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Emergency Management of Stroke & TIA - Coggle Diagram
Emergency Management of Stroke
& TIA
Intervention
Acute Stroke Unit
50% get to stoke unit
NNT15-?
Thrombolysus
10-20%
NNT7
Stroke Unit
Dedicated area in a defined ward used exclusively for stroke
Management
ABC
Call stroke decision
Get hx / collateral
Get time of onset / last seen wll
Perform examination - emphasises cardiovascular / neuro
NIH Stroke Scale
Time is the essence - Time is brain
Emergency Investigations
Imaging
Non contrast CT brain
Multiphase CT angiogram (aortic arch to vertex)
CT perfusion
Find viable brain
1.8
ECG
Bloods
Venous gas
Hb
BM blood glucose (basic metabolic)
Hypoglycaemia stroke mimic
INR if on warfarin
Ischaemic Storke Intervention
Antiplatelet (ASA 300mg/d x 2weeks)
Stroke Unit
Swallow screen
Thrombolysis
Door to needle 45 min
Thrombectomy
Big clot
Hemicraniectomy
Initital
DOnt giv aspirin until scan
NPO until checked
LEave BP unless
Thombolysus considered
Symptoms of malignant hypertentsion
Check BG
Treat very high / very low
Above 12
Check Pyexia
Treat high
Maintain hydration
Keep O2 >92%
Thrombolysis
Thrombolytic agents
Tenecteplase
Wideley available in last yr
Faster
Alteplase
Rate
9-12%
Irish ~ 12%
Timing
.< 4.5 hrs
Time may be mutable 6-12 hrs
Advanced imaging
MR brain
CT perfusion
For every 15min delay you loose 2 months of independent life
Delay
Higher relative mortality from ICH
Risk vs Benefit
NNT improvement 3-5
NNT resolution 0-3hr 10
NNT resolution 3-4.5hr 20
NNH 35
NNH death permanenet disability 100
NNG (mRS>4) 125
Prognosis
Most pt who experienec SICH have severe baseline infarct and already are destined for poor outcomes
↑ Risk of Bleeding
Antiplatelet
DAPT
Hyperglycaemic
Bigger stroke
Older
Bigger BMI
Delay
Hx HTN
Low dose
Not recommended
No subgroup did significantly worse with treatment
Hyperactute Stroke protocol SJH
Blood Pressure in Acute Ishaemic Stroke
Cerebral Autoregulation
Arterioles
Collaterals are BP dependent
Penumbra
Ischaemic brain that is savable
Ratio 1.8-1.4 on CT perfusion scan
Guidance
Leave BP alone unless 200
Lower BP
Nitrate (IV S/c) NOT sublingual
Increased cerebral oedema - raised ICP
Labetalol
Give bolus then infusion
CCB with caution
IV
Subarachnoid haemorrhage - nimodapine - need a big line - central line - wrecks veins
Thrombectomy
Stent retreiver
Suction vaccum catheter
NNT 5 (big stroke )
MEVO studies
Malignant MCA Infarction
Epidemiology
100% disability
10-20 / 100,000 / year
Female>Male
Young>Old - less space for brain to swell - less atrophy
No effective pharacological treatment
Less common now - get thrombolysed
75-80% mortality without teatment
Mx
Hemicraniectomy - release pressure
Put cranium in Abdominal fat - hemicranioctomy - 8 weeks
Calcichew - dont absorb it
Definition
Rapid neurological deterioration due to the effects of space occupying cerebral oedema following middle cerebral artery (MCA) territory stroke
Meta-analysis
Conservative tx
2/3 die
Decmpression surgery
Subarachnid Haemorrhage
Causes
HTN
Cereberal amyloid angiopathy
Aneurysm
Location
Junction between anterio communication and anterior cerebral
Management
BP control
Reduce blood pressure 150-220
Surgery
Peripheral bleeds
Drainage
Attache to menometer to find ICP
Trials
INTERACT
INTERACT 2
Intracerebral Haemorrhage
Management
CT and cT angio on admission
BP lowered - urgent scans to differentiate
Surgery
Cerebellar haemorrhages
Intraventricular haemorrhage
Shallow lobular haemorrhage?
Therapeutic Nihilism is bad
Avoid NFR orders on PICH pt unil at least 48hr following admission (and probably longer)
Early Support Discharge team
NNT 17
Reduces
Death
Long term care
TIAs
ABCD2 Scale
Prognostic scale
Age 60+
Blood pressure >140/90
Clinical Features
Unilateral weak
Speak disturbance w/o weakness
Other
Duration
.>60 min
.<60min
.<10min
Diabetes
Higher score - higher risk of recurrent event
Can only be diagnosed retrospectively
People with ABCD2 <4 can be discharged if can be seen and scanned quickly
If worried - ADMIT - we can discharge in 3 hrs
Do not diagnose if Any Neuology is still present
If someone has a headache and transient neurology do not discharge from ED unless you see ESR - Temporal arteritis