Deals with common issues like management of hypertension and diabetes during stroke, as well as the role of surgical procedures.

1. Acute Ischemic Stroke
Rahul Kumar
Consultant Interventional Neurologist
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

2. Why do we need guidelines ?
• 2.4 per 1000 people per year
• 10,00,000 strokes per year in India
• 3000 strokes a day
• 2% of all admissions
• Crude prevalence rate is 220/100,000.
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

3. Estimated Pace of Neural Circuitry Loss in a
typical, large, Supratentorial Ischemic Stroke
Neurons Lost Synapses Lost
Myelinated
Fibers Lost
Accelrated
Ageing
Per Stroke
1.2 Billion
8.3 trillion
7140 Km
36 years
Per Hour
120 million
830 billion
714 Km
3.6 years
Per Minute
1.9 million
14 billion
12 Km
3.1 weeks
Per Second
32,000
230 million
200 meters
8.7 hours
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Jeffery L Slaver, Stroke, 2006; 37, 263-66

4. Which Guidelines to follow ?
•
•
•
•
•
AHA
AAN
RCOP
Australian SA
ESA
• IAN
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

5. Which Guidelines to follow ?
•
•
•
•
•
AHA
AAN
RCOP
Australian SA
ESA
• IAN
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
• Guidelines are Guidelines
• Individualize
• Deviations
• Not applicable across the
board
• Help us in optimizing
outcomes
• Preventing therapeutic
misadventures

6. The Continuum of Stroke Care
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

7. How do we approach a patient with
suspected stroke ?
• Assesment Phase
– History, Clinical Evaluation
– Imaging
– Other Supportive Tests
• Treatment Phase
– Supportive Treatment
– Specific Treatment
• Treatment of Complications
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

8. How do we approach a patient with
suspected stroke ?
• Assesment Phase
– History, Clinical Evaluation
• Sudden Onset
• Time of Onset
• Grading of Severity - Clinical
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

9. Stroke Scales
• Severity
– NIH stroke scale
0-42, 0 = normal
valid, reproducible, assists in patient selection,
facilitates communication
• Functional Scales
– m-Rankin
– Barthel index
– Glasgow outcome
0-5, 0 = normal
100, 100 = normal
0-5, 5= normal
• in NINDS t-PA stroke trial, 0 = normal
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

10. Stroke Scales
• NIH stroke scale 0-42
0-5
mild/minor in most patients
5-15
moderate
15-20
moderately severe
> 20
very severe
underestimates volume of infarct in non-dominant
(R) hemispheric strokes
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

11. How do we approach a patient with
suspected stroke ?
• Assesment Phase
– History, Clinical Evaluation
– Imaging
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

12. Non-contrast CT of the Head
• Initial imaging study of choice
• Readily available
• Very sensitive for blood in the acute phase
– blood - 50-85 Hounsfield Units
– bone- 120 (70-200) Hounsfield Units
• Not sensitive for acute ischemic stroke
– nearly 100% sensitive by 7 days
• Posterior fossa structures - bone artifact
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

13. Other Imaging Modalities
• MRI
– standard
– DWI/PWI
• Xenon CT
• Perfusion CT
• CT Angiography
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

14. How do we approach a patient with
suspected stroke ?
• Assesment Phase
– History, Clinical Evaluation
– Imaging
– Other Supportive Tests
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

15. Diagnostic Testing
• Laboratory studies
– CBC, differential, platelets
– electrolyte profile, glucose (finger stick)
– INR, aPTT
– Troponin
• ECG
• CXR
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

16. Stroke Mimics – Exclusion Establishes Stroke
•
•
•
•
•
•
•
•
•
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Hypoglycemia
Seizure
Migraine with aura
Hypertensive encephalopathy
Wernicke’s encephalopathy
CNS tumor
Drug toxicity
CNS abscess
Psychogenic

17. Stroke – General Assessment
• Airway – Foreign Bodies, dentures, tongue
• Breathing and oxygenation – ABG, Pulse Ox
• Circulation- BP, Urine Output, Peripheral
Circulation
• Glucose > 60
• Temperature - Normothermia
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

18. How do we approach a patient with
suspected stroke ?
• Assesment Phase
– History, Clinical Evaluation
– Imaging
– Other Supportive Tests
• Treatment Phase
– Supportive Treatment
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

19. Vascular Access
•
•
•
•
Two peripheral IVs
Use .9NS or .45 NS unless hypotensive
Use .9NS if hypotensive
Replace blood products as indicated
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

20. Treatment of Hypertension
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

21. Autoregulation
• The ability of the vasculature in the brain to maintain
a constant blood flow across a wide range of blood
pressures
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

22. Autoregulation
CBF ml/100mg/min
of Cerebral Blood Flow
100
90
80
70
60
50
40
30
20
10
0
Ischemic
Normotensive
Hypertensive
MAP mm Hg
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

23. Hypertension
Ischemic Stroke
• Treat judiciously if at all
• Treatment guidelines - not receiving rt-PA
– AHA: MAP > 130 or Sys BP > 220
– NSA: 220/115
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

24. Hypertension - Ischemic Stroke
• Drugs - short acting, titrate
• Labetalol
IV: 10-20 mg increments, double dose Q 20
min, max cumulative dose 300mg
• Enalapril
Oral: 2.5 - 5.0 mg/day, max 40mg/day
IV : 0.625-1.25 mg IV Q 6hrs, max 5.0 Q 6 hrs
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

25. For how long to allow Hypertension to Continue ?
1 Hr
3 Hr
6 Hr
average
slow
fast
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

26. Hypertension: rt-PA Candidate
• Exclude for persistent BP > 185/110
• Check BP q 15 min
• May not aggressively lower BP to meet entry
criteria
• Use Labetolol or Nitropaste
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

27. Hypertension -Ischemic Stroke
• Nitroglycerine
Paste: 1-2 inches to skin
IV Drip: 5mcg/min, increase in increments of 510mcg every 3-5 min
• Nitroprusside
IV Drip: 0.3 - 10 mcg/min/kg
Continuos BP monitoring
• AVOID NIFEDIPINE
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

28. Hypotension
•
•
•
•
•
More detrimental than hypertension
Seek cause and treat aggressively
CVP monitoring may be necessary
Use .9 NS first to ensure adequate preload
Then add vasopressors if needed
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

29. Treatment of Hyperglycemia
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

30. Glucose
• Worse outcome after stroke:
– diabetics
– acute hyperglycemia at time of infarct
• Mechanism uncertain
– increase in lactate in area of ischemia
– gene induction,
– increased number of spreading depolarizations
• Insulin is a neuroprotective
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

31. Target Values
• Intensive – 80 to 110
• Desirable – 140 to 180
• Not above 200
• How to Achieve
• Oral agents
• Insulins
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

32. Sliding scale insulin
• Abandoned! Retroactive not proactive
• Variation in disease state
• Dangers of hypoglycemia
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

33. Initiating insulin: New to Insulin
For most patients with type 2 diabetes (or being initiated to insulin therapy), total
daily insulin dose can be estimated at 0.3 to 0.6 units/kg/day
The dosing range represents varying degrees of insulin resistance:
dose
kg
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
50
5
10
15
20
25
30
35
40
45
50
60
6
12
18
24
30
36
42
48
54
60
70
7
14
21
25
35
42
43
56
63
70
80
8
16
24
32
40
48
56
64
72
80
90
9
18
27
36
45
54
63
72
81
90
20
30
40
50
60
70
80
90
100
100 10
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

34. Insulin drip




Advantages
Tightest control
Good absorption
Rapid adjustments
Easy standardized
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Disadvantages
 Frequent monitoring
(ICU/IMCU needed?)
Nursing time!
 Catheter complications
 Problems when switching to
SQ regimen
 Rapid Glucose shifts?

35. Temperature
• Fever worsens outcome:
– for every 1°C rise in temp, risk of poor outcome
doubles (Reith, Lancet 1996)
• Greatest effect in the first 24 hours
• Brain temp is generally higher than core
• Treat aggressively with
acetaminophen, ibuprofen, or both
• Search for underlying cause
• Hypothermia currently under investigation
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

36. How do we approach a patient with
suspected stroke ?
• Assesment Phase
– History, Clinical Evaluation
– Imaging
– Other Supportive Tests
• Treatment Phase
– Supportive Treatment
– Specific Treatment
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

37. Recanalization, anti Ischemic Treatment
• Recanalization
IV rt-PA
IA r-proUK (FDA?)
• Neuroprotective
treatment
• Aspirin in first 48
hours
• Anticoagulant
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
37
• Hemodilution
• Therapeutic
hypothermia
• Stroke unit
• Craniectomy

38. Aspirin (mg)
EUSI
ASA
RCOP (London)
Acute treatment
100-300
325
300
2nd prevention
50-325
150-325
50-300
• Role of Clopidogrel, Dypiridamole
• Place for Combination therapy
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
38

39. Empirical Aspirin !!!
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

40. Interventional POST
Therapy
PRE
AND
Pre Procedure, NIHSS - 18
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
Post Procedure, NIHSS - 0

41. Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

42. How do we approach a patient with
suspected stroke ?
• Assesment Phase
– History, Clinical Evaluation
– Imaging
– Other Supportive Tests
• Treatment Phase
– Supportive Treatment
– Specific Treatment
• Treatment of Complications
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

43. Treatment of neurological
complication
• Seizures
• Cerebral edema and increased
intracranial
pressure, Hemorrhagic
transformation
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
43

44. Seizures
• Occur in 5% of acute strokes
• Usually generalized tonic-clonic
• Possible causes:
severe strokes
cortical involvement
unstable tissue at risk
spreading depolarizations
hx of seizure disorder
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

45. Seizures
• Protect patient from injury during ictus
• Maintain airway
• Benzodiazepines:
– lorazepam (1-2 mg IV)
– diazepam (5-10 mg IV)
• Phenytoin:
– 15 mg/kg loading dose, at 25-50 mg/min infusion with
cardiac monitor
• No need for prophylaxis
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

46. Cerebral edema and increased
intracranial pressure
• Applicable only in large artery strokes
and in some cerebellar strokes
•
•
•
•
•
Elevated head of the bed 20- 30 degrees
Avoid “Jugular vein” compression
Avoid hypotonic solution
Avoid hypoxia, consider intubation
Hyperventilation
keep pCO2 30-35 mmHg
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

47. Cerebral edema and increased intracranial
pressure
• Consider osmotherapy
20% Mannitol 0.25-0.5 g / Kg IV in 20 mins 4-6 times / day
or 10% Glycerol 250 ml IV in 30-60mins
4 time / day
or 50% Glycerol 50 ml oral
4 time / day
and / or Furosemide 1 mg / kg IV
• Avoid steroid
• Consider decompressive surgery
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist
47

48. Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

49. Hemicraniectomy not Performed
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

50. Hemicraniectomy performed within 4
hours of onset
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

51. Hemicraniectomy performed within 24
hours of onset
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

52. Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

53. Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

54. Conclusions
• Acute stroke is an emergency
condition, is the same level as
MI, serious trauma
• Emergency management is need
• rt-PA & Interventional
therapies, are the major advances
• Appropriate general care are also
need
• To improve the quality of care :
Multidisciplinary/ network
approach
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

55. Take Home Message…
•
•
•
•
•
•
•
Manitain ABC, low threshold for intubation
Hypertension better than Hypotension
Normoglycemia
No Role of Empirical Antiplatelets
Use of Statins recommended
Try to administer reperfusion if within window
More widespread use of surgical and
interventional procedures
• Treatment of Complications
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist

56. Thank You.
Rahul Kumar
MD, DNB, DM, DNB, FINR
Consultant Interventional Neurologist