Emergency Emergency Treatment of Treatment of

StrokeStroke

Normal Brain PhysiologyNormal Brain Physiology

2-3% of body weight

15% of cardiac output

20% of all O2

25% of all glucose

Cerebral Ischaemia - ThresholdCerebral Ischaemia - Threshold

Normal flow, normal functionNormal flow, normal function

Synaptic transmission failure

Membrane pump failure

2020

5050

1010

00

Time in hoursTime in hours

CB

F (

ml/1

00g

brai

n)C

BF

(m

l/100

g br

ain)

Low flow, raised O2 extraction, normal function

11 22 33 44 55

Cerebral auto regulationCerebral auto regulation

CBF

60 160

Mean systemic BP

Falling cerebral perfusionFalling cerebral perfusion

Cerebral perfusion pressure

Cerebral blood volume

O2 extraction fraction

Cerebral blood flow

Cerebral metabolic rate of O2Au

tore

gul

atio

n, n

o s

ympt

om

s

Exh

au

ste

d re

serv

e

Isch

aem

ic s

ymp

tom

s

Cerebral infarct <3hrsCerebral infarct <3hrs

Onset

Infarct

Ischaemic penumbra

Cerebral infarct 6hrsCerebral infarct 6hrs

Infarct

Ischaemic penumbra

Cerebral infarct 24hrsCerebral infarct 24hrs

Infarct

Ischaemic penumbra

NA, DopamineNA, Dopamine

Ca2+ i Ca2+ i

Ischaemic Brain InjuryIschaemic Brain InjuryIschaemia - 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

Cerebral Arterial territoryCerebral Arterial territoryAnterior cerebralAnterior cerebral

Middle cerebralMiddle cerebral

Posterior cerebralPosterior cerebral

Anterior choroidalAnterior choroidal

Partial Ant. Cir. Syndrome (PACS)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

Total Ant. Cir. SyndromeTotal Ant. Cir. Syndrome

ALL OF THESE:-

Higher Dysfunction Dysphasia

Visuospatial

Homonymous Hemianopia

Motor / Sensory Deficit >2/3 Face / Arm / Leg

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

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

Stroke types 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%

Stroke primary preventionStroke primary prevention

• Hypertension :

50% of stroke patients50% of these known to their

GP50% of these on treatment

?% on adequate treatment

Stroke secondary preventionStroke secondary prevention

• Of survivors, 30% chance CVA in 5 yr

• Risk level = to that following M Infarct

• Risk highest earlier on :

13% recurrence first yearx 15 risk of age and sex matched pop.

StrokeStroke

• Key assessments for secondary prevention– Blood pressure– Atrial fibrillation– Cholesterol– Lifestyle - smoking, diet, exercise, weight,

alcohol

Risk factors for stroke recurrenceRisk factors for stroke recurrence

• CVA/TIA• BP• Carotid stenosis• Cardiac - CHF,

arrhythmia, cardiomegaly

• Diabetes

• Hyperlipidaemia• P vascular disease• Smoking• Obesity• Inactivity

Platelet aggregationPlatelet aggregation

Platelet aggregationPlatelet aggregation Thrombus in lumenThrombus in lumen

ADP platelet ADP platelet membrane membrane receptorreceptor

ClopidrogClopidrogelel

AspirinAspirin

ThromboxanThromboxanee

DipyridamoleDipyridamole

Increase Increase Cyclic AMP Cyclic AMP and GMPand GMP

Stroke type - first everStroke type - first ever

• Infarct 80% 42%

• PICH 10% 10%

• SAH 5% 38%

• Unknown 5% 10%

AllAll 35-44 35-44 yryr

Stroke - questionsStroke - questions

• Is it a stroke ?

• What type of stroke ?

• Why did it happen ?

• How does it affect the patient ?

• What is the prognosis ?

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

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

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 /

Stroke Emergency Imaging

• CT / CTA

• MRI / MRA/ / PI/ DI

• Echocardiography

• Carotid doppler,

• Transcranial doppler

• Cerebral Angiography

• SPECT

Early sign CT - Infarction

MRA & MRI in Stroke

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

Carotid endarterectomy in TIA’s

• High grade (>60%) ipsilateral carotid

stenosis with TIA has high risk

(30%) of stroke within first week

• CE reduces mortality in such cases

“Patients who have improved neurologically

but have a persistent neurologic deficit when

seen, should be managed as a recent stroke”

“Role of Neuro-protection in Stroke is not clear and not

recommended routinely”

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”

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

Thrombolytic Therapy of Acute Ischemic stroke

Patients

• Period: 1992-00

• Total ischemic strokes 756

• Thrombolysis done 35

• Male 27

• Females 8

• Age in years 20-80

Inclusion Criteria

A. Clinical evidence for an ischemic stroke

B. Normal CT Scan

C. Age >18 years

D. Onset of stroke Ant cir 6 hr

Post cir 12 hr

E. Normal BT, CT, PT, PTT and platelet

Exclusion Criteria

A. Stroke or serious head trauma in past 3 months

B. Major surgery or invasive procedure within past 14 days

C. GI or urinary bleeding within past 21 days

D. Puncture of noncompressible artery or biopsy of internal organ within past 7 days

E. Ongoing alcohol or drug abuse

Exclusion Criteria cont..

F. Seizure preceding or during stroke

G. History of intracranial hemorrhage (including subarachnoid bleeds) or known history of cerebral vascular malformations (including aneurysms or arteriovenous malformations)

H. Pericarditis, endocarditis, septic emboli, recent pregnancy, or active inflammatory bowel disease

Thrombolysis in acute stroke

Within 3 hour of Stroke Small Vessel

Medium Vessel

IV rTPA/URK

Large Vessel

IA rTPA/URK

Stop

Thrombolytic Agents

Streptokinase: IA 1-1.5 lakh units

IV 2.5-10 lakh units

Urokinase: IV 5-10 lakh units

IA 5-10 lakh units

rTPA: IA 10-40 mg

IV 40-50 mg

Route of Administration

Drug IV IA Total

STK 7 2 9

URK 15 6 21

rTPA 3 2 5

Total 25 10 35

End Point of Treatment

• Total calculated dose given

• Patient showed significant improvement

• Significant bleeding complication

• Severe allergic reaction

Age Male Female Total

20-39 5 - 5

40-59 12 5 17

60-80 11 2 13

Total 28 7 35

Age Sex DistributionAge Sex Distribution

Arterial Territory and Severity

Artery Conscious Unconscious Total

ACA 16 10 26

PCA 2 7 9

Total 18 17 35

Outcome and Agent used

Recovery STK URK rTPA Total

Independent 4 13 2 19

Dependent 2 4 1 7

Death 3 4 2 9

Total 9 21 5 35

Outcome and Arterial Territory

Recovery ACA PCA Total

Con Unc Con Unc

Ind 12 1 2 4 19

Dep 3 3 - 1 7

Death 1 6 - 2 9

Total 16 10 2 7 35

Outcome and Timing of Treatment

Outcome <1h 1-3h 3-6h Total

Ind 6 4 9 19

Dep - 1 6 7

Death 3 - 6 9

Total 9 5 21 35

Outcome and CT scan

Outcome Normal Early Total

Independent 15 1 16

Dependent 5 2 7

Death 6 3 9

Total 26 6 32

Complication of therapy

Complication STK URK rTPA Total

Skin Rash - 1 - 1

Bronchospasm - 1 1 2

Anaphylaxis - 1 1 2

Gum bleed - 1 1 2

Gastric bleed 2 1 - 3

Urinary bleed - 1 - 1

IC bleed - 1 - 1

Hem trans 1 - - 1

Toxic edema 2 5 2 8

IC spasm - 1 - 1

Left Coronary Left Coronary angiogram angiogram showing severe showing severe atherosclerosisatherosclerosis

RightRight

middle middle cerebral cerebral artery artery block block following following coronary coronary angiogramangiogram

Right Right middle middle cerebral cerebral artery artery reperfusion reperfusion (AP) (AP) following following IA IA UrokinaseUrokinase

Conclusion

• Outcome was not related to the Drug used• Ant circulation minor stroke and posterior

circulation stroke has better prognosis• Ant. circulation major stroke did well on IA

thrombolysis.• Normal CT before treatment was not

related to good outcome. But abnormal CT has poor outcome.

• Hemorrhagic complication are dose related.

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.

Dec 31st 1999

Jan 21st 2000

Feb 11th 2000

Emergency Carotid Endarterectomy

DOA 5th Feb 00

Thank You