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8/3/2019 Acute Brain Attack
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ACUTE BRAIN ATTACK - 911
RUBEN T. DELA CRUZ MD, FPNAACUTE STROKE UNIT- MANILA ADVENTIST MEDICAL CEN
TER
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OBJECTIVES
STROKE IMPACT
KNOW THE CLASSIFICATION OFSTROKES
HOW TO DIAGNOSE STROKES
GUIDELINES FOR ACUTE STROKE
TREATMENT
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STROKE IMPACT
STROKE IS BRAIN ATTACK !Sudden onset of focal neurological deficit
lasting more than 24 hours due to anunderlying vascular pathology.
No. 2 Killer worldwideNo. 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
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CLINICAL STROKE CLASSIFICATION
TIA AND MILD STROKE
MODERATE STROKE
SEVERE STROKE
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TIA and MILD STROKE
Transient Ischemic Attack- deficits resolved within 24hours including transient blindness in one eye
OR
ALERT Patient with any of the ff:
a. mild pure motor weakness of one side of the body.
b. pure sensory deficit
c. slurred speech but intelligible
d. vertigo with incoordination
e. visual field defects alone
f. combination of a and b
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MODERATE STROKE
Awake patient with significant motor and/orsensory and/or language and/or visual deficit
OR
Disoriented, drowsy, or stuporous patient butwith purposeful response to painful stimuli
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SEVERE STROKE
Comatose patient with nonpurposefulresponse, decorticate,
OR
Decerebrate posturing to painful stimuli orcomatose patient with no response topainful stimuli
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DIAGNOSING STROKE
1. Clinical (80%)
2. Neuroimaging (20%)
* Establish the time of onset of symptoms
* Cranial CT scan is the initial imagingstudy of choice
Sudden, focal,Loss of function
History, Physical & Neurological Exam
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ROLE of DIAGNOSTIC EXAM
Confirm & establish the clinical diagnosis
Rule out stroke mimickers
Determine pathologic type
Infarct, ICH, SAH
Determine etiology & stroke mechanism
Screen for medical & neurologiccomplications of stroke
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COMMON STROKE MIMICKERS
Seizures
Systemic infection
Brain tumor Toxic-metabolic enceph
Positional vertigo
Syncope
Trauma Subdural hematoma
Herpes enceph
Transient global amnesia
Dementia
Demyelinating dse Cervical spine fracture
Myasthenia gravis
Parkinsons dse
Hypertensive enceph Conversion disorder
Bells palsy
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DIFFERENTIAL DIAGNOSIS OF STROKE
Pure hemifacial weakness (e.g. Bells palsy) Fever prior to onset of symptoms
Trauma
Recurrent seizures Weakness with atrophy
Recurrent headaches
If any of the ff conditions is present,
STROKE is probably UNLIKELY .
SSP Guidelines for the Prevention & Managementof Brain Attack, 2003
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With the advent of numerous diagnostic modalities,appropriate sequential diagnostic examinations
are most important to confirm the clinicaldiagnosis of stroke.
First-line (emergent) diagnostic exam
Second-line diagnostic investigations
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CBC, PT/ PTT,Blood sugar
Plain Cranial CT
EMERGENT DIAGNOSTIC EXAM
SSP Guidelines for the Prevention & Managementof Brain Attack, 2003
Electrocardiogram
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SECOND-LINE DIAGNOSTIC STUDIES
(To Identify Etiology and Stroke Mechanism)
Neurovascular Studies
Carotid Duplex
Transcranial Doppler studies(TCD)Catheter AngiographyCT AngiographyMagnetic Resonance Angiography (MRA)
Cardiac investigation
Echocardiography
24 hour Holter
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Hematologic StudiesHypercoagulable states Protein C, S,
Fibrinogen Antithrombin III
APAS - ANA, Anticardiolipin Ab, Lupus anticoagulant
Homocysteine
Drug Levels e.g. Metamphetamine
Genetic Familial homocystinuria, MELAS,CADASIL
SECOND-LINE DIAGNOSTIC STUDIES
(To Identify Etiology and Stroke Mechanism)
Biopsy e.g Vasculitis, Temporal arteritis
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Plain Cranial CT is recommended
Neuroimaging in Acute Stroke
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
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RATIONALE FOR NEUROIMAGING
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
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BASIC CONCEPTS
Cranial computed (x-ray) tomography scan
Air, Fluid (e.g. CSF, infarction) = hypodense
Bone, calcification, blood = hyperdense
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CT FINDINGS in HYPERACUTEINFARCTION (0 - 6 hrs)
Almost 60% of CT scans done in the first fewhours of ischemic stroke: NORMAL
However, the following signs may be seen:
Hyperdense artery (dense MCA sign)
Obscuration of lentiform nuclei
Loss of grey-white interphase along lateralinsula (insular ribbon sign)
Effacement of sulci
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Early signs of infarction on Cranial CT
Dense Artery sign Insular Ribbon sign(loss of insular stripe)
Obscuration of lentiform nuclei Effacement of sulci
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CRANIAL CT inACUTE ISCHEMIC STROKE
Infarction: focal hypodense area in cortical,subcortical, or deep gray or white matter,following a vascular territory, or watersheddistribution
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CT FINDINGS in SUBACUTE /CHRONIC INFARCTION
Wedge-shaped largecortical infarct
Round / ovoid smallsubcortical infarcts
http://www.uhrad.com/mriarc/mri045b2.jpg8/3/2019 Acute Brain Attack
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SubacuteR-ICA infarct
SubacuteL-MCA infarct
CT FINDINGS in SUBACUTE /CHRONIC INFARCTION
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Hyperdense lesionin left lentiformnucleus with
hypodense rim(vasogenic edema)
CT FINDINGS in INTRACEREBRALHEMORRHAGE
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Common Sites of Hypertensive ICH
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Common Sites of Hypertensive ICH
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Cranial CT of Hemorrhagic Stroke
Stroke Society of the Philippinesrecommendations for computation of
hematoma volume
Planimetric Method or Pixel Method
Modified Kothari method (ABC/2)
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A - greatest hemorrhage diameter
B -diameter 90 degrees to A
C - no of CT slices with hemorrhage x
by the slice thickness*
Measurement of Hematoma Volume
Modified Kothari Method
A x B x C / 2
Select the CT slice with the largestarea of hemorrhage
A
B
Hemorrhage > 75% of the largest area = 1 sliceHemorrhage > 25 75% of the largest area = 0.5 sliceHemorrhage < 25% of the largest area - 0
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Interpretation of Hematoma Volume forSupratentorial Hemorrhages
< 30cc small medical
30 50cc moderate
> 50cc large surgical
* Factor in age, neurologic status, concomitant medical conditions
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CT SCAN FINDINGS in
SUBARACHNOID HEMORRHAGE
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Advantages of Cranial MRI
DIAGNOSING STROKE:
Other Neuroimaging Techniques
More sensitive in detecting small lesions / lacunar infarcts early infarction brainstem / post fossa lesions
Can detect lesions as early as 6 hours fromonset of stroke (as early as 90 mins. forDiffusion MRI)
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Early signs of infarction on MRI
Slow flow (absence of normal flowvoid) in involved artery
Parenchymal signal changes
(hypointense on T1)
T1
DWI: acute infarctappears bright
Parenchymal signal changes
(hyperintense on T2)
T2
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R medullary Infarction
T1T2
MAGNETIC RESONANCE IMAGING in BRAINSTEMINFARCTION
R Pontine Infarction
http://www.uiowa.edu/~c064s01/NR026.JPG8/3/2019 Acute Brain Attack
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Limitations of Cranial MRI
DIAGNOSING STROKE:
Other Neuroimaging Techniques
More expensive & less widely available Longer acquisition time compared to CT
(difficult in uncooperative patients)
Contraindicated in patients with metallic
implants (e.g. pacemaker) Not sensitive in detecting acute hemorrhage
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MRI is not sensitive in detecting ACUTEHEMORRHAGE
Cranial MRI Cranial CT scan
Pontine Hemorrhage
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NEUROVASCULAREVALUATION
Ultrasound Techniques
Catheter Angiography
CT Angiography
MR Angiography
http://www.eas.asu.edu/~neurolab/objective-head.gif8/3/2019 Acute Brain Attack
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RATIONALE for NEUROVASCULAREVALUATION
Identifying occlusive arterial disease(Is there blockage ?)
Localizing the occlusion(Where ?, carotid ?, intracranial ?)
Quantifying the degree of stenosis(How severe ?)
Determining the pathology(Athero ?, dissection ?, others ?)
Identifying other vascular lesions
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Recommendations for Neurovascular
Imaging in Patients with Stroke
A non-invasive screening technique is indicated as an
initial diagnostic test
Conventional radiographic angiography may be
indicated based on findings of non-invasive
screening procedures (i.e. severe stenosis,
occlusion)
Cerebral arteriography may also be required when a
diagnosis of vasculitis, dissection, vascular
malformation needs confirmation or exclusion
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Transcranial Doppler (TCD)Carotid/vertebral Duplex
VASCULAR ULTRASOUND
NEUROSONOLOGY
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CAROTID DUPLEX
Established technique to identifyextracranial carotid / vertebral
artery disease
Advantages: non-invasive, bedsideavailability, low cost
Disadvantages: operatordependent, unable to differentiateocclusion from near occlusion
http://image.virtualmd.co.kr/community/com_imglist/small/Doppler_carotid-TEQ-01.jpghttp://www.gemedicalsystemseurope.com/euen/rad/us/images/l400/50149.jpg8/3/2019 Acute Brain Attack
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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, lowcost, allows serial monitoring, detectsmicro emboli
Disadvantages: operator dependent, poor temporalwindow, circle of Willis variation
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TCD APPLICATION in STROKE Stenosis / occlusion
Emboli detection
Collateralization
Vasospasm
Increased ICP / Brain death
Cerebral Autoregulation
MAGNETIC RESONANCECT ANGIOGRAPHY
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MAGNETIC RESONANCEANGIOGRAPHY
CT ANGIOGRAPHY
Other Non-Invasive
NeurovascularImaging
Procedures
http://images.google.com/imgres?imgurl=www.australianprescriber.com/magazines/vol24no6/images/magnetic_f1a.JPG&imgrefurl=http://www.australianprescriber.com/magazines/vol24no6/magnetic.htm&h=396&w=400&prev=/images%3Fq%3Dmagnetic%2Bresonance%2Bangiography%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DNhttp://www.rimiradiology.com/mra.jpg8/3/2019 Acute Brain Attack
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SevereCarotid Stenosis
CATHETER ANGIOGRAPHY
VertebralArtery Stenosis
MCAStenosis
Gold standard
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AV Malformation
CATHETER ANGIOGRAPHY
Venous angioma
Aneurysm
Cost, availability, invasive procedure
Risks (vascular damage, stroke,
ionizing radiation, reaction to contrast) Exclusion: poor renal function, absent
femoral pulses, coagulopathy
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cmed%5Cimages%5CLarge%5C2824MED3469-18.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cmed%5Cimages%5CLarge%5C2817MED3469-11.jpg&template=izoom28/3/2019 Acute Brain Attack
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CARDIAC EVALUATION
Holter Monitoring 2 D Echocardiography
http://image.virtualmd.co.kr/community/com_imglist/small/Echo-TEQ-01.jpghttp://images.google.com/imgres?imgurl=image.virtualmd.co.kr/community/com_imglist/small/EKG_ambulatory-TEQ-01.jpg&imgrefurl=http://www.virtualmd.co.kr/community/imglist.asp%3Fpage%3D5%26mainflag%3Dy&h=200&w=177&prev=/images%3Fq%3D%2Bechocardiography%26start%3D260%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DN8/3/2019 Acute Brain Attack
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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
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LV thrombusLV dyskinesiaMitral stenosisMitral annular calcificationMitral valve prolapse
Atrial thrombusAtrial appendage thrombusAtrial septal aneurysmPatent foramen ovaleAortic arch athero /
dissection
Transthoracic vs TransesophagealEchocardiography
TTE Preferred TEE Preferred
http://info.med.yale.edu/intmed/cardio/imaging/techniques/echo_intro/graphics/unlabelled.gifhttp://info.med.yale.edu/intmed/cardio/imaging/techniques/echo_tee/graphics/unlabelled.gif8/3/2019 Acute Brain Attack
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Proper use of diagnostic examinations instroke requires an understanding of:
Underlying disease process
Principles of test involved Advantages & limitations of each procedure
How each investigation influences patient
management
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SUMMARY
Rule out stroke mimickers
History, PE & NE should be done immediatelyon patients with stroke
Do emergent diagnostic tests to determinepatients eligibility forrTPA
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SUMMARY
CT scan remains to be the most important brainimaging 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 themanagement
Second line diagnostic tests need not be done in theER setting and should not delay treatment
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GUIDELINES FOR TIA AND MILD STROKE
MANAGEMENT PRIORITIES
Ascertain clinical diagnosis of stroke or TIA
Exclude common stroke mimickers
Monitor and manage blood pressure
SBP = 220 or DBP= 120
MAP= 130
Avoid precipitous drop in BP> 20% ofbaseline MAP
No rapid-acting sublingual agentsUse oral or easily titratable IV antihypertensive
Ensure appropriate hydration. No hypotonic IV fluids
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GUIDELINES FOR TIA AND MILD STROKE
EMERGENT diagnostics
Complete Blood count (CBC)
Blood sugar (CBG, HGT, or RBS)
Electrocardiogram (ECG)
PT/PTT (Atrial Fibrillation or possiblecardioembolic source)
Plain CT Scan Of brain as soon as possible
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GUIDELINES FOR TIA AND MILD STROKE
EARLY SPECIFIC TREATMENT FORTHROMBOTIC OR LACUNAR STROKE
(CTSCAN CONFIRMED)
Aspirin 160-325 mg start as early as possiblefor 14 days
Neuroprotection
Early rehabilitation within 72 hours
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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 notavailable)
Neuroprotection
Early rehabilitation within 72 hours
If infective endocarditis is suspected, give antibiotics anddo not anticoagulate.
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GUIDELINES FOR TIA AND MILD STROKE
EARLY SPECIFIC TREATMENT FOR HEMORRHAGIC
If there is suspicion of nonhypertensive cause for ICH(e.g. AVM, aneurysm), REFER to neurosurgeon.
Neuroprotection
Early rehabilitation with in 72 hrs
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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 intravenousheparin
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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
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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 interventionfor any of the following:
a. BP control, monitoring, and stabilization
b. Cardiac stabilization, incl. Atrial
fibrillation, CHF, acute MIc. Hydration
d. Anticoagulation, if ICH ruled out by CT
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GUIDELINES FOR TIA AND MILD STROKE
PLACE OF TREATMENT
Admit to Hospital (StrokeUnit)
3. Rapidly worsening deficits
4. >4 TIAs in 2 weeks prior to consult
5. 1-4 TIAs in 2 weeks but high risk (multipleevents within hours, increasing severity andduration of deficits
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GUIDELINES FOR TIA AND MILD STROKE
PLACE OF TREATMENTURGENT 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, cardiacarrhythmia, 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 ofdeficit.
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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
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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
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GUIDELINES FOR MODERATE STROKE
EARLY SPECIFIC TREATMENT
(CTSCAN CONFIRMED)
Ischemic- Noncardioembolic (Thrombotic/ Lacunar)
- If within 3 hours of stroke onset, consider rtPAtreatment and refer to specialist
- Aspirin 160-325 mg/day start as early aspossible
- Neuroprotection
- Early supportive rehabilitation
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GUIDELINES FOR MODERATE STROKE
EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)
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 embolismcan be demonstrated
- Neuroprotection- Early supportive rehabilitation
* If infective endocarditis is suspected, give antibiotics and DO NOTanticoagulate
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GUIDELINES FOR MODERATE STROKE
EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)HEMORRHAGIC
- Supportive treatment:
1. Mannitol 20% 0.5 mg/kg BW q 6 h
for 2- 5 days2. Neuroprotection
- Neurosurgery consult for hematomas distorting or displacing4th ventricle
- Within 12-24 h, recommended surgery for hematoma:1. size 10-30 cc (non-dominant subcortical frontal/temporal)
2. size >30 cc (subcortical, putaminal, cerebellar)
- Early supportive rehabilitation
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GUIDELINES FOR MODERATE STROKE
CT SCAN NOT AVAILABLE
= USE SCORING SYSTEM
Likely Ischemic Likely Hemorrhagic
No specific emergent drug Tx.
Neuroprotection
Refer to Specialist
Early SupportiveRehabilitation
Refer to Neurologist/
Neurosurgeon further Dxworkups and/or subsequentsurgery
Neuroprotection
Early supportive rehabilitation
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GUIDELINES FOR SEVERE STROKE
Management PrioritiesBasic Emergent supportive care (ABC of Resus.)
Neurovital signs: BP; PR, CR, RR, Temp, Pupils.
Glasgow Coma scale,
Recognize and Treat early signs of increased ICP
Monitor and manage blood pressure. Treat if SBP is
220 or DBP of 120 or MAP of 130. Precautions:
*Avoid precipitous drop in BP >20% of MAP
*Do not use sublingual agents
Ascertain clinical Dx; exclude stroke mimickers
Identify co-morbidities (cardiac dis. Gastric ulcer, etc)
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GUIDELINES FOR SEVERE STROKE
EMERGENT DIAGNOSTICS:
Complete blood count,
Blood Sugar,
PT/PTT,
Serum Na, K
Electrocardiogram,
Plain CTscan of the brain
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GUIDELINES FOR SEVERE STROKE
EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)
Non-cardioembolic (Thrombotic/Lacunar)
- May give aspirin 160-325mg/day
- Neuroprotection
- If cerebellar infarct, consult neurosurgeon ASAP
- Early supportive rehabilitation
Place of Treatment: Hospital, Intensive Care Unit orAcute Stroke Unit
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GUIDELINES FOR SEVERE STROKE
EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)HEMORRHAGIC
- Supportive Treatment:
1. Mannitol 20% 0.5 mg/kg q 6h for 2-5 days
2. Neuroprotection
- Neurosurgery consult if:
1. Patient not herniated, hematoma in putamen,subcortical, cerebellum and goal is to
reduce mortality
2. Herniated patient but family is willing
3. ICP monitoring contemplated and salvage surgery isconsidered
Place of Tx.: Intensive Care Unit
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BRING HOME MESSAGE
STROKE IS BRAIN ATTACK!
STROKE IS AN EMERGENCY!
STROKE IS TREATABLE!STROKE IS PREVENTABLE!
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CIFIC TREATMENT