A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function's) due to disturbance in the blood supply to the brain. This can be due to ischemia 85% (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage 15% (leakage of blood).

Stroke definition?

Yes< or = 4 hours for anterior circulation

limbs weaknessaphasiavisual field cut defectsensory lost

< or =6-12 hours for posterior circulation

limbs weakness, hemi./quadriplegia/paresisdysarthiadysphasiadysphasiadouble visionvisual field cut defect

“wax and wean symptoms” young patients

Above symptoms + autonomic feature may confuse the picture however stroke is NUMBER ONE to be considered

Contraindication to tPA• Minor / rapidly improving • ICH or mass on CT *• Seizure at stroke onset *• ICH ever • Stroke or serious head trauma < 3 months • GI or urinary tract haemorrhage in < 3 weeks • Major surgery/serious trauma in < 2 weeks • LP or Arterial puncture @ no compressible site < 1 week • Current: symptoms of SAH,pericarditis or MI • Pregnant • SBP >185 mm of Hg or DBP> 110 mm of Hg (try ↓) *• Aggressive Rx to ↓ BP (>3doses of labetalol) *• Glucose <2.7 or >22 mmol/L *• Platelets <100 x 109/L • INR > 1.7, PTT >40

Non-contrast CT

With treatment

No treatment

• Benefits:

• 42% vs. 26% regained independence at 3 months • NNT = 6 to have one additional patient recover to independence • NNT = 9 to have one additional patient achieve a full neurological

recovery • RISK: 6% overall risk of symptomatic brain haemorrhage (NNH: 18) •

• Dr. David Gladstone, 2004

Stroke impact on society?

-the 3rd leading cause of mortality worldwide and in UAE too?

-number of days admission +

-ICU admission+

-Cause effect++

-rehab. Cause

-family distress

-job loss

-number of working hours lost (pt./family/sponsor..)

My/your job

-public education and stroke awareness

-stroke protocol :-EMS: ACT FASTO-20min.

-ER:ACT FASTO & NIHSS score -15-20 min.

-strokologist:ACT NIHSS score/CT Rx-10-25min.re do CT scan if >45min (ER doorRx)

prehospital• EMS Prompt cards: • NEW, unilateral

weakness, slurred speech/aphasia/mute &/or aphasia, facial droop

• Can GET to hospital w/in 2 hours of clearly defined onset (“last seen normal”)

• NOT TO BE BYPASS (should go to nearest ER-not applicable in UAE-we will accept in ZMH)

EMS Rx• Paramed.guidelines for acute stroke treatment • Manage ABC’s, get IV access, O2 • Assess glucose • NPO • Call ER & go fast • DON’T give excess sugar or fluids, or drop BP too much • Pre-hospital Identification –usually @ ER

• paramedic/ASA GUIDELINES – Early Management of Acute Ischemic Stroke In Adults

FAST-O

• Face• Arms• Speech• Time• Other:

– Double vision, sever headache, numbness of face; arms and legs, was and wean quadriparesis…

case1• 75 M• PMHx:

– HTN,DM, no recent (surgery, trauma, ICH )– Seizure disorder (no event for one year)-what Q would you ask here?

• Rx:– ASA 81mg,dilantin 300mg qhs,ACEI?

• HPI:– Sudden Rt sided weakness and aphasia @ 3PM

• O/E: time of arrival 3:15PM– VSS,ABCD normal, what test you want to do/what else?– FASTO:3/5 Rt sided weakness , non-fluance speak

• Discussion: is this stroke or mimickers?

case2• 102 F• PMHx:

– Dyslipedimic ,DM, no recent (surgery, trauma, ICH,old MI 2003 )– what other Qs would you ask here?

• Rx:– Lipitor 10mg od, ASA 81mg,thiazid I od, insulin sc 20/40u

• HPI:– Wakeup at 7 with Lt sided weakness and confused.

• O/E: time of arrival 7:20AM– VSS,ABCD normal, what test you want to do/what else?– FASTO:1/5 Lt sided weakness , denial being sick? Why?

• Discussion: is this stroke or mimickers?

case3• 35 M• PMHx:

– Newly Dx HTN, no Hx (DM, seizure, surgery, trauma, ICH )– what Q would you ask here?

• Rx:– none?

• HPI:– Lower limbs weakness and difficulty of swallowing @ 12 non– Symptoms resolved @ 12 :10 non– Similar symptoms @ 1:00 PM + double vision

• O/E: time of arrival 1:13PM– VSS,ABCD normal, what test you want to do/what else?– FASTO:x4 limbs 4/5, numb. Face trunk and limbs x4, skew eyes

• Discussion: is this stroke or mimickers? Where?