Stroke

Dr. M.T.M Riffsy

MD. FRCP. FCCP
Consultant Neurologist
 F Face Smile
 A Arms Arm drift
 S Speech Repeat a simple sentence
 T Time Most critical element

Think Fast
Act Fast
Ischemic
Penumbra
Stroke chain of survival
 Detection Recognize stroke

 Dispatch Immediate EMS

 Delivery Most appropriate stroke Hospital, pre hospital notification

 Door Immediate ED triage

 Data Prompt ED evaluation

Stroke team activation
Laboratory Studies
Brain imaging
 Decision Diagnosis
Most appropriate therapy
Discussion with patient family

 Drug Administration of appropriate drug / intervention

 Disposition Timely admission to Stroke Unit / ICU

Acute Stroke Management

 Stroke – Acute loss of perfusion to a vascular

territory of the brain.
 Sudden onset – Focal neurological deficit
Weakness
Sensory deficit
Difficulties with language

Thrombosis

Ischemic Embolism

 Classified Hypo perfusion

ICH
Hemorrhage
SAH
Brain

 Most metabolically active organ – 2% body mass

15-20% total cardiac output
to provide glucose and oxygen
Blood flow <18ml / 100mg / min
Irreversible neuronal ischemia and injury
Cerebral oedema – Further damage the brain

Core – Cell death within minutes

Penumbra – Reduce perfusion/ marginal

Remain viable for several hours.
Current therapy of reperfusion
Preserve this area, cells rescued before
irreversible damage
Reperfusion should be done quickly
Preferably before 3 hours
Time is Brain
 The Burden of Stroke in Sri Lanka

• 4th leading cause of death - 9.2% of deaths

• Prevalence of stroke among the highest in the
world - ~1% of population
– Sri Lanka is in transition - demographic,
epidemiological
– Dramatic increase in vascular risk factors
– The burden of stroke will get bigger and bigger
History

 Public awareness – symptoms of stroke

 Sudden Face
 Numbness / weakness (one side) Arm
Leg

 Confusion / Difficulty in speaking

 Deterioration of vision in one or both eyes
 Difficulty in walking, dizziness , loss of balance
 Severe headache with no known cause

 Focused medical history – Identify risk factors

 Atherosclerotic and cardiac disease
HT, DM, Cholesterol, tobacco use, IHD
Physical Examination

 ABC Airway, Breathing, Circulation

 Defining the severity of neurological deficit
 Identify potential causes of the stroke
 Identify potential stroke mimics
 Identify cormorbid conditions

O/E ABC
Haemorrhage – Can deteriorate quickly
Constant reassessment
ICH / SAH - Require intervention
Air protection / ventilation
Physical Examination cont
 Vital Signs
 Blood Pressure
Hypertension at presentation is common
BP Decreases spontaneously with time
Acute reduction of BP NOT proven to be beneficial
Lowering BP in - Acute MI
- CHF
- Aortic dissection
 BP Lowering
 t-PA patients SBP >185 mmHg  IV Labetolol
DBP > 110 mmHg Enalapril
 Non t- PA SBP > 220 mmHg Sodium Nitroprusside
DBP > 140 mmHg
Physical Examination cont.

 Any evidence of head trauma

 Auscultation of neck bruit
 Cardiac - Rhythm / AF
Auscultation
Stroke can be secondary to AMI / CHF
 Extremities
Aortic dissection - Unequal pulse
Unequal BP
 Laboratory
 RBS
 SER. Electrolytes, BU, Creatinine
 FBC - Hb, PCV, Platelet count
 PT, APTT – Pts on anticoagulants
Pts for thrombulybolysis
 ECG, Cardiac enzymes ,2D ECHO
 Chest Xray
 ESR
 Lipid profile
 ANA
 Additional tests – protein C&S, Anti Throbin III, Factor V Laden
Anti cardiolipin Ab, Anti phospholipid Ab
General Management

 Admission to Stroke Unit / Gen.Medical Wd

 Blood Pressure Cerebral Auto regulation is disturbed
after stroke
 Oxygenation O2 <92% Saturation
 Control Blood Glucose Hyper. Gly. Insulin
 Fever Hyperthermia exacer.brain injury
Antipyretics
Search for infective source
Gen. Mng.
 IV fluids N. Saline to maintain cerebral perfusion
 Swallowing NGT
 Speech & Language assessment
 Advice from dietitian – Nutritional Support
 Physiotherapy Early mobilization & Rehab
 DVT prevention – Avoid dehydration
 Seizures 2% Focal/Gen AED
 Post stroke – Depression 50%
Brain Imaging

 CT Brain Should be performed

As soon as possible sp.
Thrombolysis
 Detect Ischemic / Hemorrhage
 May detect unexpected lesions
 A normal scan excludes hemorrhage but not infarct
 90% large infarcts visible at 48 hrs.
 40% small infarcts lacunar / cortical
Brain Imaging
 Before starting any specific therapy,
Class1, level A

 NECT brain will provide necessary information for emergency management

 rt-PA therapy – early ischemic stroke

other than frank hypo density on CT
class1, level A

 A non invasive vascular study

Intra arterial thrombolysis, mechanical thrombectomy
But should not delay IV rt-PA

 CT perfusion / MRI perfusion and diffusion

Measure of infarct core and penumbra
Acute reperfusion beyond the time window

 Frank hypo density NECTmay increase the risk of hemorrhage

with thrombolysis ( >1/3 MCA territory )
CT brain scan
 MCA sign

 MCA infarct
Intra cranial Hemorrhage
ICH, IVH Cerebellar Hemorrhage

SAH
MRI Brain
 In selected centers
 DWI will show changes with in minutes
 MRA Brain , Neck
 Diffusion / Perfusion Mismatch
 Differential Diagnosis
 Tumour
 Metastases
 Meningitis, Encephalitis
 SDH
 EDH
 Hypo / Hyper glycaemia
Specific Treatment –acute ischemic stroke

 IV Thrombolysis NINDS trial (1996)

 Recombinant tissue plasminogen activator
(rtPA) given within 3 hrs. benificial
Most benefit within 90 min
 ECASS 3 trial 3-4.5 hrs.
 Accurate Time of Stroke Onset
 Organized Stroke Team
 Complication Hemorrhagic transformation 6%
Malignant MCA Syndrome
Antiplatelet Drugs

 Aspirin started with in 48 hrs.

 Reduce mortality and recurrent stroke
 Aspirin + Dipyridamole
 Clopidogrel
 Anticogulation
AF or other cardio embolic cause
Treat with aspirin
Oral anticoag. Approx. 2 weeks
Intra arterial thrombolysis

 PROACT II , MELT
 MCA M1. M2 occlusions
 With in 6 hrs. of stroke symptom onset
Mechanical thrombectomy
stent retrievers
 Devices
MERCY
Peneumbra systems
Solitaire FR
TREVO
Clopidogrel and Aspirin in
acute minor stroke or TIA –
5170 pts.
 Minor stroke NIHSS score 3 or less
ABCD2 score >4

 With in 24 hrs.

 Aspirin 75-300 mg. or

Asp + Clopidogrel 300 mg. loading

75 mg. day 21 days
Followed by clop. 75 mg. upto 90 days

 Clo + Asp. Superior to aspirin alone

 90 day Reducing the risk of stroke
 Risk Aspirin 11.7%
Asp+Clop. 8.2%

 Severe Hemorrhage 0.3%, in both groups

Future of stroke in Sri Lanka

 EMS
 Stroke care hospitals
CT/MRI
Stroke units
Facilities for thrombolysis
 Tele Radiology
 Tele Stroke Consultation