Dr Sunanda Anand
Stroke
Neurological deficit lasting for >24 hrs due to vascular pathology of brain. Neuroimaging does not indicate different etiology. Includes Cerebral infarction, CVT,SAH and intracerebral bleed. 24hrs criteria excluded if patient dies or undergoes cerebrovascular surgery. Excludes strokes due to head injury or disorders like leukemia.
Stroke Programme
Acute stroke Intervention Chronic Stroke management TIAs/ministrokes Secondary Prevention Rehabilitation Maintain Data.
24/7 Services
Emergency Medical services. Imaging CT/MRI. DSA Lab : Interventional Neuroradiology. Stroke unit/ICU & Step down units. Trained Staff.
Stroke
Arterial Strokes Ischemic (80%) Hemorrhagic(20%) Venous Strokes:20% of young strokes Non hemorrhagic Hemorrhagic
Anterior circulation: Acute deficit in the Arm, Leg, Face and Speech (Abb. NIHSS). Posterior circulation: Vertigo, Altered sensorium -Coma, Hemianopia, Motor sensory deficit, Cerebellar signs etc.
When to Thrombolyse?
NEUROLOGICAL DEFICIT : NIHSS >4 WINDOW PERIOD : 0-8HOURS CT SCAN : No Hemorrhage No established infarct. i) Normal scan ii) Dense MCA sign iii) Hypodensity<1/3rd of arterial territory iv) Dense Basilar sign
Normal scan
IV Thrombolysis
NINDS, ECASS 2 & Meta analysis. Agent to be used: rtPA DOSE: 0.9mg/kg to max of 90 mgm. 10% as bolus over 2 min rest as an infusion over 1 hr. Outcome: 30% improvement in functional & neurological outcome. Symptomatic hemorrhage 6.6%.
IA Thrombolysis
rtPA and Urokinase (PROACT I &II) 0-6 Hrs for anterior circulation 24 hrs for Posterior circulation or Fluctuating neurological status.
Mechanical Devices
Concentric(Phase1&II . ongoing PhaseIII) Penumbra (Phase I. ongoing PhaseII) 0-8hrs. 1st line therapy(3-8hrs) Postoperative Anticoagulated(INR=3) Failed IV/IA tPA or Contraindications.
Ultrasound
Transcranial doppler increases lytic activity of rtPA ( Phase II ).
EKOS MicroLySUS catheter which can administer tPA + IA low energy Ultrasound.(PhaseI&II).
Neuroprotection
Brain tissue to be made more resistant to ischemic injury. Decrease functional deficit. Prolong Revascularization window. Pharmacological& Mechanical. Disappointing results.
0-2 Hrs
IV rtPA 0.9mg/Kg max 90mg Dilute 1:1 with sterile water or NS Do not agitate. 10% bolus and remainder infusion 1hr. or Combined therapy: 0.6mg/kg rtPA. 15% bolus and 85% over 30 min.
Along with First line Invg . MR DW1and PW1 mismatch +MRA or CT Perfusion+CTA (dec CBF,Inc MTT &Norm or Inc CBV). CT clinical mismatch.
Basilar Occlusion
5-8 hrs
Mechanical Devices
Special situations:
Monoplegia Paresis: MRC >3, dysarthria ,facial Visual loss Aphasia
Watch for
Severe headaches, vomiting, Acute Hypertension ,drowsiness Worsening of neurological status. (NIHSS>=4pts) DISCONTINUE INFUSION & ORDER BRAIN CT
Is There ICH?
Discontinue rtPA. Stat Blood Grouping +cross, PT, PTT, Fibrinogen level. Infuse 6 units of platelets + 6 units of FFP (or 6 units of cryoprecipitate with Factor VIII) Neurosurgery consultation for Evacuation.
Is there Angioedema?
On rtPA (1-2%) Tongue examn for enlargement every 20 min after starting infusion Breathlessness /Stridor DISCONTINUE rtPA INFUSION Treat accordingly with H1 ,H2 blockers,Steriods Adrenalin, Intubation.
Treatment of ICP
Mannitol 0.25 -1gm/kg . Max for 5 days Hypertonic Saline Hyperventilation.PCo2 to 25-30mm. Temporary Hypothermia(32-33deg) cooling blankets and ice packs. Neurosurgery of Decompression craniectomy.
Other Complications
Seizures Aspiration Penumonia ( 15-25% of deaths) dysphagia: facial palsy,altered sensorium,brainstem strokes Mechanical ventilation Immobility leading to atelectasis
Complications
UTI (16%) indwelling catheters Constipation ( Commonly forgottten) Malnutrition delays recovery(S.Albumin) Establish nutrition by 48 - 72hrs. Assess swallowing test for Oral feeding. NG tube Feeding gastrotomy (>6weeks)
Complications
DVT and pulmonary embolism(10% of deaths. Incidence 20-50%) EARLY MOBILIZATION Non ambulatory within 24 hrs then: TEDS: Thromboembolic stockings Penumatic compression devices Heparin 5000units S/C BD Low mol wt heparin
TIAS/Mini Strokes
Transient neurological deficit lasting <24hrs Commonly 15-20min. DW1 images usually positive Treatment is directed to prevent larger stroke.
Aspirin
Aspirin 300mg loading then150mg OD (75mg-325mg) Start at presentation Acute intervention start >24 hrs. Decreases recurrent stroke by 22% annually.
Clopidogrel
Clopidogrel 75mg 4 tabs loading then 1OD Preferred in cases with stroke +IHD+PVD Additional dec of 8.7% in end points.
>70% stenosis.
Intracranial Atherosclerosis.
Medical therapy
Antiplatelets Statins
Basilar stenosis.
Cardioembolic Stroke
IHD Atrial fibrillation (long term anticoagulation) Patent foramen ovale & ASD. Aortic arch atheroscelosis. Others: RHD, Prosthetic valves,atrial/ventricular thrombus,infective endocarditis,maratic endocarditis, intrcardiac tumors.
Cardioembolic Strokes
Treatment with anticoagulation. PFO :AC/Aspirin/AC/Endovascular closure
Rx Diabetes Mellitus
Fasting Glucose & HgbA1C Goal Maintain HgbA1C <7%. Rx : Diet, exercise, OHA, Insulin.
Rx Hyperlipidemia
LDL<100mg Triglycerides<200mg Cholesterol<200mg Non-HDL<130mg
Acute Rehabilitation
PT, OT & Speech therapy at the earliest. For brain plasticity and improvement Rehabilitation should be: Task specific Repetitive Motivating to Pt.
Diagnostic Modalities
High Level of suspicion CT +CT venogram MRI+ MR venogram DSA
Management
Mild Clinical grade: Heparin Severe Clinical grade: Local thrombolysis Clinical grade 3: deteriorating on Heparin >24 hrs.
Minor symptoms.
CT GRADING
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 No parenchymal change. Nonhemorrhagic venous infarct ,No mass effect. Nonhemorrhagic venous infarct with mass effect. Hemorrhagic venous infarct. ( bleed < 3cm) Hemorrhagic venous infarct with mass effect. (bleed>3cm)
DSA GRADING
Grade 1 Partial thrombosis/Recanalization. Grade 2 Dural sinus occlusion with no restriction of venous outflow.
Modalities Available
Stop Thrombolysis
Clinical improvement ( LOC). AND/ OR Recanalization of sinus with antegrade flow on Venogram. Evidence of Systemic & Intracranial bleed. (exclude puncture site oozing)
EXCLUSION CRITERIA
Clinical recovery since presentation. Sinus recanalization with no restriction to venous outflow on DSA. G.I. or G.U. tract bleeding (less than 2 weeks) Intracranial Aneurysms / AVMs / Neoplasms. Bleeding diathesis, INR > 1.7, Platelet count < 100,000
Post Thrombolysis.
Treatment with Heparin Oral anticoagulation for 6 months Adjunctive therapy. Thrombophilia workup.
Thrombophilia profile
Protein C 70140% Protein S 80---130% Antithrombin III 75---125% Lupus anticoagulant Activated protein C resistence ( Normalized ratio 0.75---1.10) S.Homocysteine male 6---16 Umol/L Female 3.4---20.5 Anticardiolipin antibodies IgG <10 GPLU/ml Anticardiolipin antibodies IgM <10 MPLU/ml ANA/ DNA Coagulation profile VDRL/HIV/hepatitis B Serum B12 G6PD
Follow Up
Clinical MR Venogram+ thrombophilia status at 3 months. To decide Further anticoagulation.