management of stroke.ppt

8/14/2019 management of stroke.ppt

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MANAGEMENT OF STROKEEmergency Department

School Medicine

Brawijaya University - Malang


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Stroke: Definition

Stroke is clinically defined as a neurologic

syndrome characterized by acute disruption of

blood flow to an area of the brain and

corresponding onset of neurologic deficitsrelated to the concerned area of the brain

Nurs Clin N Am 2002;37:35-57


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The 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

Burden is likely to increase with risk factors likeaging, smoking, adverse dietary patterns

Most common cause of disability and dependence,with more than 70% of stroke survivors remainingvocationally impaired and more than 30% requiringassistance with daily activities

Stroke 1998;29:1730-36

Neurol India 2002;50:279-81


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Stroke: Classification

Ischemic stroke: Account for 80%. Results from

occlusion in the blood vessel supplying the brain

Thrombot ic : Occlusion due to atherothrombosisof small/large vessels supplying the brain

Embol ic : Occlusion due to embolus arisingeither from heart (e.g. atrial fibrillation, valvulardisease) or blood vessel


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Classification (contd.)

Hemorrhagic stroke: Account for 20%. Results from

rupture of blood vessels leading to bleeding in brain

Intracerebral: Bleeding within the brain due torupture of small blood vessels. Occurs mainly

due to high blood pressure

Subarachnoid: Bleeding around the brain;commonest cause is rupture of aneurysm.Othercauses: Head injury


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Stroke: Predisposing factors

Age (risk doubles for every decade after age 55)

Gender (males>females) Family history of stroke/TIA

Hypertension

Diabetes

Hyperlipidemia

Hyperhomocysteinemia Obesity

Smoking

Atrial fibrillation

Sedentary lifestyle

Drug abuse (e.g. cocaine use) Hormone replacement therapy

Oral contraceptive


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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 andcontinues to worsen


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Stroke: Symptoms (contd.)

Dizziness

Confusion Loss of balance/coordination

Nausea/vomiting

Numbness/weakness on one side of the body

Seizure Severe headache

Movement disorder/speech disorder/blindness etc (dependingon the area of brain affected)

Additional symptoms for hemorrhagic stroke Pain upon looking at or into light

Painful stiff neck

P l l i il t


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People may also experience silent

strokes with no symptoms

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.


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Transient Ischemic Attack (TIA)

Mini stroke

Stroke symptoms last for less than 24 hours (usually10 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 by a

physician


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Differential Diagnosis

Kriteria Diagnosa PIS SAH Thrombosis Emboli

Umur > 40 tahun Tak tentubiasanya 20-30

5070 tahun Semua umur

Onset

Perjalanan

Aktivitas

Cepat

Aktivitas

Cepat

Bangun tidur

Bertahap

- Tak tentu

- Cepat

Gejala penyerta

Sakit kepala

Muntah

Vertigo

++

++

_

++++

++++

_

_

_

+ / -

_

_

+ / -

Risk faktor

Hipertensi

Penyakit jantung

DM

Hiperlipid

HT berat/maligna

HHD

_

_

+ / -

_

_

_

+ / -

ASHD

++

++

_

RhHD

_

_


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Differential Diagnosis

KriteriaDiagnosa

PIS SAH Thrombosis Emboli

Kesadaran / coma pelan N / N /

Kaku kuduk +/- ++++ _ _

Kelumpuhan

Hemiplegi

Tangan = kaki

/

Hemiparese +/-

Sdh 3-5 hari

Hemiparese

Tangan kaki

Hemiparese

Tangan kaki

Afasia _ _ ++/- ++/-

LP darah +/- +++++ _ _

Arteriografi Shift midline Aneerysma + Oklusi / Stenosis Oklusi

CT Scan Hiperdens ++++

Intraserebral

N / Hiperden

Ekstraserebral

Hipodens

Sdh 47 hari

Hipodens

Sdh 47 hari


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Ischemic stroke diagnostic algorithm

Acute focal brain deficit

Head CT

Ischemic Stroke

ECG

Echo

CARDIACEMBOLISM

LARGE ARTERYATHEROSCLEROSIS

SMALLVESSEL DISEASE

OTHER DETERMINEDCAUSE

DopplerMRAAngiogram

MRICT

VasculopathyCoagulopathy

CRYPTOGESTROK

Excluded hypoglycemia, migraine

with aura, post-seizure deficit

TIA (if CT/MR brain imagingwithout ischemic lesion)

< 1 hour

Lacunar syndromeCorticalsyndrome

Emergency Medical Care for Neurologic


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Emergency Medical Care for NeurologicEmergencies

Provide reassurance.

Ensure proper airway and breathing.

Place the patient in a position of comfort.

If you suspect stroke, transport immediately andnotify hospital.

Assess and care for any injuries if you suspect any

type of trauma.


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Management of acute ischemic stroke

Systemic thrombolysis: Intravenous recombinant

tissue plasminogen activator (rt-PA): Within 3 hrs ofonset of stroke. Dose 0.9 mg/kg, max 90 mg.

Antiplatelet agents: Aspirin 160-300 mg within 24-

48 hrs (not during first 24 hrs following thrombolytic

therapy). Clopidogrel a potential alternative.Combination of clopidogrel and aspirin currentlybeing evaluated



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Management of acute ischemic stroke(CONTD)

Anticoagulants: Heparin/LMWH are not

recommended in acute treatment of ischemicstroke. Recommended in setting of atrialfibrillation, acute MI risk, prosthetic valves,coagulopathies and for prevention of DVT.

Intra-arterial thrombolytics: An option fortreatment of selected patients with majorstroke of < 6 hrs duration due to large vesselocclusion.



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Management of acute ischemic stroke(CONTD)

BP management: Should be kept within higher

normal limits since low BP could precipitate perfusionfailure. Markedly elevated BP (>220/110mmHg)managed with nitroglycerin, clonidine, labetalol,sodium nitroprusside. More aggressive approach istaken if thrombolytic therapy is instituted

Blood glucose management: Should be kept withinphysiological levels using oral or IV glucose (in caseof hypoglycemia)/insulin (in case of hyperglycemia)

Elevated body temperature management:Antipyretics and use of cooling device can improve

the prognosis


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Management of Acute hemorrhagic stroke

Analgesics/Antianxiety agents: To relieve

headache. Analgesics having sedative properties arebeneficial for patients having sustained trauma (e.g.morphine sulphate)

Antihypertensives:(e.g. sodium nitroprusside,

labetolol) Hyperosmotic agents(e.g. mannitol, glycerol,

furosemide): To reduce cerebral edema, and raisedintracranial pressure.

Adequate hydration is necessary Surgical intervention may occasionally be life

saving


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Management of TIA

Evaluation within hours after onset of

symptoms CT scan is necessary in all patients

Antiplatelet therapy with aspirin (50-325 mg/d),

consider use of clopidogrel, ticlopidine, oraspirin-dipyridamole in patients who areintolerant to aspirin or those who experienceTIA despite aspirin use


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Secondary prevention of stroke

Recurrence: Annual risk is 4.5 to 6%. Five year recurrence rates rangefrom 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


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Surgical interventions

Balloon angioplasty/stenting

Carotid endarterectomy/Bypass

Decompressive surgery

management of stroke.ppt

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