arm/Leg)
·Ataxic Hemiparesis

12. Lacunar Infarct Types
·MUST HAVE NONE OF THESE:-
·New Dysphasia
·New Visuospatial Problem
·Proprioceptive Sensory Loss only
·No Vertebrobasilar features

13. Posterior Cir. syndrome (POC)
ANY OF THESE FEATURES
·Cranial Nerve Palsy AND
Contralateral Motor/Sensory
Deficit
·Bilateral Motor OR Sensory
Deficit
·Conjugate Eye Movement
problems
·Cerebellar Dysfunction
WITHOUT Ipsilateral Long
Tract Signs
·Isolated Homonymous
Hemianopia

14. Stroke types
Al 35-44 yrAl 35-44 yr
Infarct 80% 42% Athero-thrombo-embolism 50%
Intracranial small vessel 25%
Cardioembolic 20%
Rare 5%
PICH 10% 10%
SAH 5%38%
Unknown 5% 10%
75%

15. Pre Hospital Care
1. Early recognition of
Stroke warning
signal by patient
2. Call ED if a person
has symptoms of
acute stroke.
3. Emergency transport
and care

16. ED immediate care of Stroke
1. Check Vitals, general assessment
2. Stabilize: Respiration, circulation
3. Control Seizure
4. Reduce intracranial tension
5. Maintain blood sugar
6. Maintain temperature

17. Emergency tests
•Complete blood
count, PCV, TRBC,
platelet, smear for
MP,
•Blood sugar, blood
urea, serum
creatinine, serum
electrolyte,
•Blood gas,
•SGOT, SGPT,
•PT, PTT
•HIV, Hepatitis profile
•ECG / X-ray / CBC /

18. Stroke Emergency Imaging
•CT / CTA
•MRI / MRA/ / PI/ DI
•Echocardiography
•Carotid doppler,
•Transcranial doppler
•Cerebral Angiography
•SPECT

19. MRA & MRI in Stroke

20. When TIA is an emergency?
High risk TIA,S
1. A high grade vascular stenosis
2. An antiplatelet failure
3. A cardioembolic
4. Crescendo TIA.
Heparin-> warfarin if a long term
anticoagulation is required
Aspirin if anticoagulant contraindicated

21. Carotid endarterectomy in TIA’s
•High grade ipsilateral carotid stenosis
with TIA has high risk (30%) of
stroke within first week
•CE reduces mortality in such cases

22. “Patients who have improved
neurologically but have a persistent
neurologic deficit when seen, should
be managed as a recent stroke”

23. Aspirin in Acute Stroke
“In acute stroke aspirin is the only proven
antiplatelet agent. It should be commenced
as soon as the diagnosis of cerebral
infarction has been made, using a starting
dose of 150-300mg a day and continuing
until decisions have been made about
secondary prevention”

24. Anticoagulant in Acute Stroke
•Not shown to prevent progression
•LMH long term improved
• Hemorrhagic transformation is high
•Cardioembolic infarct
–Immediate for small infarct
– Delayed for large infarct
•Heparin - 1000 units/hr. PTT 1.5
•Heparinoid - 2500 to 3200 units SC BD

25. rTPA Inclusion criteria
•Clinical evidence for an ischemic stroke
•Age >18 years
•Signed consent, if possible
•Onset of stroke within 3 hours of initiation of therapy*
•Normal PT and PTT
If a patient has stroke on awakening from sleep or if the onset of
symptoms is not known, then stroke onset is determined from
time patient was last seen as "normal" (eg, when he or she went
to bed).

26. rTPA exclusion criteria
Historical
–Stroke or serious head
trauma in past 3
months
–Major surgery or
invasive procedure
within past 14 days
–GI or urinary bleeding
within past 21 days
–Puncture of
noncompressible artery
or biopsy of internal
organ within past 7
days
–Ongoing alcohol or
drug abuse
–Seizure preceding or
during stroke

27. rTPA exclusion criteria
–History of intracranial
hemorrhage (including
subarachnoid bleeds)
or known history of
cerebral vascular
malformations
–(including aneurysms
or arteriovenous
malformations)
–Pericarditis,
endocarditis, septic
emboli, recent
pregnancy, or active
inflammatory bowel
disease

28. rTPA exclusion criteria
Clinical, radiologic, or
laboratory
–SBP >185 mm Hg or
DBP >110 mm Hg
after repeated
measurements
–Rapidly improving or
minor symptoms
–Coma or stupor
–CT of brain indicative
of tumor, blood, or
early signs of cerebral
edema
–Elevated PT and/or
PTT
–Serum glucose <50
mg/dl or >400 mg/dL
–Platelet count
<100,000/mm
3

29. rTPA Protocol
•Obtain and review stat CT scan of the brain.
•Establish peripheral IV access (two separate
sites).
•Obtain CBC, chemistry panel, PT & PTT,
type and screen, and urinalysis.
•Review inclusion and exclusion criteria
•Determine patient's weight.

30. IV rTPA for Acute Ischaemic Stroke
•Administer TPA, 0.9
mg/kg (maximum, 90 mg)
as a 10% bolus over 1 to 2
minutes, followed by the
remaining 90% as a 1-
hour infusion
•Monitor for bleeding and
neurologic deterioration.
•Admit to ICU for 24
hours.
•Monitor BP
•Do not give antiplatelet or
anticoagulant therapies for
24 hours.
•Do not perform arterial
punctures, invasive
procedures, or IM
injections for 24 hours.
•Obtain CT scan of brain
24 hours postinfusion or
sooner if neurologic
deterioration occurs.

31. BP Control during thrombolysis
•Monitor BP every 15
minutes for 2 hours after
start of infusion
•Then every 30 minutes for
6 hours
•Then every hour, from the
8th hour until 24 hours
after the start of TPA
•Then per routine
•If after two readings 5-10
minutes apart:
•SBP = 180-230 mm Hg or
DBP = 105-120 mm Hg
•Give labetalol 10 mg IV
over 1-2 minutes. May
repeat or double the dose
every 10 minutes, up to
maximum of 150 mg or iv
infusion.

32. BP Control during thrombolysis
•SBP >230 mm Hg or DBP
= 121-140 mm Hg
•Give labetalol 10-20 mg
IV over 1-2 minutes. May
repeat or double the dose
every 10 minutes, up to
maximum of 150 mg or
infusion. .
•If response is inadequate,
start sodium nitroprusside
•DBP >140 mm Hg
•Give sodium nitroprusside
0.5-10 µg/kg/minute

33. Emergency CE in acute Stroke
1. Stroke in evolution with a minimal fixed
neurologic deficit,
2. A moderately severe neurologic deficit of
abrupt onset when the surgery can be
completed within the first 3 hours after the
onset of deficit, and
3. CT scan without evidence of hemorrhagic
transformation of an infarct or edema.

34. “Role of Neuro-protection
in Stroke is not clear and
not recommended routinely”

35. Subarachnoid hemorrhage
•Bed rest Analgesic
•Blood pressure control
•Oral nimodipine 60mg q6hx21 days
•Angiography for localization of bleeding
If aneurysm
•Immediate surgical clipping for
–Grade 1-3 patient without contraindication
–Grade 4-5 with intracerebral clot and deterioration

36. Primary Intracerebral hemorrhage
•Small (<3cm) hematoma has good prognosis
•Large hematoma (>6cm) in comatose patient have
poor prognosis.
•Surgical evacuation for 3-6cm superficial lobar
hematoma in a conscious patient
•Cerebellar hematoma with deteriorating level of
consciousness
• Control of BP

37. Thank You