Acute management of patients with stroke is to stabilize the patient and to complete initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of patient arrival. Critical decisions focus on the need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic intervention.

1. Start Show Notes
MANAGEMENT OF
ACUTE ISCHEMIC
STROKE

2. 2
Definition of Stroke
A stroke is a neurological impairment
caused by a disruption in blood supply
to a region of the brain.

3. 3
Objectives
• Establish the diagnosing a stroke
• Which initial imaging in acute stroke
• Know the management of acute strokes

4. 4
How Serious Is Stroke in the
INDIA?
• In India, crude prevalence rate of stroke reported
as 1.27–2.20/1000 persons.
• Present scenario of stroke care
• Only 100 centers for intravenous thrombolysis
and 50 centers intra-arterial or mechanical
thrombolysis.
• Most centers are in private health-care sector and
in urban area

5. 5
Introduction
New emerging therapies offer hope,
however the following MUST occur:
• Education of at-risk patients.
• Early recognition of stroke signs.
• Prompt transport to the hospital.
• Rapid hospital triage and evaluation.

6. 6
Introduction
With rapid, aggressive prehospital stroke care,
at-risk patients can be appropriately managed
and quickly assessed for
Fibrinolytic therapy improve outcome.

7. 7
Classification of Stroke
Two major categories:
• Ischemic strokes, caused when a blood
vessel supplying the brain is occluded by a
clot. Responsible for 75% of all strokes.
• Hemorrhagic strokes, caused when a
cerebral artery ruptures.
Both forms are life threatening.

8. 8
Hemorrhagic Stroke
• Hypertension is the most common cause of
intracerebral hemorrhage.
• Other causes:
Aneurysms and
Arteriovenous malformations.

9. 9
Risk Factors for Stroke
Although some strokes occur without
warning, most stroke victims have
prior risk factors.
Major strokes can be prevented in
many cases, but only if early signs and
symptoms are heeded.

10. 10
Well-Documented
Modifiable Risk Factors
• Hypertension
• Smoking
• Diabetes
• Asymptomatic
Carotid Stenosis
• Atrial Fibrillation
• Hyperlipidemia
• Sickle Cell Disease
• Other cardiac
diseases
Goldstein et al. Circulation. 2001:103:163

11. 11
Less Well Documented
Potentially Modifiable Risk
Factors
• Obesity
• Physical Inactivity
• Poor Diet/Nutrition
• Alcohol Abuse
• Drug Abuse
• Hypercoagulability
• Hormone Replacement
Therapy
• Oral Contraceptive Use
• Inflammatory Process
Goldstein et al. Circulation. 2001:103:163

12. 12
Non-modifiable Risk Factors
• Age
• Sex
• Race/Ethnicity
• Family History

13. 13
Stroke Diagnosis
Signs and Symptoms of Stroke

14. 14
Signs and Symptoms of
Stroke
Consider in anyone
who has:
• Sudden numbness or weakness
of face, arm, or leg, especially on
one side of the body
• Sudden confusion, trouble
speaking or understanding

15. 15
Stroke Signs and Symptoms:
Hemorrhagic Stroke
May present similar to Ischemic stroke.
Distinguishing Features:
• Appear more seriously ill
• Deteriorate more rapidly
• Severe headache
• Alteration in consciousness
• Nausea and/or vomiting
• Neck pain
• Intolerance of noise or light

16. 16
Transient Ischemic Attack
“Temporary” or “mini” stroke.
• The signs and symptoms of a TIA are
similar to those of a completed stroke;
however, they typically last only a few
minutes to several hours before
resolving.

17. 17
Transient Ischemic Attack
• TIA is the most
important
forecaster of
impending stroke.

18. 18
Stroke Patient Management
The Stroke Chain of Survival and
Recovery

19. 19
Seven Step Stroke Chain
of Survival and Recovery
Pre-arrival: Post-arrival:
1. Detection 4. Door
2. Dispatch 5. Data
3. Delivery 6. Decision
7. Drug

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1. Detection: Early Recognition
• Early treatment of stroke depends on
the victim, family members, or other
bystanders detecting the event.
• Mild signs or symptoms may go
unnoticed or be denied by the patient
or bystander.

21. 21
2. Dispatch: Early EMS Activation
and Dispatch Instructions
• Stroke victims and their families must be
taught to activate the EMS system as soon
as they detect stroke signs or symptoms.
• EMS dispatchers must appropriately
prioritize the call to ensure a rapid response
within the EMS system.

22. 22

23. 23
3. Delivery: Pre-hospital Transport
and Management
The goals :
• Rapid identification of the stroke
• Support of vital functions
• Rapid transport of the victim to the
receiving facility
• Pre-arrival notification of the
receiving facility

24. 24
3. Delivery: Pre-hospital Transport
and Management
• The presence of acute stroke is an indication for
"load and go“.
• Establish the time of onset of stroke signs and
symptoms!
• This timing will have important implications for
potential therapy. If the time of onset of symptoms
is viewed as time "zero," all assessments and
therapies can be related to that time.

25. 25
3. Delivery: Pre-hospital Transport
and Management
Once stroke is diagnosed, pre-hospital
treatment includes management of the ABCs
of critical care (Airway, Breathing, and
Circulation) and close monitoring of vital
signs.

26. 26
3. Delivery: Pre-hospital Transport
and Management
Airway:
• Paralysis of the muscles of the throat,
tongue, or mouth can lead to partial or
complete upper-airway obstruction.
• Saliva pools or vomit may be aspirated.

27. 27
3. Delivery: Pre-hospital Transport
and Management
Breathing:
• Breathing abnormalities are uncommon,
except in patients with severe stroke, and
rescue breathing is seldom needed.
• Abnormal respirations, however, are
prominent in comatose patients and portend
serious brain injury.

28. 28
3. Delivery: Pre-hospital Transport
and Management
Circulation:
• Monitor both blood pressure and cardiac rhythm as
part of the early assessment and treatment of a
stroke patient.
• Hypotension or shock is rarely due to stroke, so
other causes should be sought.

29. 29
3. Delivery: Pre-hospital Transport
and Management
Circulation:
• Hypertension is often present in
stroke patients, but it typically
subsides and does not require
treatment.
• Treatment of hypertension in the field
is not recommended!

30. 30
3. Delivery: Pre-hospital Transport
and Management
Other Supportive Measures:
• Intravenous access.
• Management of seizures, and diagnosis and
treatment of hypoglycemia, can be initiated en
route to the hospital if necessary.
• Isotonic fluids (Normal Saline or Lactated Ringer's
solution) are used for intravenous therapy;
hypotonic fluids are contraindicated.

31. 31
3. Delivery: Pre-hospital Transport
and Management
Early Notification:
• Early notification enables personnel to prepare for
the imminent arrival of any seriously ill or injured
patient.
• In many hospitals this notification shortens the
time to evaluation of, and critical interventions for,
stroke patients.

32. 32
4. Door: Emergency Department
Triage
Even if a potential stroke victim arrives in
the emergency department in a timely
fashion, too often hours may elapse before
appropriate neurological consultation and
diagnostic studies are performed.

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5. Data: Emergency Evaluation and
Management
ABCs should be
reassessed and
rechecked
frequently.

34. 34
5. Data: Emergency Evaluation and
Management
An emergency neurological
stroke assessment should
be done quickly focusing
on four key issues:
1. Level of consciousness
2. Type of stroke
(hemorrhagic versus
nonhemorrhagic)
3. Location of stroke (carotid
versus vertebrobasilar)
4. Severity of stroke

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5. Data: Emergency Evaluation and
Management
• Obtaining the exact time of stroke or onset
of symptoms from family or people at the
scene is critical.

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Emergency Diagnostic
Studies
• Currently, CT is the single most
important diagnostic test.
• Goal: CT scan obtained and read
within 45 minutes of the stroke
victim's arrival at the emergency
department.

37. 37
Emergency Diagnostic
Studies
• Anticoagulants
and fibrinolytic
agents should be
withheld until CT
has ruled out a
brain
hemorrhage.
Hemorrhagic Stroke

38. 38
Differential Diagnosis:
• Unrecognized seizures
• Confusional states
• Syncope
• Toxic or metabolic disorders
• Hypoglycemia
• Brain tumors
• Subdural hematoma
Adams et al. Stroke. 2003;34:1056

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6. Decision: Specific Stroke
Therapies
General care includes, but is not limited to:
• Prevention of aspiration
• Management of hypertension
• Management of hyper/hypo-glycemia
• Management of seizures
• Management of intra-cranial pressure (ICP)
Acute Stroke, 2003 American Heart Association

40. 40
7. Drugs: Fibrinolytic Therapy for
Ischemic Stroke
• Intravenous tPA represents the first FDA-approved
therapy for acute ischemic stroke.
• In the NINDS trial, patients treated with tPA within 3
hours of onset of symptoms were at least 30% more
likely to have minimal or no disability at 3 months
compared with those treated with placebo.

41. 41
7. Drugs: Fibrinolytic Therapy for
Ischemic Stroke
• However, there were 10-fold increases in the risk of
fatal intracranial hemorrhage in the treated group
(3% vs 0.3%) and the frequency of all symptomatic
hemorrhage (6.4% vs. 0.6%).
• This increase in symptomatic hemorrhage did not
lead to an overall increase in mortality in the
treated group.

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7. Drugs: Fibrinolytic Therapy for
Ischemic Stroke
Careful patient selection and strict
adherence to the treatment protocol are
essential!

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7. Drugs: Fibrinolytic Therapy for
Ischemic Stroke
Because of the time criteria and risk
associated with fibrinolytic therapy, it is
important for hospitals to develop specific
strategies and protocols that will achieve
rapid initiation of therapy.

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NINDS-Recommended Stroke Evaluation
Targets for Potential Fibrinolytic
Candidates*
Door to doctor 10 minutes
Door to CT† completion 25 minutes
Door to CT read 45 minutes
Door to treatment 60 minutes
Access to neurological expertise‡ 15 minutes
Access to neurosurgical expertise‡ 2 hours
Admit to monitored bed 3 hours
*Target times will not be achieved in all cases, but they represent a reasonable goal.
†CT indicates computed tomography.
‡By phone or in person.
Time Target

45. 45
Management of Hemorrhagic
Stroke
Optimal management:
• Prevention of continued bleeding.
• Appropriate management of ICP.
• Timely neurosurgical decompression when
warranted.
Large intracerebral or cerebellar hematomas
often require surgical intervention.

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Summary: Pre-hospital Critical
Actions and Management
This is what should happen:
 Recognize the signs of stroke and TIA
 Rapid neuro exam (Cincinnati Stroke Scale or
similar).
 Determine time of symptom onset (if possible).
 Provide rapid transport to an ED capable of caring
for acute stroke (pre-notify).
 Perform finger-stick to assess serum glucose
levels.

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Summary: Pre-hospital
UNACCEPTABLE Actions
• Failure to recognize signs and symptoms of
stroke/TIA
• Failure to attempt to determine symptom
onset.
• Delay in transport.
• Transporting a potential stroke patient to
an ED not capable of treating acute
ischemic stroke with fibrinolytic therapy.

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Summary: Pre-hospital
UNACCEPTABLE Actions
• Attempts to treat hypertension in
the field.
• Failure to notify receiving ED.

49. In patients with asymptomatic carotid stenosis,
carotid endarterectomy or stenting should not be
performed.
(Rosenfield et al 2016 [123]; Raman et al 2013
[140]; Bangalore et al 2011 [149]; Abbot et al 2009
[164]).
49

50. Corticosteroids
• Corticosteroids are not recommended for
management of stroke patients with
brain oedema and raised intracranial pressure.
(Sandercock et al 2011 [91])
50

51. Decompressive surgery
Patient with supratentorial intracerebral haemorrhage
(lobar, basal ganglia and/or thalamic locations),
routine surgical evacuation is not recommended
outside the context of research.
(Mendelow et al 2013 [103]; Xiao et al 2012 [104];
Gregson et al 2012 [106])
51

52. • For selected patients with large (>3cm)
cerebellar haemorrhage, decompressive surgery
should be offered.
• Infratentorial haemorrhages (<3cm cerebellar,
brainstem) the value of surgical intervention is
unclear.
• Ventricular drainage as treatment for
hydrocephalus is reasonable, especially in patients
with decreased level of consciousness.
52

53. Neuroprotective Agents in
Human Clinical Stroke Trials
• Patients with acute ischaemic stroke who
were receiving statins prior to admission
can continue statin treatment
53

54. International Citicoline Trial on
Acute Stroke (ICTUS)
• No significant difference in recovery was
observed between the citicoline and placebo
treatment groups.
54

55. Cerebrolysin
• A total of 1070 patients were administered aspirin
and either Cerebrolysin (30 mL/day) or placebo
over a period of 10 days.
• Although no significant difference between
treatment groups was seen after 90 days, a
positive trend was seen in those patients with an
NIHSS score greater than 12.
55

56. 56
Conclusion:
Now, fibrinolytic and other emerging
therapies offer practitioners the opportunity
to limit neurological insult and improve
outcome in stroke patients.

57. 57
Conclusion:
• Education of at-risk patients
• Early recognition of stroke signs
• Prompt transport to the hospital
• Rapid hospital triage and evaluation

58. Carotid endarterectomy
Recent (<3 months) non-disabling carotid artery
territory ischaemic stroke or TIA with ipsilateral
carotid stenosis measured at 70-99% (NASCET
criteria)
• In selected patients (<3 months) non-
disabling ischaemic stroke or TIA patients carotid
stenosis of 50–69% (NASCET criteria)
• Carotid endarterectomy performed as soon as
possible (ideally within two weeks) after
the ischaemic stroke or TIA.
• All patients with carotid stenosis should be treated
with intensive vascular secondary prevention therapy.
• (Bangalore et al 2011 [149], Rerkasem & Rothwell 2011
[167]) 58