2. 60yrs old male patient k/c/o systemic HT had missed
dose of antihypertensive since last 7 days presented in
casualty with sudden onset loss of consciousness 3 hrs
back.
O/e- patient stupors
BP-160/100
Responds to deep painful stimuli by moving left upper
limb and lower limb
Spasticity right UL & LL
DTR +++on RT UL & LL
Planter RT. ↑
What is your diagnosis ?
& How will you manage ?
3. Diagnosis- STROKE.
Investigations
Diagnostic question Investigation
Is it a vascular lesion ? CT/MRI
Is it ischaemic or haemorrhage? CT/MRI
Is there any cardiac source of embolism? ECG, Echocardiogram
What is the underlying vascular disease? Duplex ultrasound , MRA, CT angiography
What are the risk factors ? Full blood count, Cholesterol, Blood
glucose
Is there an unusual cause ? ESR, Serum protein electrophoresis,
Clotting/ Thrombophilia screen
4. Management
1. General measures
• Airway- maintain adequate airway with periodic clearance of
secretion and keep patient nil by mouth if swallowing unsafe
or aspiration occurs.
• Breathing- administer oxygen if oxygen saturation <95%.
• Circulation- check peripheral perfusion, pulse and BP and
treat abnormalities with fluid replacement , anti-arrhythmics
and inotropic drugs as appropriate.
• Hydration- if signs of dehydration, give fluids parenterally or
by nasogastric tube.
• Nutrition-assess nutritional status and provide nutritional
supplements if necessary. If dysphagia persists for >48hrs ,
start feeding via nasogastric tube.
5. • Blood pressure- unless there is heart or renal failure ,
evidence of hypertensive encephalopathy or aortic dissection
, do not lower BP in 1st week as it may reduce cerebral
perfusion.
• Blood glucose- check blood glucose, treat hypoglycemia with
50% dextrose, treat hyperglycemia by insulin infusion or
glucose/potassium/insulin(GKI).
• Temperature- investigate and control with antipyretics, as
raised brain temperature may increase infarct volume.
• Pressure areas- turn immobile patients regularly to prevent
bed sore.
• Incontinence- bladder catheterisation if incontinence or
retention has occurred.
• Mobilisation – passive movements of limbs to prevent
contractures, edema of the limbs, venous stasis and
pulmonary embolism.
6. 2. Specific measures
• Thrombolysis- i.v recombinant tissue plasminogen
activator (rTPA) has been shown to be beneficial when
initiated within the first 3-4.5 hrs. However, it increases the
risk of haemorrhagic transformation of the cerebral infarct
with potentially fatal results.
Indication-
i. Clinical diagnosis of stroke
ii. Onset of symptoms to time of drug administration <4.5 hrs
iii. CT scan showing no hemorrhage or edema of >1/3 of the
MCA territory
iv. Age ≥ 18 yrs
v. Consent by patient or surrogate
7. Contraindication
i. Sustained BP>185/110mmHg despite treatment
ii. Platelets<100,000, HCT<25%, glucose <50 or >400mg/dl
iii. Use of heparin within 48h & prolonged PTT or elevated INR
iv. Rapidly improving symptoms
v. Prior stroke or head injury within 3mo , prior intracranial
hemorrhage
vi. Major surgery in preceding 14 days
vii. Minor stroke symptoms
viii. GI bleeding in preceding 21 days
ix. Recent myocardial infarction
x. Coma or stupor
Administration- administer 0.9mg/kg IV (max 90mg)IV as
10% of total dose by bolus followed by remainder of total dose
over 1hr. No other antithrombotic t/t for 24hr.
8. • Platelet inhibition- In the absence of C/I , Aspirin
(300mg daily) should be started immediately after an
ischaemic stroke unless rTPA has been given , in which case it
should be withheld for at least 24h. Aspirin reduces risk of
early recurrence and has a small but clinically worthwile
effect on long term outcome.
• Anticoagulation- role of heparin in acute stage is
controversial and at present not recommended.
• Carotid endarterectomy & angioplasty- if a
carotid territory ischaemic stroke or TIA is diagnosed, such
patients have greater than average risk of stroke recurrence .
For those without major residual disability , removal of
stenosis has been shown to reduce the overall risk of
recurrence. Surgery is most effective in pts with more severe
stenosis(70-99%)and in those it is performed within first
couple of wks after stroke or TIA. Carotid angioplasty and
stenting are not as effective as endarterectomy.
