A Collaborative Effort to Improve Emergency Stroke Care: Mobile Stroke Unit
Stroke emergency treatment for 26th march 00
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Transcript of Stroke emergency treatment for 26th march 00
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 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 - 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
Thrombolysis in acute stroke
Within 3 hour of Stroke Small Vessel
Medium Vessel
IV rTPA/URK
Large Vessel
IA rTPA/URK
Stop
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%
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
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
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
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
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
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
Thank You