Acute Stroke Management
Acute Stroke Management
This is a Learning in 10 voice annotated presentation (VAP) on acute stroke management.
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Content
0 ->
0.95 -> Stroke is a leading cause
2.36 -> of death and disability
4.24 -> worldwide.
5.45 -> Stroke is a clinical diagnosis
7.23 -> and is defined by the World
8.64 -> Health Organization
9.98 -> as a clinical syndrome
11.51 -> consisting of rapidly developing
13.36 -> clinical signs of focal
15.49 -> and at times global disturbance
17.37 -> of cerebral function,
18.85 -> lasting more than 24 hours
20.55 -> or leading to death,
21.92 -> with no other apparent cost,
23.85 -> other than that of vascular
25.24 -> origin.
26.58 -> It is a medical emergency
27.849 -> for which there are
28.64 -> effective strategies to help
30.36 -> reduce neurological disabilities
32.5 -> and mortality.
34.27 -> Management of acute stroke
35.85 -> can be divided into acute phase
37.63 -> and chronic management phase.
39.78 -> Ischemic stroke accounts for 80%
41.63 -> to 85% of all strokes.
44.15 -> The acute management
45.04 -> of ischemic stroke
46.06 -> will be presented here.
47.312 ->
50.41 -> At the end of the presentation,
52.267 -> you should be able to understand
53.6 -> the importance of stabilizing
55.22 -> the patient,
56.2 -> and to promptly treat
57.28 -> reversible medical conditions
59.16 -> to reduce neurological damage.
61.88 -> You should also
62.55 -> be
63.05 -> aware of the initial evaluation
64.849 -> of the patient presenting
66.36 -> with acute focal neurological
68.27 -> symptoms, in order to exclude
70.33 -> stroke mimics, and confirm
72.16 -> ischemic strokes.
73.76 -> Next, you should be
74.7 -> familiar
75.21 -> with the various treatment
76.34 -> options in patients
77.7 -> with acute stroke.
78.72 ->
81.75 -> The early goals
82.78 -> in the acute stroke management
84.38 -> are first, to stabilize
86.27 -> the patient following
87.37 -> the basic principles
88.59 -> or resuscitation
90.03 -> by ensuring a patient's airways,
92.3 -> checking that the patient is
93.53 -> breathing spontaneously,
95.02 -> and making sure
95.76 -> that a hemodynamic status is not
97.83 -> compromised.
99.16 -> Second, to confirm
100.66 -> that the neurological symptoms
102.31 -> are likely due to a vascular
103.82 -> process, as well as exclude
105.8 -> potential stroke mimics.
107.8 -> Third, to manage the patient
109.72 -> in a stroke unit, where patients
111.65 -> can be monitored and cared
113.3 -> for by trained personnel.
115.75 -> Treatment options
116.66 -> in the acute setting
117.77 -> include, reperfusion therapy
119.71 -> with thrombolytics,
120.71 -> or antiplatelets.
122.51 -> These will be be elaborated
123.73 -> further.
124.23 ->
127.46 -> Protection
128.02 -> of the airway and maintaining
129.52 -> self-oxygenation
131.02 -> is of paramount importance.
133.256 -> Airway integrity needs to be
134.87 -> established and monitored
136.75 -> if the patient has depressed
138.21 -> consciousness or evidence
139.93 -> of brain stem dysfunction.
142.336 -> Oxygen should be given
143.34 -> if patient's hypoxic.
145.16 -> The patient's blood pressure
146.44 -> should also be checked.
148.18 -> Hypertension in the acute phase
150.05 -> need not be treated,
151.134 -> unless there are
151.8 -> specific indications,
153.48 -> such as hypertensive
154.61 -> encephalopathy,
156 -> renal or myocardial compromise,
158.34 -> and if the patient is being
159.55 -> prepared for thrombolytic.
160.82 -> Treatment.
162.53 -> If the patient is hypertensive,
164.31 -> fluid resuscitation
165.53 -> has to be instituted
167.13 -> as hypoperfusion,
168.42 -> or exacerbate
169.38 -> the neurological disability
171.17 -> by further damaging
172.4 -> the ischemic penumbra.
174.96 -> The ischemic penumbra is a rim
176.76 -> of mild to moderately ischemic
178.47 -> tissue, lying between normally
180.38 -> perfused tissue
181.81 -> and infarcted tissue.
183.38 -> And this area may remain
184.99 -> viable for several hours
186.82 -> if appropriate treatment is
188.12 -> given.
189.49 -> The concept
190.08 -> of the ischemic penumbra
191.37 -> is illustrated in the example
192.79 -> on the right on the effects
194.54 -> of hypoglycemia
195.86 -> on the penumbral tissue.
197.93 -> Examples of other conditions
199.53 -> that may exacerbate brain damage
201.54 -> and needs to be properly treated
202.946 -> are hypoglycemia, seizure,
205.725 -> and fever.
206.225 ->
209.59 -> After initial stabilization
211.23 -> of the patient, a history
212.89 -> and physical examination
214.23 -> should be performed.
215.879 -> They may not always
216.67 -> be possible to obtain a history
218.33 -> from stroke patients,
219.74 -> and hence, such history needs
221.45 -> to be obtained from eye
222.67 -> witnesses.
224.02 -> The aims are determined
225.44 -> if the presentation is
226.61 -> consistent with a vascular
228.34 -> etiology
229.32 -> to localize
229.93 -> the cerebral structure
230.89 -> is likely to be affected,
232.42 -> and to exclude other stroke
233.82 -> mimics, such as [INAUDIBLE]
235.15 -> paralysis, hemiplegic migraine,
237.31 -> et cetera.
239.42 -> An urgent brain CT, or MRI
242.01 -> brain, should be performed
243.55 -> to exclude
244.22 -> intracranial hemorrhage.
246.28 -> Brain imaging may also review
248.03 -> other brain pathology,
249.24 -> such as tumor mimicking stroke.
252.07 -> Laboratory investigations are
253.69 -> important to rule out
254.97 -> toxic metabolic causes, as well
256.98 -> as anemia, which may exacerbate
259.14 -> the patient's condition.
261.2 -> Other investigations,
262.65 -> such as ECG,
263.83 -> is important for diagnosis
264.98 -> of
265.48 -> concomitant myocardial
266.77 -> infarction, and rhythm disorder,
268.82 -> such as atrial fibrillation.
270.175 ->
273.63 -> Patients with acute stroke
275.17 -> are best managed
276.15 -> in the acute stroke unit, which
278.09 -> is a geographical area
279.47 -> for the multi-disciplinary care
281.19 -> of these patients.
282.94 -> This allows close monitoring
284.75 -> of neurological and medical
286.25 -> parameters.
287.55 -> It is staffed by a team
288.85 -> of health care professionals,
290.42 -> specialized in the care
291.58 -> of stroke patients.
293.236 -> Care in a stroke unit
294.78 -> has been shown to reduce
296.08 -> mortality, improve
297.56 -> neurological and functional
298.97 -> outcome,
299.83 -> decrease stroke
300.74 -> related complications,
302.25 -> as well as reduce hospital
303.907 -> readmissions.
304.448 ->
307.87 -> The concept of reperfusion
309.38 -> therapy
310.07 -> is arterial recanalization
312.1 -> to serve with ischemic tissue,
314.1 -> thus limiting tissue damage,
316.11 -> therefore improving
317.33 -> neurological and functional
318.76 -> outcome.
320.35 -> Intravenous thrombolysis
321.76 -> with recombinant tissue
323.17 -> plasminogen activator, or RTPA,
326.04 -> has been shown
326.73 -> in clinical trials
327.61 -> to be efficacious,
328.88 -> if administered
329.71 -> to appropriate patients
331.26 -> within 4.5 hours
332.88 -> from onset of symptoms.
335.44 -> Patients treated with IVTPA
337.39 -> are more likely to be
338.38 -> functionally
339.02 -> independent after three months.
342.06 -> Intra-arterial thrombolysis
343.67 -> involves direct installation
345.16 -> of the lytic agent to the clot,
347.07 -> and has been shown to improve
348.43 -> clinical outcome.
350.18 -> However, intra-arterial
351.77 -> thrombolysis for acute stroke
353.51 -> has not received regulatory
355.22 -> approval, and should not
356.66 -> preclude treatment with
358.07 -> intravenous RPTA in otherwise
360.55 -> eligible patient's.
362.77 -> Current guidelines suggest
364.33 -> that intra-arterial thrombolysis
366.28 -> is reasonable in patients
368.03 -> where contraindications
369.64 -> to intravenous thrombolysis,
371.52 -> such as those
372.34 -> with recent surgery.
374.37 -> Endovascular techniques,
375.731 -> such as
376.23 -> mechanical, thrombectomy, and
378.09 -> clot aspiration in stroke,
379.99 -> have been proven to increase
381.73 -> our likelihood of recanalization
384.08 -> and are under investigation
385.66 -> for efficacy
386.42 -> for clinical outcome.
388.33 -> These methods can be employed
389.71 -> alone, in combination,
391.39 -> or as a ischemic
392.439 -> to intra-arterial thrombolysis.
393.73 ->
397.46 -> It has been shown
398.32 -> that early treatments of aspirin
400 -> within 48 hours
401.34 -> of presumed stroke onset
403.23 -> decreases the risk of recurring
405.01 -> stroke,
405.68 -> as well as leading
406.67 -> to an improved long term outcome
408.55 -> for patients,
409.58 -> without any major risk
410.86 -> of early hemorrhagic
411.97 -> complications.
413.45 -> Aspirin or clopidogrel loading
415.49 -> is usually given for patients
417.02 -> with acute stroke, who are
418.37 -> naive to antiplatelet agents.
420.257 ->
423.53 -> This presentation outlined
425.19 -> the key principles
426.21 -> of acute management
427.25 -> of ischemic stroke patients.
429.18 -> We hope you fond it useful.
430.697 -> Thank you for your attention.
431.905 ->
435.01 -> The illustrations are obtained
436.26 -> with the kind permission
437.5 -> from the following sources.
439.72 ->
Source: https://www.youtube.com/watch?v=eGqdhHQjV4o