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OBJECTIVES
STROKE IMPACT KNOW THE CLASSIFICATION OF STROKES HOW TO DIAGNOSE STROKES GUIDELINES FOR ACUTE STROKE TREATMENT
STROKE IMPACT
STROKE IS BRAIN ATTACK ! Sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathology. No. 2 Killer worldwide No. 1 Killer in Asia- Western Pacific, China, and Japan 20 million people every year with 5 million deaths Locally: 500 strokes per 100,000 population
MODERATE STROKE
Awake patient with significant motor and/or sensory and/or language and/or visual deficit OR Disoriented, drowsy, or stuporous patient but with purposeful response to painful stimuli
SEVERE STROKE
Comatose patient with nonpurposeful response, decorticate, OR Decerebrate posturing to painful stimuli or comatose patient with no response to painful stimuli
DIAGNOSING STROKE
1. Clinical (80%)
History, Physical & Neurological Exam
* Establish the time of onset of symptoms
Sudden, focal, Loss of function
2. Neuroimaging (20%)
* Cranial CT scan is the initial imaging study of choice
With the advent of numerous diagnostic modalities, appropriate sequential diagnostic examinations are most important to confirm the clinical diagnosis of stroke.
Plain Cranial CT
Electrocardiogram
SSP Guidelines for the Prevention & Management of Brain Attack, 2003
Neurovascular Studies
Carotid Duplex Transcranial Doppler studies(TCD) Catheter Angiography CT Angiography Magnetic Resonance Angiography (MRA)
Cardiac investigation
Echocardiography 24 hour Holter
Hematologic Studies
Hypercoagulable states Protein C, S, Fibrinogen Antithrombin III
Drug Levels e.g. Metamphetamine Biopsy e.g Vasculitis, Temporal arteritis Genetic Familial homocystinuria, MELAS, CADASIL
Hyperacute 3 hours
12 hours
48 hours
First-line modality imaging in suspected stroke cases Widely available, relatively inexpensive, non - invasive & quick Accurately differentiates hemorrhagic and ischemic strokes Should be performed & interpreted ASAP
Identify the lesion (is it a stroke?) Determine the type of stroke (ischemic or hemorrhage?) Localize the stroke (where is it?) Quantify the lesion (how large is it?) Determine the age of the lesion
However, the following signs may be seen: Hyperdense artery (dense MCA sign) Obscuration of lentiform nuclei Loss of grey-white interphase along lateral insula (insular ribbon sign) Effacement of sulci
Effacement of sulci
subcortical, or deep gray or white matter, following a vascular territory, or watershed distribution
Hyperdense lesion in left lentiform nucleus with hypodense rim (vasogenic edema)
30 50cc
> 50cc
moderate
large surgical
DIAGNOSING STROKE:
Other Neuroimaging Techniques
T1
Parenchymal signal changes (hypointense on T1)
T2
Parenchymal signal changes (hyperintense on T2)
T1
T2 R Pontine Infarction
R medullary Infarction
DIAGNOSING STROKE:
Other Neuroimaging Techniques
ACUTE
Pontine Hemorrhage
Cranial MRI
Cranial CT scan
NEUROVASCULAR EVALUATION
Ultrasound Techniques
Catheter Angiography
CT Angiography MR Angiography
Cerebral arteriography may also be required when a diagnosis of vasculitis, dissection, vascular malformation needs confirmation or exclusion
Carotid/vertebral Duplex
CAROTID DUPLEX
Established technique to identify extracranial carotid / vertebral artery disease Advantages: non-invasive, bedside availability, low cost
TRANSCRANIAL DOPPLER
Established technique to evaluate basal intracranial arteries Established utility in stroke (e.g. stenosis, vasospasm, ICP, vasomotor reactivity) Advantages: non-invasive, bedside availability, low cost, allows serial monitoring, detects micro emboli Disadvantages: operator dependent, poor temporal window, circle of Willis variation
Stenosis / occlusion Emboli detection Collateralization Vasospasm Increased ICP / Brain death Cerebral Autoregulation
CT ANGIOGRAPHY
Other NonInvasive
Neurovascular Imaging
Procedures
MCA Stenosis
CATHETER ANGIOGRAPHY
AV Malformation
Aneurysm
Cost, availability, invasive procedure Risks (vascular damage, stroke, ionizing radiation, reaction to contrast) Exclusion: poor renal function, absent femoral pulses, coagulopathy
Venous angioma
CARDIAC EVALUATION
Holter Monitoring
2 D Echocardiography
Recommendations for Echocardiography in Patients with Stroke Clinical evidence of heart disease Less than or equal 45 years of age Older patients, without evidence of extra or intracranial occlusive disease or other obvious cause Abrupt occlusion of major peripheral or visceral artery Suspect embolic disease (non-lacunar syndrome, multiple arterial territory involvement) Clinical therapeutic decision will depend on results of echocardiography
TTE Preferred
TEE Preferred
LV thrombus LV dyskinesia Mitral stenosis Mitral annular calcification Mitral valve prolapse
Atrial thrombus Atrial appendage thrombus Atrial septal aneurysm Patent foramen ovale Aortic arch athero / dissection
SUMMARY
Rule out stroke mimickers History, PE & NE should be done immediately on patients with stroke Do emergent diagnostic tests to determine patients eligibility for rTPA
SUMMARY
CT scan remains to be the most important brain imaging test. Cranial MRI is not recommended for routine evaluation of acute stroke patients Differentiation of ischemic & hemorrhagic stroke is important because of marked difference in the management Second line diagnostic tests need not be done in the ER setting and should not delay treatment
EARLY SPECIFIC TREATMENT FOR THROMBOTIC OR LACUNAR STROKE (CTSCAN CONFIRMED) Aspirin 160-325 mg start as early as possible for 14 days Neuroprotection Early rehabilitation within 72 hours
GUIDELINES FOR TIA AND MILD STROKE EARLY SPECIFIC TREATMENT FOR CARDIOEMBOLIC (CTSCAN CONFIRMED) Anticoagulation with IV heparin or subcutaneous LMWH Or Aspirin 160-325 mg/day (If anticoagulation not available) Neuroprotection Early rehabilitation within 72 hours If infective endocarditis is suspected, give antibiotics and do not anticoagulate.
GUIDELINES FOR TIA AND MILD STROKE EARLY SPECIFIC TREATMENT FOR T.I.A. Aspirin 160-325 mg/ day If crescendo T I A (multiple events within hours, Increasing severity and duration of deficits), consider ANTICOAGULATION with intravenous heparin
GUIDELINES FOR TIA AND MILD STROKE CT SCAN NOT AVAILABLE No specific emergent drug treatment recommended Neuroprotection Consult a neurologist or neurosurgeon Early supportive rehabilitation
GUIDELINES FOR TIA AND MILD STROKE PLACE OF TREATMENT Admit to Hospital (Stroke Unit) 1. Stroke onset within 48 hours 2. Patients requiring specific active intervention for any of the following: a. BP control, monitoring, and stabilization b. Cardiac stabilization, incl. Atrial fibrillation, CHF, acute MI c. Hydration d. Anticoagulation, if ICH ruled out by CT
GUIDELINES FOR TIA AND MILD STROKE PLACE OF TREATMENT URGENT OUTPATIENT WORK-UP 1. Single TIA more than 2 weeks ago 2. 1-4 TIAs in 2 weeks, but not high risk (no change in severity and duration of deficit, cardiac arrhythmia, carotid bruit) 3. Transient monocular blindness alone 4. Stable mild strokes occurring > 48 hrs not requiring specific active intervention *Advise immediate re-consult if there is worsening of deficit.
GUIDELINES FOR MODERATE STROKE MANAGEMENT PRIORITIES 1. Basic emergent supportive care (ABC of resuscitation) 2. Monitor and manage blood pressure. Treat if SBP>220; DBP>120; MAP= >130 Precautions: Avoid precipitous drop in BP >20% MAP No Sublingual agents 3. Exclude stroke mimickers 4. Identify co-morbidities (cardiac dis. Gastric ulcer, etc) 5. Recognize and treat early signs of increased ICP
GUIDELINES FOR MODERATE STROKE EMERGENT DIAGNOSTICS Complete Blood Count Blood sugar (CBG, HGT, RBS) PT/PTT Serum Na and K+ Electrocardiogram (ECG) Plain CT Scan of brain ASAP
GUIDELINES FOR MODERATE STROKE EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED) Ischemic- Noncardioembolic (Thrombotic/ Lacunar) - If within 3 hours of stroke onset, consider rtPA treatment and refer to specialist - Aspirin 160-325 mg/day start as early as possible - Neuroprotection - Early supportive rehabilitation
CARDIOEMBOLIC - If within 3 hours of stroke onset consider rtPA ` treatment and refer to specialist - Aspirin 150- 325 mg/day start as early as pos. - Early anticoagulation if source of embolism can be demonstrated - Neuroprotection - Early supportive rehabilitation * If infective endocarditis is suspected, give antibiotics and DO NOT anticoagulate
GUIDELINES FOR MODERATE STROKE CT SCAN NOT AVAILABLE = USE SCORING SYSTEM Likely Ischemic
No specific emergent drug Tx. Neuroprotection Refer to Specialist Early Supportive Rehabilitation
Likely Hemorrhagic
Refer to Neurologist/ Neurosurgeon further Dx workups and/or subsequent surgery Neuroprotection Early supportive rehabilitation
CIFIC TREATMENT