Download - management of stroke.ppt
-
8/14/2019 management of stroke.ppt
1/24
MANAGEMENT OF STROKEEmergency Department
School Medicine
Brawijaya University - Malang
-
8/14/2019 management of stroke.ppt
2/24
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
-
8/14/2019 management of stroke.ppt
3/24
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
-
8/14/2019 management of stroke.ppt
4/24
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
-
8/14/2019 management of stroke.ppt
5/24
-
8/14/2019 management of stroke.ppt
6/24
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
-
8/14/2019 management of stroke.ppt
7/24
-
8/14/2019 management of stroke.ppt
8/24
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
-
8/14/2019 management of stroke.ppt
9/24
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
-
8/14/2019 management of stroke.ppt
10/24
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
-
8/14/2019 management of stroke.ppt
11/24
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.
-
8/14/2019 management of stroke.ppt
12/24
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
-
8/14/2019 management of stroke.ppt
13/24
-
8/14/2019 management of stroke.ppt
14/24
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
_
_
-
8/14/2019 management of stroke.ppt
15/24
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
-
8/14/2019 management of stroke.ppt
16/24
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
-
8/14/2019 management of stroke.ppt
17/24
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.
-
8/14/2019 management of stroke.ppt
18/24
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
Management of acute ischemic stroke
-
8/14/2019 management of stroke.ppt
19/24
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.
Management of acute ischemic stroke
-
8/14/2019 management of stroke.ppt
20/24
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
-
8/14/2019 management of stroke.ppt
21/24
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
-
8/14/2019 management of stroke.ppt
22/24
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
-
8/14/2019 management of stroke.ppt
23/24
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
-
8/14/2019 management of stroke.ppt
24/24
Surgical interventions
Balloon angioplasty/stenting
Carotid endarterectomy/Bypass
Decompressive surgery