stroke emergency treatment for 26th march 00
TRANSCRIPT
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Emergency Emergency Treatment of Treatment of
StrokeStroke
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Normal Brain PhysiologyNormal Brain Physiology
2-3% of body weight
15% of cardiac output
20% of all O2
25% of all glucose
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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
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Cerebral infarct <3hrsCerebral infarct <3hrs
Onset
Infarct
Ischaemic penumbra
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Cerebral infarct 6hrsCerebral infarct 6hrs
Infarct
Ischaemic penumbra
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Cerebral infarct 24hrsCerebral infarct 24hrs
Infarct
Ischaemic penumbra
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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
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Cerebral Arterial territoryCerebral Arterial territoryAnterior cerebralAnterior cerebral
Middle cerebralMiddle cerebral
Posterior cerebralPosterior cerebral
Anterior choroidalAnterior choroidal
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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
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Total Ant. Cir. SyndromeTotal Ant. Cir. Syndrome
ALL OF THESE:-
Higher Dysfunction Dysphasia
Visuospatial
Homonymous Hemianopia
Motor / Sensory Deficit >2/3 Face / Arm / Leg
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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
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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
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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%
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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 ?
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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
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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
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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 /
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Stroke Emergency Imaging
• CT / CTA
• MRI / MRA/ / PI/ DI
• Echocardiography
• Carotid doppler,
• Transcranial doppler
• Cerebral Angiography
• SPECT
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Early sign CT - Infarction
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MRA & MRI in Stroke
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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
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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
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“Patients who have improved neurologically
but have a persistent neurologic deficit when
seen, should be managed as a recent stroke”
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“Role of Neuro-protection in Stroke is not clear and not
recommended routinely”
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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”
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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
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Thrombolysis in acute stroke
Within 3 hour of Stroke Small Vessel
Medium Vessel
IV rTPA/URK
Large Vessel
IA rTPA/URK
Stop
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IV rTPA for Acute Ischaemic Stroke
• Patient - within 3 hours of onset
- Normal CT scan
- BP <180/100 mmHg.
- No bleeding tendency
• Dose - 0.9mg /Kg. (max 90mg)
- 10% bolus, Rest 60 min. infusion
• Risk - ICH in 6% of patients
• Promise - Reduced morbidity by 30%
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Left Coronary Left Coronary angiogram angiogram showing severe showing severe atherosclerosisatherosclerosis
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RightRight
middle middle cerebral cerebral artery artery block block following following coronary coronary angiogramangiogram
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Right Right middle middle cerebral cerebral artery artery reperfusion reperfusion (AP) (AP) following following IA IA UrokinaseUrokinase
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Outcome of Thrombolytic therapy
Recovery STK URK rTPA Total
Independent 4 9 2 15
Dependent 2 3 1 6
Death 3 5 2 10
Total 9 17 5 31
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Complication of Thrombolytic Therapy
Complication STK URK rTPA Total
Skin Rash - 1 - 1
Bronchospasm - 2 1 3
Anaphylaxis - 1 1 2
Gum Bleed - 1 1 2
Gast Bleed 2 1 - 3
Uri. Bleed - 1 - 1
?Hem Trans. 1 - - 1
IC-bleed - 1 - 1
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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.
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Dec 31st 1999
Jan 21st 2000
Feb 11th 2000
Emergency Carotid Endarterectomy
DOA 5th Feb 00
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Subarachnoid hemorrhage
• Bed rest Analgesic• Blood pressure control• Oral nimodipine 60mg q6hx21 days• Angiography for localization of bleedingIf aneurysm • Immediate surgical clipping for
– Grade 1-3 patient without contraindication– Grade 4-5 with intracerebral clot and deterioration
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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
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Thank You