1. Emergency Treatment of Stroke

2. Normal Brain Physiology 2-3% of body weight 15% of cardiac output 20% of all O2 25% of all glucose

3. Cerebral Ischaemia - Threshold Normal flow, normal function Synaptic transmission failure Membrane pump failure 20 50 10 0 Time in hours CBF (ml/100g brain) Low flow, raised O2 extraction, normal function 1 2 3 4 5

4. Cerebral infarct <3hrs Onset Infarct Ischaemic penumbra

5. Cerebral infarct 6hrs Infarct Ischaemic penumbra

6. Cerebral infarct 24hrs Infarct Ischaemic penumbra

7. NA, Dopamine Ca2+ i  Ischaemic Brain Injury Ischaemia - 02  glucose  Anoxic depolarisation  lactate Glutamate Hi  Free Fe2+ Free radicals Lipolysis NO synthase Proteolysis

8. Cerebral Arterial territory Anterior cerebral Middle cerebral Posterior cerebral Anterior choroidal

13. Stroke types Al 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%

19. Early sign CT - Infarction

20. MRA & MRI in Stroke

24. “ Patients who have improved neurologically but have a persistent neurologic deficit when seen, should be managed as a recent stroke ”

25. “ Role of Neuro-protection in Stroke is not clear and not recommended routinely ”

28. Thrombolysis in acute stroke Within 3 hour of Stroke Small Vessel Medium Vessel IV rTPA/URK Large Vessel IA rTPA/URK Stop

30. Left Coronary angiogram showing severe atherosclerosis

31. Right middle cerebral artery block following coronary angiogram

32. Right middle cerebral artery reperfusion (AP) following IA Urokinase

33. Outcome of Thrombolytic therapy

34. Complication of Thrombolytic Therapy

36. Dec 31 st 1999 Jan 21 st 2000 Feb 11 th 2000 Emergency Carotid Endarterectomy DOA 5 th Feb 00

39. Thank You