management of stroke three to twenty four hours

Prof.A.V.Srinivasan , MD, DM, Ph.D, DSc,F.R.C.P.(London)

F.A.A.N, F.I.A.N

Emeritus Professor,The Tamilnadu Dr.M.G.R.Medical university

Former Professor and Head ,

INSTITUTE OF NEUROLOGY

Madras Medical Colege

Prof.A.V.Srinivasan , MD, DM, Ph.D, DSc,F.R.C.P.(London)

F.A.A.N, F.I.A.N

Emeritus Professor,The Tamilnadu Dr.M.G.R.Medical university

Former Professor and Head ,

INSTITUTE OF NEUROLOGY

Madras Medical Colege

Management of Stroke(Three to Twenty Four Hours)

The sign wasn’t placed there

By the Big Printer in the sky

OBJECTIVE Definition

Stroke burden

Types & Mechanisms

Risk factors

Clinical evaluation

Investigations

Treatment of ischaemic stroke

Treatment of h hemorrhagic stroke & SAH

Rehabilitation

Newer developments – Interventions & neuroprotectives.

Stroke: WHO Definition

Stroke is clinically defined as a neurologic syndrome characterized by “Rapidly developing clinical signs

of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of

vascular origin”.

CONCEPT OF “BRAIN ATTACK”

In all of us, even in good men, there is a wild - beast nature which peers out in sleep

Burden of Stroke Most common life-threatening neurologic disease Third most common cause of death globally Incidence in India: 73/1,00,000 per year No formal registry available. Burden is likely to increase with risk factors like

aging, smoking, adverse dietary patterns Most common cause of disability and dependence. 70% of stroke survivors remaining vocationally

impaired 30% requiring assistance with daily activities

The True Art of Memory is The Art of Attention - S.Johnson

26 per lac per year

Ischaemic – 69%

Hemorragic –23%

SAH – 3%

Undetermined – 5%

Burden of Stroke

We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts

R.B. Schmeck

Types & mechanisms

Ischaemic – Atherothrombotic

Embolic

Lacunar

Hemorrhagic – ICH

SAH

Global hypoperfusion – Watershed infarcts.

A true commitment is a heart felt promise to yourself from which

you will not back down - D. Mcnally

Stroke: Classification

Ischemic stroke: Account for 80%.

Results from occlusion in the blood vessel supplying the brain

Thrombotic: Occlusion due to atherothrombosis of small/large vessels supplying the brain

Embolic: Occlusion due to embolus arising either from heart (e.g. atrial fibrillation, valvular disease) or blood vessel

Serious, sincere, systematic study surely secures supreme success

Classification (contd.)

Hemorrhagic stroke: Account for 20%. Results from rupture of blood vessels leading to bleeding in brain

Intracerebral: Bleeding within the brain due to rupture of small blood vessels. Occurs mainly due to high blood pressure

Subarachnoid: Bleeding around the brain; commonest cause is rupture of aneurysm.Other causes: Head injury

Habit is either the best of servants or worst of masters

LACUNAR INFARCT <10mm in size.

Absence of cortical sings.

Super lacune >15mm.

Syndromes- ataxic hemiparesis

pure motor, pure sensory,sensory-motor

dysarthria clumsy hand, pure dysarthria,

hemichorea& unilateral asterixis.

Success in life is a matter not so much of talent and opportunity

as of concentration and perseverance - C.W. Wendte

Associated with Systemic hypertension, DM

Weight of the heart exceeds 400g.

Prognosis -no mortality,

lenticulo striate territory-good recovery

ant.cho.artery-poor recovery.

LACUNAR INFARCT

Give us the GRACE to accept with serenity the things that cannot be changed the COURAGE to change the things that should be changed and the WISDOM to

know the difference

Anterior circulation stroke – Total (TACS)

Anterior circulation stroke – Partial (PACS)

Posterior circulation stroke – PCS

Lacunar Strokes.- (LS)

Oxfordshire Community Stroke project (OCSP)

“ He who cannot forgive others destroys the bridge over which he himself must pass”- Annoy

Differentials

Focal epilepsy.

Migraine.

Transient Global Amnesia.

Tumor

Metabolic Encephalopathy

Multiple Sclerosis.

The secret of walking on water is

Knowing where the stones are

Transient Ischemic Attack (TIA)

“Mini stroke”

Stroke symptoms last for less than 24 hours (usually 10 to 15 mins)

Result as a brief interruption in blood flow to brain

Every TIA is an emergency

TIA may be a warning sign of a larger stroke

Patients with possible TIA should be evaluated

If you think you can or you can’t

You are always right

TIA- contd

Few minutes to 24hrs (>85% within 30mts).

12% atherosclerotic infarct

Predominantly negative symptoms.

Weakness/numbness of UL/UL&LL,speech disturbance,mono ocular blindness, weakness of thumb&index finger.

Memory, the daughter of attention ,

is the teeming mother of knowledge - Martin Tupper

Stroke: Predisposing factors

Age (risk doubles for every decade after 55yrs) Gender (males>females) Family history of stroke/TIA Hypertension Diabetes Hyperlipidemia Hyperhomocysteinemia

As long as you get there before

It’s over you’re never late

Obesity Smoking Atrial fibrillation Sedentary lifestyle Drug abuse (e.g. cocaine use) Hormone replacement therapy Oral contraceptive

Stroke: Predisposing factors

Discipline Weighs ounces

Regret weighs Tons

Genetics & stroke Single gene disorder

Sickle cell disease

Homocystinuria

Marfans syndrome – dolichoectasia

Fabry’s disease Vascular risk factors

Genetic hypercoagulable disorders

Metabolic disorders with vasculopathy

Hereditary intracranial aneurysms

Some people feel the rain;

Others just get wet

CADASIL – Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and Leucoencephalopathy.

Recurrent episodes of subcortical infarcts or TIAs

Onset 30 – 50 years

Stroke, dementia, pseudobulbar palsy, migraine

MRI shows extensive leucoencephalopathy

Genetics & stroke

Opinion is ultimately determined by the feelings

and not by the intellect

Genetics & stroke

Multiple infarcts in the basal ganglia and in the periventricular regions .

U- fibers are spared. Skin biopsy is diagnostic- granular,

eosinophilic, electron dense material in the media of the arterial wall.

Familial clusters with hemiplegic migraine- CADASIL - M

Experience can be defined as

yesterday’s answer to today’s problems

Stroke: Symptoms

Onset of stroke symptoms varies as per type of stroke

Thrombotic stroke: Develop more gradually

Embolic stroke: Hits suddenly

Hemorrhagic stroke: Hits suddenly and continues to worsen

It is the province of the knowledge to speak

and it is the privilege of the wisdom to listen - Hodly’s

Stroke: Symptoms (contd.) Dizziness Confusion Loss of balance/coordination Nausea/vomiting Numbness/weakness on one side of the body Seizure Severe headache Movement disorder/speech disorder/blindness etc (depending on the area of

brain affected)

Additional symptoms for hemorrhagic stroke Pain upon looking at or into light Painful stiff neck

“SILENT STROKES”

A silent stroke is a stroke which causes brain damage, but does not exhibit classic

symptoms of stroke. They are detected only when a person undergoes a brain scan. –

Multi infarct state.

The meek shall inherit the earth

- but not its mineral rights

Stroke management

“TIME

IS

BRAIN”

Our best thoughts come from others

Detection

Dispatch

Door

Data

Decision

Drug

Stroke management

6 Ds

It’s not over until it’s over

DETECTION

Success is a prize to be won. Action is the road to it.

Chance is what may lurk in the shadows at the road side.

- O. Henry

Cincinatti stroke Score

- Facial droop

- Arm drift

- Slurred speech

1 out of 3 - > 72% probability of stroke.

Stroke management - Detection

Thinking is the hardest work there is, which is probable reason

why so few engage in it.

- Henry Ford

Los Angeles Probable stroke Score.(LAPSS)

Includes arm drift, facial droop, slurring of spech, age , presence of risk factors like hypertension, DM, previous TIAs,

Little cumbersome.

No better than Cincinatti Score.

Stroke management - Detection

People of mediocre ability often achieve success because

they don’t know enough to quit - Bernard Baruch

DISPATCH

TO HOSPITAL

EMR

Whatever the Mind can conceive and Believe, the mind can Achieve

Napoleon Hill

On suspicion of stroke the person should be dispatched to the Emergency Medical Room as early as possible.( Within minutes)

Maintain vitals and arrange for transport.

No Aspirin or heparin to be administered.

Stroke management – to Door

“Social Isolation is in itself a pathogenicFactor for disease production”

DATA

EMERGENCY IMAGING – CT/ MRI

BIOCHEMICAL PROFILE

Possible investigations.

Science is below the mind; Spirituality is beyond the mind

Physical examination: Vitals,Neurologic

Brain imaging (cranial CT and/or MRI): discriminate between ischemic and hemorrhagic

Stroke Doppler ultrasonography/Angiography: Detect large vessel atherosclerosis

ECG/Echocardiography: Detect cardiac embolism

Exclusion of conditions mimicking stroke (hypoglycemia, migraine, seizure)

Stroke management – Door to data

Speak obligingly even if you cannot oblige

Ischemic stroke diagnostic algorithm

Acute focal brain deficit

Head CT

Ischemic Stroke

ECGEcho

CARDIACEMBOLISM

LARGE ARTERYATHEROSCLEROSIS

SMALLVESSEL DISEASE

OTHER DETERMINEDCAUSE

DopplerMRAAngiogram

MRICT

VasculopathyCoagulopathy

CRYPTOGENICSTROKE

Excluded hypoglycemia, migraine

with aura, post-seizure deficit

TIA (if CT/MR brain imagingwithout ischemic lesion)

< 1 hour

Lacunar syndromeCortical syndrome

A woman’s desire for revenge outlasts all her other emotions

General management

ABC Fluids & electrolytes Dysphagia, aspiration Urinary dysfunction Venous thromboembolism Seizures Skin care Depression

Maintaining the right attitude is easier than

regaining the right mental attitude

Management of acute ischemic stroke

Systemic thrombolysis: Intravenous recombinant tissue plasminogen

activator (rt-PA) Within 3 hrs of onset of stroke. Dose 0.9 mg/kg, max 90 mg. Intra arterial thrombolysis is being tried.- time

window is upto 6 hrs. – technically demanding. No Aspirin or heparin for 24 hrs. following

thrombolysis

When they tell you to grow up, they mean stop growingWhen they tell you to grow up, they mean stop growing

Management of acute ischemic stroke (contd..)

Anticoagulants: Heparin/LMWH NOT recommended in acute ischemic stroke routinely.

Recommended in setting of atrial fibrillation, acute MI risk, prosthetic valves, coagulopathies and for prevention of DVT.

Intra-arterial thrombolytics: An option for treatment of selected patients with major stroke of < 6 hrs duration due to large vessel occlusion.

Why should I question the monkeywhen I can question the organ grinder?

Management of acute ischemic stroke (contd)- hypertension

BP Should be kept within higher normal limits since low BP could precipitate perfusion failure.

Reduction of BP in acute stroke phase is controversial. Reduce BP if there is severe end organ damage like

pulmonary edema, encephalopathy, uremia. Markedly elevated BP (>220/110mmHg) managed with

nitroglycerin, clonidine, labetalol, sodium nitroprusside.

More aggressive approach is taken if thrombolytic therapy is instituted

He is free who knows how to keep in his own hands

the power to decide

Management of acute ischemic stroke Glucose & pyrexia

Blood glucose Should be kept within physiological levels using oral or IV glucose (in case of hypoglycemia)

insulin (in case of hyperglycemia) RBS >300 mg

Avoid routine glucose infusions Elevated body temperature management:

Antipyretics and use of cooling device can improve the prognosis

To get to the promised land you have to

negotiate your way through the wilderness

Specific therapy - Ischaemic

Thrombolytic therapy- r- tPA

Time window – 3 hrs.

0.9 mg/kg max. 90mg.

10% bolus & 90% as infusion in 1 hour.

Risk of hemorrage – 6%

It is a great misfortune not to possess sufficient wit to speak well

nor sufficient judgment to keep silent

La Broyers character

Ancrod

Venom of Malaysian pit viper.

Fibrinogen & viscosity

RBC aggregation

Endogenous tPA upregulation

Vasodilatation

Anticoagulant activity.

We possess by nature the factors out of which personality can be made, and to organize them into effective personal life is every man’s primary responsibility

- Harry Emerson Fosdick

Hemorrheologic therapy

Hemodilution

Pentoxyfylline

Ancrod – Malaysian pit viper venom.

Mind is the great level of all things;

human thought is the process by which

human ends are ultimately answered

Thrombolytic drugs

t NK- Tenectoplase – derived from t PA.

Desmoteplase

Alteplase

r- pro UK

Gp IIIa Iib receptor blockers.

Lys- plasminogen


Secondary prevention of stroke Recurrence: Annual risk is 4.5 to 6%. Five year recurrence rates range from 24 to 42% one-third occur within first 30 days, hence high priority

should be given to secondary prevention. Patients with TIA or stroke have an increased risk of MI

or vascular event. Management of hypertension (goal <140/85 mm Hg)

A bad teacher complains;

A good teacher explains;

The best teacher inspires;

Diabetes control (goal<126 mg/dL) Lipid management: Statins (goal

cholesterol<200 mg/dL, LDL<100 mg/dL) Anticoagulants: Warfarin (target INR 2 to

3); esp. recommended in patients with cardioembolic stroke

Appropriate life style modification (cessation of smoking, exercise, diet etc)

Secondary prevention of stroke

Knowledge without action is useless;

Action without knowledge is foolish

Antiplatelet agents: Aspirin (50-325 mg), clopidogrel (75 mg). Ticlopidine 200mg bid Aspirin + ER Dipyridamole Sulfinpyrazone Suloctidil A combination of the two drug may also be used


Reputation is made in a moment; character is built in a life time

Complications of stroke

Cerebral edema – 30% of patients worsen after stroke due to cerebral edema.

24 – 96 hrs after acute stroke.

Initially cytotoxic(gray matter),later vasogenic (white matter)

Excitatory amino acids (EAA) – produces neurotoxic edema – accelarates apoptosis.

Vedanta admits realization

But defies verbal definition



Hemorrhagic transformation occurs in about 40%.

Occurs in first 2 weeks.

10% of patients worsen.

Increased risk with antithrombotics, anticoagulants, and thrombolytic therapy.

Size (>1/3rd) of the vascular territory and elderly are more prone for hemorrhagic transformation.

Complications of ischaemic stroke

Pure love ever gives; Never seeks Pure love ever gives; Never seeks

Management of Acute hemorrhagic stroke

Analgesics/Antianxiety agents: To relieve headache. Analgesics having sedative properties are beneficial

Hyperosmotic agents (e.g. mannitol, glycerol, furosemide): To reduce cerebral edema, and raised intracranial pressure.

Adequate hydration is necessary Surgical intervention may occasionally be life

savingWhat is mind no matter

What is matter never mind

What is mind no matter


Surgical interventions

Balloon angioplasty/stenting

Carotid endarterectomy/Bypass

Decompressive craniectomy

Stem cell therapy.

Every thing should be made as simple as possible;

but not simpler

Carotid endarterectomy & stenting

CEA in symptomatic patients provides protection against stroke. ( >70% stenosis)

In 50 –69% stenosis the benefit is marginal compared to medical therapy.

The stroke reduction is realized early after surgery and persisted for extended periods.

In TIA CEA has to be performed as early as possible if there is significant stenosis

ECST and NASCET trials have proved the benefit.

Hate screeches, fear squeals; conceits trumpets

but love since lullabies

“ FROM KNIFE TO STENT” In patients having a increased surgical risk. CCF, severe COPD, unstable angina, past

radiation therapy, local tumor mass etc.,. SAPPHIRE study has shown benefit in a

group of patients. Angioguard emboli protection device is

used.

Carotid stenting & angioplasty

Learn to adapt, adjust and accommodate

Learn to give, not to take and learn to serve not to rule

Sub arachnoid hemorrhage (SAH)

Aneurysmal or non aneurysmal.

Vasospasm is a critical factor.

Autoregulation impaired with vasospasm.

Hunt and Hess grading – Clinical

Fisher grading – CT scan

Lumbar puncture may be necessary.

Teachers are reservoirs from which, through the process of education, the students draw the water of life

SAH - TRIPLE - H Therapy

Hypertension

Hypervolemia

Hemodilution

Nimodipine – used to treat vasospasm.

Love is selfishness and selfishness is lovelessness

SAH - Surgical

Aneurysmal clipping within 48 – 72 hours

Prevents early rebleeding

Permits aggressive therapy for vasospasm

Endovascular therapy – coiling with GDC coils or thrombogenic platinum coils

Asymptomatic aneurysms - > 6mm diameter-

Expert is one who thinks to his

chosen mode of ignorance

GUIDELINES

History And Examination Guide: 1 & 2

a. Stroke clerking Performa (1994) R.C.P.

1. Improved patient Assessment

2. Improved Management & outcome- not clear

b. Examination

1.Secure Diagnosis of Stroke

2.Specify Impairment

3. Identify sub type of Ischemic stroke

God is a comedian performing before an audience

that is afraid to laugh

Guide: 3 (B) - CPR

– Impaired consciousness in stroke is common in posterior circulation strokes.

– Impaired Consciousness - From Stroke Resuscitation is rarely successful - Schneider 1993

“Prediction is always difficult – especially when it concerns the future”

– Oscar Wilde

Guide: 4 - CXR

Chest x-ray abnormal in 16%

– Only 4% change clinical management

– Order x-ray chest if WT Loss or chest symptoms present

- Not recommended in routine stroke management.

If I were to choose between pain and nothing… I would choose pain

-- William Faulkner

Guide: 5 - ECG Detection of cerebrogenic cardiovascular

disturbance. Acute ST- T changes,rhythm abnormalities are

common (upto 40%) Insular cortex involvement is an independent risk

factor Rt. Sided lesions, age ,HT/DM/IHD are other factors Cardiac cause of Death (30 days)

ALL STROKE PATIENTS TO HAVE ECG

Pain is god’s greatest gift to mankind - Paul Brand.

Guide: 6 - ECHO

To identify stroke mechanism.

LV clot, Patent Foramen Ovale (PFO), Infective endocarditis, AF,Silent lesions

Detects silent cardiac lesions

Lesions of aorta

TEE is more useful than TTE.

High yield in ischaemic lesions.

RECOMMENDED IN SETTINGS WHERE AVAILABLE

The Truth is fear and immorality are two of the greatest inhibitors of Performance to progress

Guide: 7 - CT scan brain

ABSOLUTE INTEGRAL PART IN STROKE Differentiates between ischaemia, hemorrhage,

SAH Early signs are useful in deciding about

thrombolytic therapy. (Hyperdense MCA sign,insular ribbon sign,sulcal effacement)

Helical and CT Angio are useful. MUST IN ALL STROKES

Develop the heart; art comes automatically

Guide 8: M.R.I.

Not Routine in Acute Stroke

Diffusion & perfusion weighted images are very useful in the acute phase in ischaemic infarction

Along with MRA gives valuable information

NOT ROUTINELY INDICATED

“ My opinions are founded on knowledge

but modified by experience”

Guide 9: - Doppler studies

B-mode, Duplex, continuous wave and pulsed doppler systems, Color doppler flow imaging, TCD

Shows changes in flow patterns near plaques. Gives idea about the vulnerability of the plaque. Useful in assessing the Vasospasm, collateral

circulation, hemodynamic effects, reserve capacity To plan carotid endarterectomy. USEFUL IN APPROPRIATE CLINICAL SETTINGS.

I don’t like peripheral neuritis– it interferes with work

Guide 10: (B) - FEVER

Fever (Worst Prog.) – 1 * C increases the metabolic need by 7% . Treatment of fever has consistently produced good results.

Hypothermia theoretically useful. – not proved

TEMPERATURE REDUCTION IS INDICATED.

In any field, find the strangest thing and explore it

Guide 11: (B) - OXYGENATION

Hypoxia ( Moroney 1996) – Exacerbated by seizures Pneumonia and Arrhythmias - Worst outcome

Oxygenation bas been Consistently useful.

Hyperbaric O2 ineffective (Nighoghossaln 1995)

OXYGEN ADMINISTRATION IS USEFUL AND RECOMMENDED.

He can’t walk and chew gum at the same timeHe can’t walk and chew gum at the same time

Hyperglycemia DM & hyperglycemia are associated with

larger infarcts and fasting hypoglycemia with smaller infarcts.

Worsening in hyperglycemia is due to lactic acidosis

Optimal blood glucose is less than 130 mg%

Treat hyperglycemia with insulin.

Take time to think; it is the source of power

Take time to read; it is the foundation of wisdom

Take time to work; it is the price of success

Guide: 12- Anti edema measures.

Steroids are ineffective in stroke Mannitol, Glycerol, Hypertonic saline is useful in

some cases. Loop diuretics are useful. Albumin can also be used – not proved in major

trials Hyperventilation – useful for short periods,

rebound edema is common- not recommended routinely.

Thought is the labour of the intellectReverie is its pleasure

Guide 13: (B) - OTHERS

Haemodilution- Plasm Expanders TRIPLE – H therapy useful in SAH. Mean Arterial Pressure – 120-130 mm Hg CVP – 10-12 mm Hg PCWP –14-18mm Hg Hematocrit 30-33% Check ABG only if Hypoxia suspected.

Guide: 14 - OTHERS

Barbiturate coma and propofol to reduce the elevated intracranial pressure have been useful in large ischaemic strokes.

They produce hypotension and hence may be detrimental in some patients.

Judicious use is advised. Indomethacin 50mg I.v. has been used in stroke

to lower ICP – may reduce CBF- only case reports are available

Guide: 14 - OTHERS

Sedation, pain control and neuromuscular blockade may be necessary in patients with altered sensorium as pain and irritation impede cerebral venous return

Sedation reduces sympathetic overactivity, increases co operation for procedures and nursing care.

Helpful in reducing the cerebral metabolism.

Guide 12: (B) - Blood Pressure

Defer - acute reduction of BP - 10 days unless HT Encephalopathy or aortic dissection present

Increase in BP - falls in 10 days (Moris 1997) HT - Prim. stroke prevention ACE- I are very useful in managing HT A diuretic may also be combined. NO DEFINITE LOWER LEVEL BP

Guide 13: (A/B) - AF

AF / LV clot - warfarin after 48 Hrs – start along with heparin

Aspirin for others

EAFT 1995 Prothrombin time- Less than 2 - No effect

PT- > 5 - Bleeding (SPAF 1996 )

Guide 15: Cholesterol

Dietary and pharmacologic measures in reducing cholesterol are very effective

Proven in large controlled trials

Statins are very useful

Start all patients with stroke on Statins.

At twenty the will rules

At thirty the intellect

At forty the Judgment

Guide 16: Deep vein thrombosis

50% stroke Pts –develop DVT 10 days (Kalra 1995 Pulmonary embolism in 6-16% only (Sandercock

1993 ) Heparin 5000IU QID or 12500IU twice daily -

Hemorrage greater Gradual stocking is of value -Use with caution - if

peripheral artery insufficiency is present HEPARIN IS USEFUL IN PREVENTING DVT.

Guide 18: (A) –Antithrombotic drugs

Aspirin 75 - 150 /Day

3 yrs 40% reduces of vascular events in 1000 pts (APTC - 1994)

Stroke sub type value ? (TACI, PACI, LACI, POCI)

synergy possible with clopidogrel ,ticlopidine etc.

Anti Coagulation

Warfarin - AF In sinus rhythm - uncertain Spirit 1997 low dose aspirin + Warfarin in TIA & Minorstorke Heparin (IST 1997) - Signif. reduction in early death (12

fewor in 1000) not better than aspirin So avoid Heparin (A)

Guide 20: (I) Hemorrhage

Supra tentorial evacuation for ICH is controversial - Avoid (Hankey and Hon 1997)

Infra tentorial hematomas- early evacuation

Main Indication - Deteriorating or depressed consciousness

Other measures.

Nutritional maintenance especially if dysphagiais present

Prevention of pulmonary complications Prevention/treatment of UTI Prevention of decubiti Treatment of depression Physiotherapy and rehabilitation

GOALS ACHIEVED ?

Prevent first stroke

Facilitate recovery

improve neurological function

Dedicated to my family for making everything worthwhile

READ not to contradict or confute

Nor to Believe and Take for Granted

but TO WEIGH AND CONSIDER

THANK YOUMy sincere thanks to Mr. G. Kakuthan,

for his meticulous computer work

DECISION

TO USE THROMBOLYTIC

NATURE, TIME AND PATIENCE are the 3 great physicians

DRUG - r tPA

Before administering thrombolytic therapy the following investigations have to be carried out apart from the MANDATORY CT SCAN BRAIN which rules out hemorrhage.

Routine blood biochemistry.

Coagulation profile – PT,PTT

Doppler studies.

The world shall perish not for lack of wonders but lack of wonder

Multimodal monitoring

CBF monitoring –

Xenon enhanced CT scanning

laser doppler flowmetry (qualitative)

Thermal diffusion ( quantitative)

Brain tissue oxygenation

tissue partial pressure of oxygen (Ptio2)

Directly measured with electrodes.

Through Action You Create your Own Education- D.B. ELLIS

Intracerebral microdialysis Monitor the chemistry of the extracellular

space in living tissues.

Physiological salt solution is slowly pumped through the microdialysis probe, the solution equilibrates with the surrounding extracellular tissue fluid.

The microdialysate is then extracted and analysed for lactate and glutamate etc..,

“Knowledge can be communicated but not Wisdom”- Hermann Hesse

Emergency Medical Care for Neurologic Emergencies

• Provide reassurance.• Ensure proper airway and breathing.• Place the patient in a position of comfort.• Assess and care for any injuries if you suspect

any type of trauma.

Many Ideas grow better when transplanted into another mind than in the one where they sprang UP

O.W. Holmos