academic day lecture

1. Bader Almasaad

2.  Definition.
 In 2008 stroke dropped from being 3rd
leading cause of death in the USA to the 4th
 Less than 50% of calls to 911 were made
within one hour of symptoms, less than 50%
of those who called thought stroke was the
diagnosis.
 Public education is a priority

3. Patient or bystander recognition of stroke
signs and symptoms
Detection
Immediate activation of 911 and priority EMS
dispatch
dispatch
Prompt triage and transport to most
appropriate stroke hospital and prehospital
notification
delivery
Immediate ED triage to high-acuity areadoor
Prompt ED evaluation, stroke team
activation, laboratory studies, and brain
imaging
data
Diagnosis and determination of most
appropriate therapy; discussion with patient
and family
decision
Administration of appropriate drugs or other
interventions
drug
Timely admission to stroke unit, intensive
care unit, or transfer
disposition

4.  Primary stroke centre(PSC)
 Comprehensive stroke centre(CSC)
 Acute stroke ready hospital (ASRH)
 The biggest reduction in stroke morbidity and
mortality is achieved by admission to a CSC.

5. TimeAction
<10 minsDoor to physician
<15 minsDoor to stroke team
<25 minsDoor to CT initiation
<45 minsDoor to CT interpretation
<60 minsDoor to drug
<3 hrsDoor to stroke unit admission

6. Selected patientsAll patients
TT and ECT if indicatedNon contrast brain CT or brain MRI
LFTBlood glucose
Toxicology screenOxygen saturation
Blood alcohol levelSerum electrolytes/renal function
tests
Pregnancy testComplete blood count, including
platelet count
ABG( if hypoxia suspected)Markers of cardiac ischemia
Chest x-rayProthrombin time/INR
LP (if SAH suspected after negative
CT)
APTT
EEG (if seizures suspected)ECG

7.  CT (plain)
 MRI (DWI)
 Contrast CT, MRI, angio
 TCD

8.  Hypoxia:
 Up to 63% of hemiparetic patients develop hypoxia
 Common causes found were:
• Partial airway obstruction
• Hypoventilation
• Aspiration
• Atelectasis
• Pneumonia
 Central periodic breathing (cheyne-stokes respirations) associated with
decreases in oxygen saturation
 Hypoxia is detrimental to ischemic brain tissue and associated with poorer
outcomes
 Must be corrected (<94%) and continuously monitored for

9.  Patient positioning:
 Can influence O2 sats, CPP, MCA mean flow velocity, ICP.
 In the non hypoxic patient able to tolerate lying flat, the supine position is
recommended.
 Otherwise head up position at 15 to 30 degrees
 Supplemental oxygen
 Supplemental oxygen should be provided via least invasive method to
provide o2 sats of >94% ( class I, level C)
 Airway support and ventilatory assistance recommended for patients with
decreased LOC or who have bulbar dysfunction that compromises the airway
( class I, level C)

10.  Temperature control
 Hyperthermia:
• Associated with 2 fold increase in short term mortality in patients with
hyperthermia in the first 24 hours of hospitalization.
• Hyperthermia should be corrected and causes sought out (class I, level c)
 Hypothermia:
• No data available about the utility of induced hypothermia in stroke patients
at present

11.  Blood pressure:
 In patients with markedly elevated BP (consensus is that that is BP
>220 / >120) not receiving fibrinolysis, a reasonable goal is to
lower BP by 15% during the first 24 hours (class I, level C)
 Initiation of anti-hypertensives within 24 hours of stroke is relatively
safe including restarting medications for previously hypertensive
patients ( class IIa, level B)

12. patient otherwise eligible for A.R.T except that BP is >185/110:
Labetalol 10-20mg IV over 1-2 mins, may repeat once
Nicardipine 5mg/hr IV up to maximum of 15 mg/hr
other agents (hydralazine, enalapril) may be considered
If BP is not maintained <185/110 do not administer rTPA
Management of BP during or after A.R.T at or below 180/105
Monitor BP every 15 mins for 2 hours post A.R.T, then ½ hourly for 6 hrs
If BP >180-230 or >105-120:
Labetalol 10mg IV followed by infusion 2-8 mg/min or;
Nicardipine 5mg/hr IV up to maximum of 15mg/hr
If BP not controlled of diastolic >140 consider sodium nitroprusside

13.  Blood sugar
 Persistent in-hospital hyperglycemia during the first 24 hours
after stroke is associated with worse outcomes than
normoglycemia so hyperglycemia should be treated to a
target range of 8-10. (class IIa, level c)
 Hypoglycemia has to be corrected

14.  Approved by FDA in 1996.
 Window is 3 hours, extended to 4.5 hours in
selected patients.
 Time is brain
 In eligible patients treatment should be
started as early as possible, with door to
needle time of less than 60 minutes (class I,
level A)

17.  IV rTPA (0.9 mg/kg max. 90 mg) is recommended for eligible
patients within 3 hours of symptom onset (class I, level A)
 Physicians should be aware of and be prepared to treat
complications of rtPA such as ICH and angioedema that may cause
partial airway obstruction in 1-5% of patients.
 The effectiveness of sonothrombolysis for treatment of stroke
patients is not well established (class IIb, level B)
 The use of IV rtPA in patients on direct thrombin inhibitors or direct
factor Xa inhibitors is not recommended unless sensitive lab tests
are normal or patient not received any of these drugs for more than
2 days (class III, level C)

18.  Patients eligible for IV rtPA should receive it even if IA
treatment is considered (class I, level A)
 IA fibrinolysis is beneficial for selected patients with major
ischemic strokes of <6 hours duration involving the MCA who
are otherwise not candidates for IV fibrinolysis.(class I, level
B)
 Rescue IA fibrinolysis or mechanical thrombectomy may be
reasonable approaches to re-canalization in patients with
large artery occlusion not responsive to IV rtPA.( class IIb,
level B)

19.  Urgent anticoagulation with the goal of preventing early
recurrent stroke, halting neurological worsening or improving
outcome after acute ischemic stroke is not recommended
(class III, level A)
 Urgent anticoagulation for the management of non-
cerebrovascular conditions is not recommended for patients
with moderate to severe stroke because of increased risk of
serious ICH complications. (class III, level A)
 Initiation of anticoagulation within 24 hours of IV rtPA is not
recommended (class III, level B)

20.  Oral administration of aspirin (initial dose 325mg) within 24
to 48 hours is recommended. ( class I, level A)
 The usefulness of clopidogrel for the treatment of acute
ischemic stroke is not well established (class IIb, level C)
 The administration of aspirin or other anti platelets as an
adjunctive therapy within 24 hours of IV fibrinolysis is not
recommended (class III, level C)

21.  In exceptional cases with systemic hypotension producing
neurological sequelae, a physician may prescribe
vasopressors to improve cerebral blood flow under close
observation ( class I, level C)
 The administration of high dose albumin is not well
established as a treatment for most patients with acute
ischemic stroke (class IIb, level B)

22.  Measures to reduce brain edema are recommended during the
first days after stroke ( class I, level A)
 Decompressive surgery should be considered urgently in all
patients with cerebellar infarcts, and individualized but
encouraged early (before signs of herniation) in all large volume
supratentorial hemispheric infarcts ( mortality reduced from
78%-29%).
 No studies to date have indicated a benefit of prophylactic
anticonvulsants after ischemic stroke.
 Prophylactic enoxaparin 40mg od is recommended in all
ischemic stroke patients and studies show no increase risk of
hemorrhagic transformation. Enoxaparin was found to be
superior to UFH.

23.  The risk of developing DVT after TBI in the absence of
prophylaxis is 20%
 Thrombi in the proximal lower limbs are more likely to
embolize
 Mechanical thromboprophylaxis intuitively carries less risk of
ICH progression without affecting MAP, ICP or CVP however
does carry risk of local skin injury.
 Studies have shown that pharmacological
thromboprophylaxis is more efficacious than mechanical.

24.  Level III evidence supports use of graduated compression
stockings for DVT prophylaxis in patients with severe TBI
unless lower limb injuries prevent their use.
 Level III evidence supports the use of prophylaxis with low
dose heparin or LMWH for prevention of DVT in patients with
severe TBI
 Brain trauma foundation recommendations (2007)

25.  Administration of SQ LMWH or UFH in patients with ICH
and/or IVH for DVT prophylaxis in the acute or sub acute
period(2-5 days) is generally safe.
 Retrospective analysis, no prospective data available yet.
 AHA/ASA recommendation in 2011