Acute Brain Attack

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.jpg


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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.JPG


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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.gif


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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.jpg


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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.jpg


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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=izoom2


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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%3DN


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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.gif


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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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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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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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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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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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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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CT SCAN NOT AVAILABLE

No specific emergent drug treatment recommended

Neuroprotection

Consult a neurologist or neurosurgeon Early supportive rehabilitation


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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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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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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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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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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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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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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)



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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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EMERGENT DIAGNOSTICS:

Complete blood count,

Blood Sugar,

PT/PTT,

Serum Na, K

Electrocardiogram,

Plain CTscan of the brain


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EARLY SPECIFIC TREATMENT (CTSCAN CONFIRMED)

Non-cardioembolic (Thrombotic/Lacunar)

- May give aspirin 160-325mg/day

- Neuroprotection

- If cerebellar infarct, consult neurosurgeon ASAP


Place of Treatment: Hospital, Intensive Care Unit orAcute Stroke Unit


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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

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Acute Brain Attack