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Vijay Kumar
per year
long-term
disability
Estimated U.S. cost for 2008 = $65.5
billion
In
Pre-hospital management
Initial assessment and emergency
management
Thrombolysis
Acute stroke intervention
Medical support
Antiplatelet agents
Anticoagulation
Surgery
10
20
30
40
50
minutes
60
70
80
90
Penumbra
Core
CEREBRAL
BLOOD
FLOW
20
(ml/100g/min)
15
10
Normal
function
Neuronal
dysfunction
PENUMBRA
CORE
5
1
Neuronal
death
TIME (hours)
Time is Brain
CBF
8-18
CBF
<8
~4h 40min
NNT 5
NNT 20
Courtesy Brott T
Penumbra
damaged by:
Hypoperfusion
Hypoxia
Acidosis
Hyperglycemia
Fever
Seizure
Emergency
dispatch
Priority transport with notification of the
receiving hospital
Guidelines Ischaemic Stroke
Imaging
Is it stroke?
Type of stroke
Ischemic
Stroke
85%
Clot occluding
artery
Subarachnoid
Hemorrhage
Intracerebral
Hemorrhage
10%
Bleeding
into brain
5%
Bleeding
around brain
Cranial
HYPERACUTE STROKE ON CT
WINDOW PERIOD UPTO 6 HOURS
EARLY ISCHEMIC CHANGES (EIC)
1.
2.
3.
4.
EFFACEMENT OF SULCI
5.
LOSS OF CM DIFFERENTIATION
INSULAR RIBBON?
NCCT
CTA
NCCT
CTA
Hyperdense ACA
86 year old with acute onset of rt side weakness,leg more weak than arm
and difficulty in speech ,came in 1.5 hrs of onset. CT scan shows hyperdense
left ACA. CTA shows clot in left ACA
Specificity 100%
Basilar artery
thrombus
A
M1
M4
C
L
IC
M5
M2
M6
M3
P
P
Fig 1a
ASPECTS
8-10 8-10
8-10
89
3-7
4-7
4-7
0-2
104
119
0-3
0-3
10
21
DISADVANTAGE OF CT
Less sensitive than MRI
Posterior fossa stroke
Stroke mimics diagnosis is inferior to MRI
Window period 3 to 6 hours- identification of penumbra
not possible
In
The
Multimodal
Class II Recommendations
Vascular imagingis necessary
as a
Class
III Recommendations
Emergency
Vascular
I. Triage10 min
Review t-PA criteria
Page acute stroke team
Draw pre t-PA labs
NIHSS
Obtain 12-lead ECG
Send patient to CT
IV. Treatment60
min
Start IV t-PA
Monitor for ICH sxs
HTN, headache
neuro status
IV thrombolysis
NINDS, ECASS I
OTT
+ II, ATLANTIS
Hemorrhage
0-1.5 h
2.81
3.1%
1.5-3 h
1.55
5.6%
3-4.5 h
1.40
5.9%
4.5-6 h
1.15
6.9%
Infuse
hours
hourly until 24 hours after treatment
Discontinue
Delay
ECASS
III
% Normal at
3 mo.*
Symptomatic
ICH**
tPA
52%
2.4%
Placebo**
45%
0.2%
3.0-4.5 Hours
Do NOT give if:
Pt > 80 yr
NIHSS > 25
DM / previous stroke
Taking warfarin at all
Mismatch
Treatment
Concept
need to be individualised
average
slow
fast
1 Hr
3 Hr
6 Hr
CT perfusion
Parameters
Definition of
Penumbra
Advantages
CBF, CBV,
CT
Perfusion MTT, TTP
MTT
threshold at
145%
Combined
CBF, CBV,
MTT, TTP,
ADC
Relative
TTP (or
MTT) delay
>45s and
normal DWI
Sensitive
DWI-PWI
MRI
with plain
CT
Available
Fast
No
radiation
Limitations
Limited
brain coverage
Poorly sensitive to posterior
circulation
Iodonated contrast
Limited
availability
Patient cooperation
required
Frequent contraindications
Diffusion
Echoplanar
Imaging Thrombolytic
Evaluation Trial (EPITHET)
Lancet Neurol2008;7:299309.
= 101
RCT
Placebo controlled
non-significantly
lower rates of
infarct growth were seen in PWI/DWI
mismatch patients who received rtPA
Intra-arterial
Bridging
thrombolysis
therapy
Mechanical
thrombolysis
in 74% of patients,
Baseline angiogram
demonstrates complete occlusion
of the right ICA terminus (black
arrow).
Chronic Hypertensive
Autoregulation is impaired/abolished in
stroke.
CBF follows perfusion pressure
Blood pressure
>220 systolic or > 120 dystolic BP only needs
Hypertensive encephalopathy
Symptomatic ischemic heart disease
Congestive cardiac failure
Rapidly progressive renal dysfunction
Before and after thrombolytic therapy
Deterioration of patient due to hmgic conversion of
infarct.
Aortic dissection
Ideal
Drug
Short acting
easily titrated
predictable
response
Drug used
Labetolol
Nicardipine
infusion
Avoid
Drugs
that dilate
intracranial
vessels and
increase ICT .e.g.
-nitroglycerine
Use of nifidepine
strongly
discouraged
Hypoglycemia
Mimicker
Can compromise penumbra
Hyperglycemia
Related to poor outcome in both
Majority
Asprin
Fast
Stroke. 2007;38:1655-1711
Heparin
Controversial
Meta-analysis
of 24 trials involving 23
748 participants
showed no benefit with regards to death
Not
Low
(orgaran)
High
dose statins
SPARCL study
disease,
reduced
the overall incidence of strokes and of
cardiovascular events,
despite a small increase in the
incidence of hemorrhagic stroke.
Stroke Prevention by Aggressive Reduction in Cholesterol Levels
(SPARCL) trial.
ICH
on Heparin
heparin
ICH
- on Warfarin
5-25 mg Vitamin K1
FFP (10-20 ml/ kg)
Recombinant factor VIIa
ICH
on Thrombolytic therapy
Management
of raised ICP
Cerebellar
40 ml
Vermian hematoma
lobar clots >30 mL and within1
cm of the surface
For
MISTIE
SIHCPA
RCT -2003
71 pts, 36
randomised to
surgery
Statistically
significant reduction
in the volume of clot
No reduction in
mortality at 6 months
High risk of
rebleeding 22%
RCT
, 2007
ongoing
Clot reduction in
46% in surgery
arm vs 4% in
control arm
Adverse events
within safety limits
rtPA, urokinase
Acute
IV
thrombolysis to be administered
at the earliest in eligible candidates
Medical
management to be
optimized to ensure adequate
perfusion of penumbra
Adams
Novakovic
Guidelines
A.
B.
C.
D.
ASPECTS <7
NIHSS >25
Age > 65
Coronary A. Disease
A.
B.
C.
D.
Thalamic bleed
Intraventricular bleed
Lobar ICH
Brainstem bleed