Clinical Stroke Neurology & Protocols

Dr Sunanda Anand

Stroke
Neurological deficit lasting for >24 hrs due to vascular pathology 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.

Stroke Programme
Acute stroke Intervention Chronic Stroke management TIAs/ministrokes Secondary Prevention Rehabilitation Maintain Data.

24/7 Services
Emergency Medical services. Imaging CT/MRI. DSA Lab : Interventional Neuroradiology. Stroke unit/ICU & Step down units. Trained Staff.

Stroke
Arterial Strokes Ischemic (80%) Hemorrhagic(20%) Venous Strokes:20% of young strokes Non hemorrhagic Hemorrhagic

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, Motor sensory deficit, Cerebellar signs etc.

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<1/3rd of arterial territory iv) Dense Basilar sign

Normal scan

Dense MCA sign

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

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.

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 infusion over 1 hr. Outcome: 30% improvement in functional & neurological outcome. Symptomatic hemorrhage 6.6%.

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.

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.

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.

Ultrasound
Transcranial doppler increases lytic activity of rtPA ( Phase II ).
EKOS MicroLySUS catheter which can administer tPA + IA low energy Ultrasound.(PhaseI&II).

Neuroprotection
Brain tissue to be made more resistant to ischemic injury. Decrease functional deficit. Prolong Revascularization window. Pharmacological& Mechanical. Disappointing results.

Multi Modality Approach

Recent+Future

IV+IA I/V +Mechanical IV+ IA +Mechanical IA+Mechanical + Neuroprotection Ultrasonic

Patient comes to Casualty with Acute Stroke

Confirm diagnosis &onset time Perform NIHSS+-GCS Secure 2 IV lines ( Avoid dextrose) Nasal Oxygen if Sat<95% Brain CT Send Invg: Glucose,electrolytes,creatinine, CBC,Platelets,INR, PTT, Pregnancy Test

Casualty into Action

Patient fulfills inclusion& exclusion criteria. Discuss Treatment options Treat BP to required level(<185/104) Correct Hyperglycemia(80 to 120mg%) Platelets >100,000. Other Invg not to delay therapy if Clinical H/O is not relevant. If Foleys/Intubation/RT is required insert prior to treatment.

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.

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 Inc CBV). CT clinical mismatch.

Large Artery occlusion

Basilar Occlusion

5-8 hrs

Mechanical Devices

Special situations:
Monoplegia Paresis: MRC >3, dysarthria ,facial Visual loss Aphasia

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 2 hrs Then every 30min for next 6 hrs Every Hr for next 16 hrs Then every 4 hrs.

ICU /Stroke unit in Action

Control BP ( <180/104) Aggressive hyperglycemic control Maintain Normothermia DVT prophylaxis CT brain 24 +/- 6 hrs. Antiplatelets/ Heparin after 24 hrs.

Watch for
Severe headaches, vomiting, Acute Hypertension ,drowsiness Worsening of neurological status. (NIHSS>=4pts) DISCONTINUE INFUSION & ORDER BRAIN CT

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.

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 ,H2 blockers,Steriods Adrenalin, Intubation.

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.

How to Manage ICP?

Monitoring ICP? Raise Head by 30-45 Deg.

Treat agitation/cough with Propfol/Fentanyl

Neuromuscular paralysis if Pt is bucking on Ventilator.

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.

Other Complications
Seizures Aspiration Penumonia ( 15-25% of deaths) dysphagia: facial palsy,altered sensorium,brainstem strokes Mechanical ventilation Immobility leading to atelectasis

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)

Complications
DVT and pulmonary embolism(10% of deaths. 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

TIAS/Mini Strokes
Transient neurological deficit lasting <24hrs Commonly 15-20min. DW1 images usually positive Treatment is directed to prevent larger stroke.

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 days High Risk: Age>60yrs DM TIAs >10 min

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)

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)

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.

Aspirin
Aspirin 300mg loading then150mg OD (75mg-325mg) Start at presentation Acute intervention start >24 hrs. Decreases recurrent stroke by 22% annually.

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%.

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.(except large hemispheric strokes) Fall back therapy if antiplatelets fail.

Large vessel Atherosclerosis

Carotids: Advised Stenting

>70% stenosis.

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

Intracranial Atherosclerosis.
Medical therapy

Antiplatelets Statins

26% recurrent stroke(by2yrs) on optimum medical management. (WASID)

Intracranial Stenting/EC-IC bypass

Recurrent symptoms

Hemodynamic dependent lesion

Basilar stenosis.

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.

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.

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.

Aggressive Risk factor Management in all Strokes

Rx Hypertension : Control BP preferably to 120/80mm Hg

First line : ACE inhibitors /ARBs Thiazide diuretics.

Rx Diabetes Mellitus
Fasting Glucose & HgbA1C Goal Maintain HgbA1C <7%. Rx : Diet, exercise, OHA, Insulin.

Rx Hyperlipidemia
LDL<100mg Triglycerides<200mg Cholesterol<200mg Non-HDL<130mg

Rx : Diet, Exercise, Inc Fibers Drugs: Statins.

Discharge Instructions: Life style modifications

Quit Smoking/tobacco Quit Alcohol Weight management 30 min of mod intensity exercise/day

Acute Rehabilitation
PT, OT & Speech therapy at the earliest. For brain plasticity and improvement Rehabilitation should be: Task specific Repetitive Motivating to Pt.

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.

Diagnostic Modalities
High Level of suspicion CT +CT venogram MRI+ MR venogram DSA

Management
Mild Clinical grade: Heparin Severe Clinical grade: Local thrombolysis Clinical grade 3: deteriorating on Heparin >24 hrs.

CLINICAL GRADING (GCS) Mild Clinical Grade

Status 1 No symptoms. Status 2 Status 3

Minor symptoms.

Major neurological deficit.

Severe Clinical grade

Status 4 Impaired state of alertness but capable of protective & adaptive response to noxious stimuli. Status 5 Status 6 Poorly responsive but with stable vital signs Not responsive to shaking, No adaptive response to noxious stimuli and progressive instability of vital signs.

CT GRADING
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 No parenchymal change. Nonhemorrhagic venous infarct ,No mass effect. Nonhemorrhagic venous infarct with mass effect. Hemorrhagic venous infarct. ( bleed < 3cm) Hemorrhagic venous infarct with mass effect. (bleed>3cm)

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 Stroke?

Clinical Grade :Severe(4,5,6) on admission + DSA: Dural venous sinus thrombosis with restrictive venous outflow

Clinical grade : Mild (3) worsening on Heparin therapy

Severe grade +DSA

Patient deteriorating on Heparin

Modalities Available

Thrombolytic : Urokinase /rtPA

Mechanical : (Investigational) Glide wires/Balloons/Penumbra

Stop Thrombolysis
Clinical improvement ( LOC). AND/ OR Recanalization of sinus with antegrade flow on Venogram. Evidence of Systemic & Intracranial bleed. (exclude puncture site oozing)

EXCLUSION CRITERIA
Clinical recovery since presentation. Sinus recanalization with no restriction to venous outflow on DSA. G.I. or G.U. tract bleeding (less than 2 weeks) Intracranial Aneurysms / AVMs / Neoplasms. Bleeding diathesis, INR > 1.7, Platelet count < 100,000

Post Thrombolysis.
Treatment with Heparin Oral anticoagulation for 6 months Adjunctive therapy. Thrombophilia workup.

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 <10 GPLU/ml Anticardiolipin antibodies IgM <10 MPLU/ml ANA/ DNA Coagulation profile VDRL/HIV/hepatitis B Serum B12 G6PD

Follow Up
Clinical MR Venogram+ thrombophilia status at 3 months. To decide Further anticoagulation.