clinical stroke neurology[1].1

7/27/2019 Clinical Stroke Neurology[1].1

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Clinical Stroke Neurology

&Protocols

Dr Sunanda Anand


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Stroke

Neurological deficit lasting for >24 hrs due to vascularpathology of brain.

Neuroimaging does not indicate different

etiology.

Includes Cerebral infarction, CVT,SAH and

intracerebral bleed.

24hrs criteria excluded if patient dies or undergoes

cerebrovascular surgery. Excludes strokes due to head injury or disorders

like leukemia.


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Stroke Programme

Acute stroke Intervention

Chronic Stroke management

TIAs/ministrokes Secondary Prevention

Rehabilitation

Maintain Data.


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24/7 Services

Emergency Medical services.

Imaging CT/MRI.

DSA Lab : Interventional Neuroradiology. Stroke unit/ICU & Step down units.

Trained Staff.


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Stroke

Arterial Strokes

Ischemic (80%)

Hemorrhagic(20%)

Venous Strokes:20% of young strokes

Non hemorrhagic Hemorrhagic


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How to Diagnose Stroke?

PARALYSIS = STROKE

Anterior circulation: Acute deficit in the Arm,

Leg, Face and Speech (Abb. NIHSS).

Posterior circulation: Vertigo, Altered sensorium

-Coma, Hemianopia, Motorsensory

deficit, Cerebellar signs etc.


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When to Thrombolyse?

NEUROLOGICAL DEFICIT : NIHSS >4

WINDOW PERIOD : 0-8HOURS

CT SCAN : No Hemorrhage No established

infarct.

i) Normal scan

ii) Dense MCA sign

iii) Hypodensity


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Normal scan Dense MCA sign


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What to Do? When to Do?

0-3 hrs: I/V thrombolysis

3-6 hrs: I/A thrombolysis/Mechanical

6-8 hrs: Mechanical devices

Others:

Rescue therapy (Drip &Ship)

Ultrasonic recanalization.

Neuroprotection


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When not to Thrombolyse?

More than 8 hrs for anterior circulation.

Mild or rapidly improving deficit.

Neurological deficit noticed on waking up from

sleep.

Hemorrhage or established acute infarct on CT.

Known CNS vascular malformation or tumor.

Bacterial endocarditis, Bleeding diathesis etc.


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IV Thrombolysis

NINDS, ECASS 2 & Meta analysis.

Agent to be used: rtPA

DOSE: 0.9mg/kg to max of 90 mgm.

10% as bolus over 2 min rest as an infusionover 1 hr.

Outcome: 30% improvement in functional &neurological outcome.

Symptomatic hemorrhage 6.6%.


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IA Thrombolysis

rtPA and Urokinase (PROACT I &II)

0-6 Hrs for anterior circulation

24 hrs for Posterior circulation or Fluctuating neurological status.

Recent surgery, trauma,other contraindications for IV thrombolysis .

Patient having (PTCA) & embolic stroke

40% improvement in outcome at 3mths.


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Mechanical Devices

Concentric(Phase1&II . ongoing PhaseIII)

Penumbra (Phase I. ongoing PhaseII)

0-8hrs.

1st line therapy(3-8hrs)

Postoperative

Anticoagulated(INR=3)

Failed IV/IA tPA or Contraindications.


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Drip & Ship Therapy

IV + IA

Is combination of I/V and I/A.

IMS Trial (Phase 1&II).

Ongoing Phase III (randomised with IV rtPA).

Mod Severe Strokes NIHSS>=10.

0.6mg/kg IV rtPA.

Followed by 0.3 mg /kg IA rtPA if the clot is

visualized.


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Ultrasound

Transcranial doppler increases lytic

activity of rtPA ( Phase II ).

EKOS MicroLySUS catheter which can

administer tPA + IA low energyUltrasound.(PhaseI&II).


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Neuroprotection

Brain tissue to be made more resistant to

ischemic injury.

Decrease functional deficit.

Prolong Revascularization window.

Pharmacological& Mechanical. Disappointing results.


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Multi Modality ApproachRecent+Future

IV+IA

I/V +Mechanical

IV+ IA +Mechanical IA+Mechanical

+

Neuroprotection Ultrasonic


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Patient comes to Casualty with

Acute Stroke

Confirm diagnosis &onset time

Perform NIHSS+-GCS

Secure 2 IV lines ( Avoid dextrose) Nasal Oxygen if Sat


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Casualty into Action

Patient fulfills inclusion& exclusion criteria.

Discuss Treatment options

Treat BP to required level(100,000.

Other Invg not to delay therapy if Clinical H/O is not

relevant.

If Foleys/Intubation/RT is required insert prior totreatment.


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0-2 Hrs

IV rtPA

0.9mg/Kg max 90mg

Dilute 1:1 with sterile water or NS

Do not agitate.

10% bolus and remainder infusion 1hr.

or

Combined therapy: 0.6mg/kg rtPA.

15% bolus and 85% over 30 min.


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3-5 hrs.

Alert Interventional Neuroradiology. IA rtPA 0.3mg/kg.(max40mg)

IA Urokinase 7.5 00,000 units.(1.2million)

Mechanical Devices.

Multimodality.

Along with First line Invg .

MR DW1and PW1 mismatch +MRA or

CT Perfusion+CTA (dec CBF,Inc MTT &Norm or IncCBV).

CT clinical mismatch.


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Large Artery occlusion


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Basilar Occlusion


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5-8 hrs

Mechanical Devices


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Special situations:

Monoplegia

Paresis: MRC >3, dysarthria ,facial

Visual loss

Aphasia


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Post Intervention management

24 hrs

Shift to ICU/Stroke unit

NPO/ Sat>95%/Cardiac Monitoring.

IV NS maintenance drip(50cc/hr)

NIHSS & BP checks every 15 min for 1st 2hrs

Then every 30min for next 6 hrs

Every Hr for next 16 hrs

Then every 4 hrs.


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ICU /Stroke unit in Action

Control BP (


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Watch for

Severe headaches, vomiting,

Acute Hypertension ,drowsiness

Worsening of neurological status.(NIHSS>=4pts)

DISCONTINUE INFUSION &ORDER BRAIN CT


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Is There ICH?

Discontinue rtPA.

Stat Blood Grouping +cross, PT, PTT,

Fibrinogen level.

Infuse 6 units of platelets + 6 units of FFP

(or 6 units of cryoprecipitate with Factor

VIII)

Neurosurgery consultation for Evacuation.


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Is there Angioedema?

On rtPA (1-2%)

Tongue examn for enlargement every 20

min after starting infusion

Breathlessness /Stridor

DISCONTINUE rtPA INFUSION

Treat accordingly with H1 ,H2blockers,Steriods Adrenalin, Intubation.


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Is there Raised ICP?

Suspect in large hemispheric and

cerebellar strokes

Peaks at 72 hrs.

Change IN LOC.

Agitation, Increase BP, Dec Pulse rate

Change In respiratory pattern Pupillary changes,Fundus, Decerebrate

Posturing.


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How to Manage ICP?

Monitoring ICP?

Raise Head by 30-45 Deg.

Treat agitation/cough with Propfol/Fentanyl

Neuromuscular paralysis if Pt is bucking onVentilator.


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Treatment of ICP

Mannitol 0.25 -1gm/kg . Max for 5 days

Hypertonic Saline

Hyperventilation.PCo2 to 25-30mm. Temporary

Hypothermia(32-33deg) cooling blankets and ice

packs.

Neurosurgery of Decompression craniectomy.


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Other Complications

Seizures

Aspiration Penumonia ( 15-25% of

deaths)

dysphagia: facial palsy,altered

sensorium,brainstem strokes

Mechanical ventilation

Immobility leading to atelectasis


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Complications

UTI (16%) indwelling catheters

Constipation ( Commonly forgottten)

Malnutrition delays recovery(S.Albumin) Establish nutrition by 48 - 72hrs.

Assess swallowing test for Oral feeding.

NG tube

Feeding gastrotomy (>6weeks)


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Complications

DVT and pulmonary embolism(10% ofdeaths. Incidence 20-50%)

EARLY MOBILIZATION

Non ambulatory within 24 hrs then:- TEDS: Thromboembolic stockings

Penumatic compression devices

Heparin 5000units S/C BD Low mol wt heparin


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TIAS/Mini Strokes

Transient neurological deficit lasting


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Risk with TIAS

25-30% of strokes are preceded by TIAS

10% chance of stroke in next 90 days

50% of these in next 2 daysHigh Risk:-

Age>60yrs

DM

TIAs >10 min


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How to prevent recurrence?

Secondary Prevention

Recurrent strokes 5-18%.

Strategies according to Causes:-

Cardioembolic (20%) Large vessel atherosclerosis(15%)

Small vessel disease(15%)

Others(hpercoaguablity,dissection) (5%)

Cryptogenic(45% R/O PFO)


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Essential Stroke workup

in all cases

Echocardiography (thoracic /TEE)

Doppler for Carotid and vertebral arteries

Or MRA/CTA for Neck& Cerebral arteries.

Fasting lipids & DM workup.

Hypercoaguable workup (young strokes)


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Large+Small vessel atherosclerosis

First Line drugs

Aspirin + Clopidogrel for 1 month.

Then Single drug for lifelong.

Only CVD prefer Aspirin. CVA+CAD+-PVD prefer clopidogrel.

Statins If CVA +IHD

Treat Etiology.

If Antiplatelets fails add Anticoagulation.


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Aspirin

Aspirin 300mg loading then150mg OD

(75mg-325mg)

Start at presentation

Acute intervention start >24 hrs.

Decreases recurrent stroke by 22%

annually.


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Clopidogrel

Clopidogrel 75mg 4 tabs loading then 1OD Preferred in cases with stroke +IHD+PVD

Additional dec of 8.7% in end points.

ASA-Dipyridamole

Dec risk of recurrence by 23%.


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Heparin & Coumadians

First line therapy in Cardioembolic strokes

Controversial in acute stroke(TOAST&IST)

Our Practice: low mol wt heparin If partial recanalization in Acute stroke

intervention>24hrs.

Ist 48hrs in Acute stroke & TIAS.(exceptlarge hemispheric strokes)

Fall back therapy if antiplatelets fail.


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Large vessel Atherosclerosis

Carotids: Advised Stenting

>70% stenosis.

50-69% stenosis: Male gender, Precedinghemispheric stroke,Contalateral occlusion.


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Intracranial Atherosclerosis.

Medical therapy

Antiplatelets

Statins

26% recurrent stroke(by2yrs) on optimummedical management. (WASID)


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Intracranial Stenting/EC-IC bypass

Recurrent symptoms

Hemodynamic dependent lesion

Basilar stenosis.


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Cardioembolic Stroke

IHD

Atrial fibrillation (long term anticoagulation)

Patent foramen ovale & ASD.

Aortic arch atheroscelosis.

Others: RHD, Prosthetic valves,atrial/ventricular

thrombus,infective endocarditis,maratic

endocarditis, intrcardiac tumors.


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Atrial fibrillation & Stroke

AF : Risk of stroke 12%.

Anticoagulation risk : 4%.

Aspirin : 10%.

AF with acute Ischemic stroke : Delay

anticoagulation from 1-2 weeks weighing

the risk of hemorrhagic conversion.


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Cardioembolic Strokes

Treatment with anticoagulation.

PFO :AC/Aspirin/AC/Endovascular closure

Ascending Aortic arch atheroma>4mm,ulcerated ,mobile.

Rx with AC/Aspirin

CHF with stroke Rx with AC.

A i Ri k f t


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Aggressive Risk factor

Management in all Strokes

Rx Hypertension : Control BP preferably to

120/80mm Hg

First line : ACE inhibitors /ARBs

Thiazide diuretics.

R Di b t M llit


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Rx Diabetes Mellitus

Fasting Glucose & HgbA1C

Goal Maintain HgbA1C


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Rx Hyperlipidemia

LDL


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Discharge Instructions:

Life style modifications

Quit Smoking/tobacco

Quit Alcohol

Weight management

30 min of mod intensity exercise/day


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Acute Rehabilitation

PT, OT & Speech therapy at the earliest.

For brain plasticity and improvement

Rehabilitation should be:

Task specific

Repetitive

Motivating to Pt.


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Acute Venous Strokes

Clinical presentation: varied

Headache ,Focal deficits, Seizures,

Altered sensorium , Raised ICP etc.

Encephalopathy on admission or

progressive deterioration in LOC are bad

prognostic features.


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Diagnostic Modalities

High Level of suspicion

CT +CT venogram

MRI+ MR venogram

DSA


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Management

Mild Clinical grade: Heparin

Severe Clinical grade: Localthrombolysis

Clinical grade 3: deteriorating onHeparin >24 hrs.

CLINICAL GRADING


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CLINICAL GRADING

(GCS)

Mild Clinical Grade

Status 1 No symptoms.

Status 2 Minor symptoms.

Status 3 Major neurological deficit.


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Severe Clinical grade

Status 4 Impaired state of alertness butcapable of protective & adaptive

response to noxious stimuli.

Status 5 Poorly responsive but with

stable vital signs

Status 6 Not responsive to shaking, No

adaptive response to noxious stimuliand progressive instability of vital

signs.

CT GRADING


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CT GRADING Grade 1 No parenchymal change.

Grade 2 Nonhemorrhagic venous infarct ,No

mass effect.

Grade 3 Nonhemorrhagic venous infarct withmass effect.

Grade 4 Hemorrhagic venous infarct.

( bleed < 3cm)

Grade 5 Hemorrhagic venous infarct with

mass effect. (bleed>3cm)


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DSA GRADING

Grade 1 Partial thrombosis/Recanalization.

Grade 2 Dural sinus occlusion with no

restriction of venous outflow.

Grade 3 Dural sinus occlusion with

restriction of venous outflow.

Grade 4 Deep venous system occlusion.

Grade 5 Deep and superficial system

occlusion.

When to Thrombolyse in Venous


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When to Thrombolyse in Venous

Stroke? Clinical Grade :Severe(4,5,6) on

admission

+

DSA: Dural venous sinus thrombosis withrestrictive venous outflow

Clinical grade : Mild (3) worsening onHeparin therapy


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Severe grade +DSA

Patient deteriorating on Heparin


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Patient deteriorating on Heparin


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Stop Thrombolysis

Clinical improvement ( LOC).

AND/ OR

Recanalization of sinus with antegrade

flow on Venogram.

Evidence of Systemic & Intracranialbleed. (exclude puncture site oozing)

EXCLUSION CRITERIA


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EXCLUSION CRITERIA

Clinical recovery since presentation.

Sinus recanalization with no restriction tovenous outflow on DSA.

G.I. or G.U. tract bleeding (less than 2weeks)

Intracranial Aneurysms / AVMs /

Neoplasms. Bleeding diathesis, INR > 1.7, Platelet

count < 100,000


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Post Thrombolysis.

Treatment with Heparin

Oral anticoagulation for 6 months

Adjunctive therapy.

Thrombophilia workup.


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Thrombophilia profile

Protein C 70140%

Protein S 80---130%

Antithrombin III 75---125%

Lupus anticoagulant

Activated protein C resistence ( Normalized ratio 0.75---1.10)

S.Homocysteine male 6---16 Umol/L Female 3.4---20.5

Anticardiolipin antibodies IgG


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Follow Up

Clinical

MR Venogram+ thrombophilia status at 3

months.

To decide Further anticoagulation.

clinical stroke neurology[1].1

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