Management of stroke three to twenty four hours

The sign wasn’t placed there
By the Big Printer in the sky

Management of Stroke
( Three to Twenty Four Hours )
Prof.A.V.Srinivasan , M D, DM, Ph.D, DSc,F.R.C.P.(London)
F.A.A.N, F.I.A.N
Emeritus Professor,
The Tamilnadu Dr.M.G.R.Medical university
Former Professor and Head ,
INSTITUTE OF NEUROLOGY
Madras Medical Colege

OBJECTIVE
 Definition
 Stroke burden
 Types & Mechanisms
 Risk factors
 Clinical evaluation
 Investigations
 Treatment of ischaemic stroke
 Treatment of h hemorrhagic stroke & SAH
 Rehabilitation
 Newer developments – Interventions & neuroprotectives.

Stroke: WHO Definition
Stroke is clinically defined as a neurologic
syndrome characterized by “Rapidly developing
clinical signs of focal (at times global)
disturbance of cerebral function, lasting more
than 24 hours or leading to death with no
apparent cause other than that of vascular
origin”.

CONCEPT OF “BRAIN ATTACK”
In all of us, even in good men, there is a
wild - beast nature which peers out in sleep

Burden of Stroke
 Most common life-threatening neurologic disease
 Third most common cause of death globally
 Incidence in India: 73/1,00,000 per year
 No formal registry available.
 Burden is likely to increase with risk factors like
aging, smoking, adverse dietary patterns
 Most common cause of disability and
dependence.
 70% of stroke survivors remaining vocationally
impaired
 30% requiring assistance with daily activities
The True Art of Memory is The Art of Attention
- S.Johnson

Burden of Stroke

 26 per lac per year
 Ischaemic – 69%
 Hemorragic –23%
 SAH – 3%
 Undetermined – 5%

We learn by thinking and the quality of the learning outcome is
determined by the quality of our thoughts
R.B. Schmeck

Types & mechanisms
 Ischaemic – Atherothrombotic
Embolic
Lacunar
 Hemorrhagic – ICH
SAH
 Global hypoperfusion – Watershed
infarcts.
A true commitment is a heart felt promise to yourself from which
you will not back down
- D. Mcnally

Stroke: Classification

Ischemic stroke: Account for 80%.
 Results from occlusion in the blood vessel
supplying the brain
 Thrombotic: Occlusion due to
atherothrombosis of small/large vessels
supplying the brain
 Embolic: Occlusion due to embolus arising
either from heart (e.g. atrial fibrillation,
valvular disease) or blood vessel

Serious, sincere, systematic study surely secures supreme success

Classification (contd.)
Hemorrhagic stroke: Account for 20%. Results
from rupture of blood vessels leading to
bleeding in brain
 Intracerebral: Bleeding within the brain due
to rupture of small blood vessels. Occurs
mainly due to high blood pressure
 Subarachnoid: Bleeding around the brain;
commonest cause is rupture of
aneurysm.Other causes: Head injury

Habit is either the best of servants or worst of masters

LACUNAR INFARCT
 <10mm in size.
 Absence of cortical sings.
 Super lacune >15mm.
 Syndromes- ataxic hemiparesis
 pure motor, pure sensory,sensory-motor
 dysarthria clumsy hand, pure dysarthria,
 hemichorea& unilateral asterixis.

Success in life is a matter not so much of talent and opportunity
as of concentration and perseverance - C.W. Wendte

LACUNAR INFARCT
 Associated with Systemic hypertension,
DM
 Weight of the heart exceeds 400g.
 Prognosis -no mortality,
 lenticulo striate territory-good recovery
 ant.cho.artery-poor recovery.

Give us the GR ACE to acce pt with se re nity the thing s that canno t be
chang e d the COUR AGE to chang e the thing s that sho uld be chang e d
and the WISDOM to kno w the diffe re nce

Oxfordshire Community Stroke
project (OCSP)
 Anterior circulation stroke – Total
(TACS)
 Anterior circulation stroke – Partial
(PACS)
 Posterior circulation stroke – PCS
 Lacunar Strokes.- (LS)
“ He who cannot forgive others destroy the bridge over which he
s
him m pass”
self ust - Annoy

Differentials
 Focal epilepsy.
 Migraine.
 Transient Global Amnesia.
 Tumor
 Metabolic Encephalopathy
 Multiple Sclerosis.

The secret of walking on water is
Knowing where the stones are

Transient Ischemic Attack (TIA)
 “Mini stroke”
 Stroke symptoms last for less than 24 hours
(usually 10 to 15 mins)
 Result as a brief interruption in blood flow to
brain
 Every TIA is an emergency
 TIA may be a warning sign of a larger stroke
 Patients with possible TIA should be evaluated
If you think you can or you can’t
You are always right

TIA- contd
 Few minutes to 24hrs (>85% within
30mts).
 12% atherosclerotic infarct
 Predominantly negative symptoms.
 Weakness/numbness of
UL/UL&LL,speech disturbance,mono
ocular blindness, weakness of
thumb&index the daughter of attention ,
Memory, finger.
is the teeming mother of knowledge - Martin Tupper

Stroke: Predisposing factors
 Age (risk doubles for every decade after
55yrs)
 Gender (males>females)
 Family history of stroke/TIA
 Hypertension
 Diabetes
 Hyperlipidemia
 Hyperhomocysteinemia
As long as you get there before
It’s over you’re never late

Stroke: Predisposing factors
 Obesity
 Smoking
 Atrial fibrillation
 Sedentary lifestyle
 Drug abuse (e.g. cocaine use)
 Hormone replacement therapy
 Oral contraceptive

Discipline Weighs ounces
Regret weighs Tons

Genetics & stroke
 Single gene disorder
Sickle cell disease
Homocystinuria
Marfans syndrome – dolichoectasia
Fabry’s disease
 Vascular risk factors
Genetic hypercoagulable disorders
Metabolic disorders with vasculopathy
Hereditary intracranial aneurysms
Some people feel the rain;
Others just get wet

Genetics & stroke
 CADASIL – Cerebral Autosomal Dominant
Arteriopathy with Subcortical infarcts and
Leucoencephalopathy.
 Recurrent episodes of subcortical infarcts or
TIAs
 Onset 30 – 50 years
 Stroke, dementia, pseudobulbar palsy,
migraine
 MRI shows extensive leucoencephalopathy
Opinion is ultimately determined by the feelings
and not by the intellect

Genetics & stroke
 Multiple infarcts in the basal ganglia
and in the periventricular regions .
 U- fibers are spared.
 Skin biopsy is diagnostic- granular,
eosinophilic, electron dense material in
the media of the arterial wall.
 Familial clusters with hemiplegic
migraine- CADASIL - M
Experience can be defined as
yesterday’s answer to today’s problems

Stroke: Symptoms
 Onset of stroke symptoms varies as per type
of stroke

 Thrombotic stroke: Develop more
gradually
 Embolic stroke: Hits suddenly
 Hemorrhagic stroke: Hits suddenly and
continues to worsen
It is the province of the knowledge to speak
and it is the privilege of the wisdomto listen - Hodly’s

Stroke: Symptoms (contd.)
 Dizziness
 Confusion
 Loss of balance/coordination
 Nausea/vomiting
 Numbness/weakness on one side of the body
 Seizure
 Severe headache
 M ovement disorder/speech disorder/blindness etc
(depending on the area of brain affected)
Additional symptoms for hemorrhagic stroke
 Pain upon looking at or into light
 Painful stiff neck

“SILENT STROKES”

A silent stroke is a stroke which causes
brain damage, but does not exhibit classic
symptoms of stroke. They are detected only
when a person undergoes a brain scan. –
Multi infarct state.

The meek shall inherit the earth
- but not its mineral rights

Stroke management

“TIME
IS
BRAIN”
Our best thoughts come from others

Stroke management

 Detection
 Dispatch



Door
Data
6 Ds
 Decision
 Drug
It’s not over until it’s over

DETECTION

Success is a prize to be won. Action is the road to it.
Chance is what may lurk in the shadows at the road side.
- O. Henry

Stroke management - Detection
 Cincinatti stroke Score
- Facial droop
- Arm drift
- Slurred speech

1 out of 3 - > 72% probability of stroke.
Thinking is the hardest work there is, which is probable reason
why so few engage in it.
- Henry Ford

Stroke management - Detection
 Los Angeles Probable stroke Score.
(LAPSS)
 Includes arm drift, facial droop, slurring
of spech, age , presence of risk factors
like hypertension, DM, previous TIAs,
 Little cumbersome.
 No better than Cincinatti Score.
People of mediocre ability often achieve success because
they don’t know enough to quit - Bernard Baruch

DISPATCH

TO HOSPITAL

EMR
Whatever the Mind can conceive and Believe,
the mind can Achieve
Napoleon Hill

Stroke management – to Door

 On suspicion of stroke the person
should be dispatched to the
Emergency Medical Room as early as
possible.( Within minutes)
 Maintain vitals and arrange for
transport.
 No Aspirin or heparin to be
administered.
“ Social Isolation is in itself a pathogenic
Factor for disease production”

 DATA

EMERGENCY IMAGING – CT/
MRI
BIOCHEMICAL PROFILE
Possible investigations.

Science is below the mind; Spirituality is beyond the mind

Stroke management – Door to data
 Physical examination: Vitals,Neurologic
 Brain imaging (cranial CT and/or
MRI): discriminate between ischemic
and hemorrhagic
 Stroke Doppler ultrasonography/Angiography:
Detect large vessel atherosclerosis
 ECG/Echocardiography: Detect cardiac
embolism
 Exclusion of conditions mimicking stroke
(hypoglycemia, migraine, seizure)
Speak obligingly even if you cannot oblige

Ischemic stroke diagnostic algorithm

Acute focal brain deficit Excluded hypoglycemia, migraine
with aura, post-seizure deficit

< 1 hour TIA (if CT/MR brain imaging
Head CT without ischemic lesion)

Ischemic Stroke

Lacunar syndrome
Cortical
syndrome Doppler MRI Vasculopathy CRYPTOGENIC
MRA CT Coagulopathy STROKE
ECG Angiogram
Echo

CARDIAC LARGE ARTERY SMALL OTHER DETERMINED
EMBOLISM ATHEROSCLEROSIS VESSEL DISEASE CAUSE

A woman’s desire for revenge outlasts all her other emotions

General management
 ABC
 Fluids & electrolytes
 Dysphagia, aspiration
 Urinary dysfunction
 Venous thromboembolism
 Seizures
 Skin care
 Depression
Maintaining the right attitude is easier than
regaining the right mental attitude

Management of acute ischemic stroke
 Systemic thrombolysis:
 Intravenous recombinant tissue plasminogen
activator (rt-PA)
 Within 3 hrs of onset of stroke.
 Dose 0.9 mg/kg, max 90 mg.
 Intra arterial thrombolysis is being tried.-
time window is upto 6 hrs. – technically
demanding.
No Aspirin or heparin for 24 hrs. following
thrombolysis
When they tell you to grow up, they mean stop growing

(contd..)
 Anticoagulants: Heparin/LMWH NOT
recommended in acute ischemic stroke routinely.
 Recommended in setting of atrial fibrillation,
acute MI risk, prosthetic valves, coagulopathies
and for prevention of DVT.
 Intra-arterial thrombolytics: An option for
treatment of selected patients with major stroke
of < 6 hrs duration due to large vessel occlusion.
Why should I question the monkey
when I can question the organ grinder?

(contd)- hypertension
 BP Should be kept within higher normal limits
since low BP could precipitate perfusion failure.
 Reduction of BP in acute stroke phase is
controversial.
 Reduce BP if there is severe end organ damage
like pulmonary edema, encephalopathy, uremia.
 Markedly elevated BP (>220/110mmHg) managed
with nitroglycerin, clonidine, labetalol, sodium
nitroprusside.
 More aggressive approach is taken if thrombolytic
therapy is instituted
He is free who knows how to keep in his own hands
the power to decide

Glucose & pyrexia
 Blood glucose Should be kept within
physiological levels using oral or IV
glucose (in case of hypoglycemia)
 insulin (in case of hyperglycemia) RBS
>300 mg
 Avoid routine glucose infusions
 Elevated body temperature
management: Antipyretics and use of
cooling device can improve the
prognosis
To get to the promised land you have to
negotiate your way through the wilderness

Specific therapy - Ischaemic
 Thrombolytic therapy- r- tPA
 Time window – 3 hrs.
 0.9 mg/kg max. 90mg.
 10% bolus & 90% as infusion in 1 hour.
 Risk of hemorrage – 6%

It is a great misfortune not to possess sufficient wit to speak well
nor sufficient judgment to keep silent
La Broyers character

Ancrod
 Venom of Malaysian pit viper.
 ↓Fibrinogen & viscosity
 ↓ RBC aggregation
 Endogenous tPA upregulation
 Vasodilatation
 Anticoagulant activity.

We possess by nature the factors out of which personality can be made, and to organize them
into effective personal life is every man’s primary responsibility
- Harry Emerson Fosdick

Hemorrheologic therapy
 Hemodilution
 Pentoxyfylline
 Ancrod – Malaysian pit viper venom.

Mind is the great level of all things;
human thought is the process by which
human ends are ultimately answered

Thrombolytic drugs
 t NK- Tenectoplase – derived from t
PA.
 Desmoteplase
 Alteplase
 r- pro UK
 Gp IIIa Iib receptor blockers.
 Lys- plasminogen
“ Social Isolation is in itself a pathogenic
Factor for disease production”

Secondary prevention of stroke
 Recurrence: Annual risk is 4.5 to 6%.
 Five year recurrence rates range from 24 to 42%
 one-third occur within first 30 days, hence high
priority should be given to secondary prevention.
 Patients with TIA or stroke have an increased risk
of MI or vascular event.
 Management of hypertension (goal <140/85 mm Hg)

A bad teacher complains;
A good teacher explains;
The best teacher inspires;


 Diabetes control (goal<126 mg/dL)
 Lipid management: Statins (goal
cholesterol<200 mg/dL, LDL<100
mg/dL)
 Anticoagulants: Warfarin (target INR 2
to 3); esp. recommended in patients
with cardioembolic stroke
 Appropriate life style modification
(cessation of smoking, exercise, diet
etc) Knowledge without action is useless;
Action without knowledge is foolish

Antiplatelet agents:
 Aspirin (50-325 mg),
 clopidogrel (75 mg).
 Ticlopidine 200mg bid
 Aspirin + ER Dipyridamole
 Sulfinpyrazone
 Suloctidil
 A combination of the two drug may also be
used
Reputation is made in a moment; character is built in a life time

Complications of stroke
 Cerebral edema – 30% of patients
worsen after stroke due to cerebral
edema.
 24 – 96 hrs after acute stroke.
 Initially cytotoxic(gray matter),later
vasogenic (white matter)
 Excitatory amino acids (EAA) –
produces neurotoxic edema –
Vedanta admits realization
accelarates apoptosis.
But defies verbal definition

Complications of ischaemic stroke
 Hemorrhagic transformation occurs in about
40%.
 Occurs in first 2 weeks.
 10% of patients worsen.
 Increased risk with antithrombotics,
anticoagulants, and thrombolytic therapy.
 Size (>1/3 rd) of the vascular territory and
elderly are more prone for hemorrhagic
transformation.
Pure love ever gives; Never seeks

Management of Acute hemorrhagic
stroke
 Analgesics/Antianxiety agents: To relieve
headache. Analgesics having sedative
properties are beneficial
 Hyperosmotic agents (e.g. mannitol,
glycerol, furosemide): To reduce cerebral
edema, and raised intracranial pressure.
 Adequate hydration is necessary
 Surgical intervention may occasionally be
life saving
What is mind no matter
What is matter never mind

Surgical interventions
 Balloon angioplasty/stenting
 Carotid endarterectomy/Bypass
 Decompressive craniectomy
 Stem cell therapy.

Every thing should be made as simple as possible;
but not simpler

Carotid endarterectomy & stenting
 CEA in symptomatic patients provides
protection against stroke. ( >70% stenosis)
 In 50 –69% stenosis the benefit is marginal
compared to medical therapy.
 The stroke reduction is realized early after
surgery and persisted for extended periods.
 In TIA CEA has to be performed as early as
possible if there is significant stenosis
 ECST and NASCET trials have proved the
benefit.
Hate screeches, fear squeals; conceits trumpets
but love since lullabies

Carotid stenting & angioplasty
“ FROM KNIFE TO STENT”
 In patients having a increased surgical
risk.
 CCF, severe COPD, unstable angina,
past radiation therapy, local tumor
mass etc.,.
 SAPPHIRE study has shown benefit in
a group of patients.
 Angioguardadapt, adjust and accommodate device is
Learn to emboli protection
used. to give, not to take and learn to serve not to rule
Learn

Sub arachnoid hemorrhage (SAH)
 Aneurysmal or non aneurysmal.
 Vasospasm is a critical factor.
 Autoregulation impaired with
vasospasm.
 Hunt and Hess grading – Clinical
 Fisher grading – CT scan
 Lumbar puncture may be necessary.
Teachers are reservoirs from which, through the process of
education, the students draw the water of life

SAH - TRIPLE - H Therapy
 Hypertension
 Hypervolemia
 Hemodilution
 Nimodipine – used to treat vasospasm.

Love is selfishness and selfishness is lovelessness

SAH - Surgical
 Aneurysmal clipping within 48 – 72
hours
 Prevents early rebleeding
 Permits aggressive therapy for
vasospasm
 Endovascular therapy – coiling with
GDC coils or thrombogenic platinum
coils
 Asymptomatic one who thinks to his> 6mm
Expert is aneurysms -
chosen mode of ignorance

History And Examination
Guide: 1 & 2
a. Stroke clerking Performa (1994)
R.C.P.
1. Improved patient Assessment
2. Improved Management & outcome- not
clear

b. Examination
1. Secure Diagnosis of Stroke
2. Specify Impairment
3. Identify sub type of Ischemic an audience
God is a comedian performing before stroke
that is afraid to laugh

Guide: 3 (B) - CPR

– Impaired consciousness in stroke is common in
posterior circulation strokes.
– Impaired Consciousness - From Stroke
Resuscitation is rarely successful -
Schneider 1993

“Prediction is always difficult – especially when it concerns the future”
– Oscar Wilde

Guide: 4 - CXR

Chest x-ray abnormal in 16%
– Only 4% change clinical management
– Order x-ray chest if WT Loss or chest
symptoms present
- Not recommended in routine stroke
management.

If I were to choose between pain and nothing… I would choose pain
-- William Faulkner

Guide: 5 - ECG
 Detection of cerebrogenic cardiovascular
disturbance.
 Acute ST- T changes,rhythm abnormalities
are common (upto 40%)
 Insular cortex involvement is an independent
risk factor
 Rt. Sided lesions, age ,HT/DM/IHD are other
factors
 Cardiac cause of Death (30 days)
 ALL STROKE PATIENTS TO HAVE ECG
Pain is god’s greatest gift to mankind - Paul Brand.

Guide: 6 - ECHO
 To identify stroke mechanism.
 LV clot, Patent Foramen Ovale (PFO), Infective
endocarditis, AF,Silent lesions
 Detects silent cardiac lesions
 Lesions of aorta
 TEE is more useful than TTE.
 High yield in ischaemic lesions.
 RECOMMENDED IN SETTINGS WHERE
AVAILABLE and im oralityare two of the greatest inhibitors of
The Truth is fear m
Performance to progress

Guide: 7 - CT scan brain
 ABSOLUTE INTEGRAL PART IN STROKE
 Differentiates between ischaemia, hemorrhage,
SAH
 Early signs are useful in deciding about
thrombolytic therapy. (Hyperdense MCA
sign,insular ribbon sign,sulcal effacement)
 Helical and CT Angio are useful.
 MUST IN ALL STROKES
Develop the heart; art comes automatically

Guide 8: M.R.I.

 Not Routine in Acute Stroke
 Diffusion & perfusion weighted images are
very useful in the acute phase in ischaemic
infarction
 Along with MRA gives valuable information
 NOT ROUTINELY INDICATED

“ My opinions are founded on knowledge
but modified by experience”

Guide 9: - Doppler studies
 B-mode, Duplex, continuous wave and pulsed
doppler systems, Color doppler flow imaging,
TCD
 Shows changes in flow patterns near
plaques.
 Gives idea about the vulnerability of the
plaque.
 Useful in assessing the Vasospasm,
collateral circulation, hemodynamic effects,
reserve capacity
 To plan carotid endarterectomy.
 IUSEFUL peripheral neuritis– it interferes with work
don’t like IN APPROPRIATE CLINICAL

Guide 10: (B) - FEVER
 Fever (Worst Prog.) – 1 * C increases the
metabolic need by 7% . Treatment of fever has
consistently produced good results.
 Hypothermia theoretically useful. – not proved
 TEMPERATURE REDUCTION IS
INDICATED.

In any field, find the strangest thing and explore it

Guide 11: (B) - OXYGENATION
 Hypoxia ( Moroney 1996) – Exacerbated by
seizures Pneumonia and Arrhythmias - Worst
outcome
 Oxygenation bas been Consistently useful.
 Hyperbaric O2 ineffective (Nighoghossaln
1995)
 OXYGEN ADMINISTRATION IS
USEFUL AND RECOMMENDED.

He can’t walk and chew gum at the same time

Hyperglycemia
 DM & hyperglycemia are associated with
larger infarcts and fasting hypoglycemia with
smaller infarcts.
 Worsening in hyperglycemia is due to lactic
acidosis
 Optimal blood glucose is less than 130 mg%
 Treat hyperglycemia with insulin.
Take time to think; it is the source of power
Take time to read; it is the foundation of wisdom
Take time to work; it is the price of success

Guide: 12- Anti edema measures.
 Steroids are ineffective in stroke
 Mannitol, Glycerol, Hypertonic saline is
useful in some cases.
 Loop diuretics are useful.
 Albumin can also be used – not proved in
major trials
 Hyperventilation – useful for short periods,
rebound edema is common- not
recommended routinely.

Thought is the labour of the intellect
Reverie is its pleasure

Guide 13: (B) - OTHERS
 Haemodilution- Plasm Expanders
 TRIPLE – H therapy useful in SAH.
 Mean Arterial Pressure – 120-130 mm
Hg
 CVP – 10-12 mm Hg
 PCWP –14-18mm Hg
 Hematocrit 30-33%
 Check ABG only if Hypoxia suspected.

Guide: 14 - OTHERS
 Barbiturate coma and propofol to reduce the
elevated intracranial pressure have been
useful in large ischaemic strokes.
 They produce hypotension and hence may be
detrimental in some patients.
 Judicious use is advised.
 Indomethacin 50mg I.v. has been used in
stroke to lower ICP – may reduce CBF- only
case reports are available

Guide: 14 - OTHERS

 Sedation, pain control and neuromuscular
blockade may be necessary in patients with
altered sensorium as pain and irritation
impede cerebral venous return
 Sedation reduces sympathetic overactivity,
increases co operation for procedures and
nursing care.
 Helpful in reducing the cerebral metabolism.

Guide 12: (B) - Blood Pressure
 Defer
- acute reduction of BP - 10 days unless
HT Encephalopathy or aortic dissection
present
 Increase in BP - falls in 10 days (Moris 1997)
 HT - Prim. stroke prevention
 ACE- I are very useful in managing HT
A diuretic may also be combined.
 NO DEFINITE LOWER LEVEL BP

Guide 13: (A/B) - AF
 AF / LV clot - warfarin after 48 Hrs – start
along with heparin
 Aspirin for others
 EAFT 1995 Prothrombin time- Less than 2 -
No effect
 PT- > 5 - Bleeding (SPAF 1996 )

Guide 15: Cholesterol
 Dietary and pharmacologic measures in
reducing cholesterol are very effective
 Proven in large controlled trials
 Statins are very useful
 Start all patients with stroke on Statins.
At twenty the will rules
At thirty the intellect
At forty the Judgment

Guide 16: Deep vein thrombosis

50% stroke Pts –develop DVT 10 days (Kalra 1995
 Pulmonary embolism in 6-16% only (Sandercock 1993
)
 Heparin 5000IU QID or 12500IU twice daily -
Hemorrage greater
 Gradual stocking is of value -Use with caution - if
peripheral artery insufficiency is present
 HEPARIN IS USEFUL IN PREVENTING DVT.

Guide 18: (A) –Antithrombotic
drugs
 Aspirin 75 - 150 /Day
 3 yrs 40% reduces of vascular events in 1000
pts (APTC - 1994)
 Stroke sub type value ? (TACI, PACI, LACI,
POCI)
 synergy possible with clopidogrel ,ticlopidine
etc.

Anti Coagulation
Warfarin - AF
 In sinus rhythm - uncertain
 Spirit 1997 low dose aspirin + Warfarin in TIA &
Minorstorke
 Heparin (IST 1997) - Signif. reduction in early death (12
fewor in 1000) not better than aspirin
 So avoid Heparin (A)

Guide 20: (I) Hemorrhage

 Supra tentorial evacuation for ICH is
controversial - Avoid (Hankey and Hon 1997)
 Infra tentorial hematomas- early evacuation
 Main Indication - Deteriorating or depressed
consciousness

Other measures.
 Nutritional maintenance especially if
dysphagiais present
 Prevention of pulmonary complications
 Prevention/treatment of UTI
 Prevention of decubiti
 Treatment of depression
 Physiotherapy and rehabilitation

GOALS ACHIEVED ?
 Prevent first stroke
 Facilitate recovery
 improve neurological function

Dedicated to my family for
making everything worthwhile

READ not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER

THANK YOU
My sincere thanks to Mr. G. Kakuthan,

for his meticulous computer work

DECISION
TO USE THROMBOLYTIC

NATURE, TIME AND PATIENCE
are the 3 great physicians

DRUG - r tPA
 Before administering thrombolytic therapy
the following investigations have to be
carried out apart from the MANDATORY
CT SCAN BRAIN which rules out
hemorrhage.
 Routine blood biochemistry.
 Coagulation profile – PT,PTT
 Doppler studies.

The world shall perish not for lack of wonders but lack of wonder

Multimodal monitoring
 CBF monitoring –
Xenon enhanced CT scanning
laser doppler flowmetry (qualitative)
Thermal diffusion ( quantitative)
 Brain tissue oxygenation
tissue partial pressure of oxygen
(Ptio2)
Directly measured with electrodes.
Through Action You Create your Own Education
- D.B. ELLIS

Intracerebral microdialysis
 Monitor the chemistry of the
extracellular space in living tissues.
 Physiological salt solution is slowly
pumped through the microdialysis
probe, the solution equilibrates with
the surrounding extracellular tissue
fluid.
 The microdialysate is then extracted
and analysed for lactate and glutamate
“Knowledge can be communicated but not Wisdom”
etc..,
- Hermann Hesse

Emergency Medical Care for Neurologic
Emergencies

• Provide reassurance.
• Ensure proper airway and breathing.
• Place the patient in a position of comfort.
• Assess and care for any injuries if you
suspect any type of trauma.

Many Ideas grow better when transplanted into another mind
than in the one where they sprang UP
O.W. Holmos

Number of events, fatal and nonfatal strokes and fatal and nonfatal
myocardial infarctions (MI) reported in recent prospective hypertension
trials
Trial Average Patients Strokes MI (n)
age randomized (n)
(years) (n)
STOP-I 76 1627 82 53
SHEP 72 4736 269 165
STONE 67 1632 52 4
Syst-Eur 70 4695 124 78
Syst-China 67 2394 104 16
HOT 61 18790 294 209
CAPPP 53 10985 340 327
STOP-2 76 6614 452 293
NICS 70 414 20 4
NORDIL 60 1088 355 340
INSIGHT 67 6575 1141 138

MODIFIABLE RISK FACTOR
Well documented risk factors
 Hypertension
 Cardiac diseases
 Atrial fibrillation
 Infective endocarditis
 Mitral stenosis
 Recent extensive myocardial infarction
 Cigarette smoking
 Transient ischemic attack
 Asymptomatic carotid stenosis
 Diabetes mellitus
 Hyperhomocystinemia
 Left ventricular hypertrohy

Less well documented risk factors

 Elevated blood cholesterol and  Spontaneous
lipids echocardiographic
 Cardiac disease contrast
 Cardiomyopathy
 Segmental well motion
abnormalities
 Bacterial endocarditis
 Aortic stenosis
 Mitral annular calcification
 Patent foramen ovale
 Mitral valve prolapse
 Atrial septum aneurysm
 Valve strands

A good teacher is a perpetual learner

 Use of oral contraceptives  Hypercoagulability and inflammation
 Consumption of alcohol  Fibrin formation and fibrinolysis
 Use of illicit drugs  Fibrinogen
 Physical inactivity  Anticardiolipin antibodies
 Obesity  Genetic and acquired causes
 Migraine  Subclinical diseases
 Elevated hematocrit  Carotid intima-media thickness
 Dietary factors  Aortic atheroma
 Hyperinsulinemia and insulin  MRI evidence of infarct like
resistance
lesions
 Acute triggers (stress)  Socio economic features

“ He who cannot forgive others destroy the bridge over
s
which he him m pass”- Annoy
self ust

Non modifiable risk factors
 Age
 Gender
 Hereditary / familial factors
 Race / ethnicity
 Geographic location

It is not your position that makes you happy or unhappy
It is your disposition

Stroke incidence compared between
antihypertensive drug trials
Drug treatment Relative risk P
(95% CI)
β-Blockers and/or diuretics vs 0.64 (0.41 – 0.90) <0.01
placebo
ACEIs vs placebo 0.70 (0.57 – 0.85) <0.01
Calcium antagonists vs placebo 0.61 (0.44 – 0.85) <0.01
ACEIs vs β-blockers and/or 1.05 (0.92 – 1.19) NS
diuretics
Calcium antagonists vs β- 0.86 (0.76 – 0.98) NS
blockers and/or diuretics
ACEIs vs calcium antagonists 1.02 (0.85 – 1.21) NS

Control of risk factors
 Smoking cessation
 Reduction of alcohol consumption
 Physical exercise
 Dietary control
Medical interventions
 Antihypertensive drug treatment
 Antithrombotic therapy
 Hypocholesterolemic drug treatment
 Antibiabetic and lipid-lowering treatment

Let the wave of memory, the storm of desire, a fire of emotion pass
through without affecting your equanimity

Stroke subtypes and risk factor associations
Risk factor
Stroke Age HT Smoking Diabete AF CHO
subtypes s L
Ischemic +++ ++ ++ ++ ++ +
Intracerebral +++ +++ - - - -
hemorrhage
Subarachnoid ++ ++ - - - -
hemorrhage

Learn to adapt, adjust and accommodate
Learn to give, not to take and learn to serve not to rule

Ischemic stroke subtypes and risk factor
associations
Risk factor
Ischemic Age HT Smoking Diabete AF CHO
Stroke s L
subtypes
Artery-to- +++ ++ ++ ++ - +
artery
Lacunar +++ +++ +++ ++ - ±
Cardioembolic +++ ++ ++ ++ +++ +
Aortic arch +++ ++ ++ ++ - +
Border zone +++ ++ ++ ++ ± +

Risk of thromboembolism in patients with
atrial fibrillation

Clinical risk group Thromboembolism rate
per year (95% CI)
No risk factors 2.5 (1.3 – 5.0)
One risk factor 7.2 (4.8 – 10.8)
Two or more risk factors 17.6 (10.5 – 29.9)

Character gets y out of bed; com itm m
ou m ent oves y to action faith, hope and
ou
Discipline follow through to completion

Recommendations for pre clinical evaluation
of neuroprotectants in experimntal brain
ischemia
Drug dose Generate dose-response curves in several
species; assess likelihood of drug
penetration of tissue at risk
Therapeutic Assess carefully the time interval after the
time window onset of ischemia or reperfusion when the
drug can be successfully administered
Animal Study permanent and transient ischemia
models models initially in rats/mice, the possibly in
cats or primates in a radomized and
blinded fashion; results should be
replicated by independent laboratories;
consider influence of sex

Physiological Monitor blood pressure, blood gases,
monitoring hemoglobin, glucose, brain temperature and
cerebral blood flow for as long as possible

Outcome Evaluate acute and long-term outcome
measures (typically reduced infarct volume). Assess
functional recovery in multiple animal
species

Target It is uncertain if benefit in young, healthy
populations animals can be extrapolated to elderly, sick
humans
Combination Consider using agents that affect multiple
therapy mechanisms of neuronal injury after
ischemia, simultaneously or in successions
(the “cocktail” approach

Studies of moderate hypothermia after cardiac
arrest
Study Method Favourable
outcome (OR, 95
CI)

N Engl J Med 2002; N=77; 330C<2 hrs 5.25 (1.47-18.76)
346:549-556 after the return of
spontaneous P = 0.011
circulation for 12 hrs

N Engl J Med 2002; N=27; 320C-340C for 1.4 (1.08-1.81)
346:557-563 24 hrs; median
interval between P = 0.009
restoration of
circulation and
initiation of cooling;
105 min

Management of stroke three to twenty four hours

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