Acute Stroke:

How to Recognise &

What to Do
‘Time is Brain’
 The Brain
THE BRAIN IS THE MOST OUTSTANDING ORGAN.

IT WORKS FOR
24 HOURS,
365 DAYS,
RIGHT FROM
YOUR BIRTH
UNTIL YOU
FALL IN LOVE
 What is a stroke?
• A Stroke is a medical emergency
• Defined as an acute loss of
neurological function due to an
interruption in the blood supply to
a part of the brain.
• Lack of blood – decreased oxygen or
nutrients to brain cells - become
damaged or permanently destroyed
• Depending on which part of the brain
is affected, different symptoms can
occur
 Stroke in India
• 1.5 Million Strokes every year

• 3,000-4,000 strokes every day in India

• 13,500 thrombolysis per year!!!!(2017)

• But growth rate is 30% per year!

• Much Fewer interventions.

Types of stroke
Ischaemic Stroke
ISCHAEMIC CORE
(BRAIN TISSUE
DESTINED TO DIE)

RESTORATION OF
BLOOD FLOW

PENUMBRA
(SALVAGEABLE BRAIN
AREA)
What are the
signs and
symptoms?
HOW TO RECOGNISE A STROKE?
 Types of stroke
STROKE STROKE
LEFT BRAIN RIGHT BRAIN

PARALYSED PARALYSED
RIGHT SIDE LEFT SIDE

SPEECH SPATIAL
LANGUAGE PERCEPTUAL
DEFICITS DEFICITS
SLOW, CAUTIOUS QUICK, IMPULSIVE
BEHAVIOURAL STYLE BEHAVIOURAL STYLE
MEMORY MEMORY
DEFICITS DEFICITS
 Middle cerebral artery (MCA)
occlusion
CENTRAL SULCUS
PRECENTRAL GYRUS
CONTRALATERAL LOWER FACE WEAKNESS POSTCENTRAL GYRUS
LATERAL SULCUS
CONTRALATERAL HEMIPLEGIA PARIETAL LOBE

CONTRALATERAL HEMIANESTHESIA
FRONTAL LOBE

ATAXIA OCCIPITAL
LOBE
SPEECH IMPAIRMENTS (LEFT BRAIN) TEMPORAL LOBE

PONS
PERCEPTUAL DEFICITS (RIGHT BRAIN) MEDULLA OBLONGATA CEREBELLUM

VISUAL DEFICITS
 Anterior cerebral artery (ACA)
occlusion
CENTRAL SULCUS
PRECENTRAL GYRUS
WEAKNESS OF FOOT AND LEG POSTCENTRAL GYRUS
LATERAL SULCUS
SENSORY LOSS OF FOOT AND LEG PARIETAL LOBE

ATAXIA
FRONTAL LOBE

INCONTINENCE OCCIPITAL
LOBE
TEMPORAL LOBE
SLOWNESS AND LACK OF SPONTANEITY
PONS
MEDULLA OBLONGATA CEREBELLUM
 Posterior cerebral artery (PCA)
occlusion
CENTRAL SULCUS
PRECENTRAL GYRUS
MIDBRAIN SYNDROME (WEBER’S SYNDROME) POSTCENTRAL GYRUS
Third nerve palsy LATERAL SULCUS

Contralateral hemiplegia PARIETAL LOBE

THALAMIC SYNDROMES
Hemiballismus FRONTAL LOBE
Hemisensory disturbances OCCIPITAL
VISUAL FIELD DEFICITS(MACULAR SPARING) TEMPORAL LOBE
LOBE

VISUAL HALLUCINATIONS PONS

MEDULLA OBLONGATA CEREBELLUM
MEMORY PROBLEMS
 Brainstem stroke
DOUBLE VISION
FACE WEAKNESS AND SENSATION
WEAKNESS
TASTE DISTURBANCES
HEARING LOSS
DIFFICULTIES IN BALANCING AND DIZZINESS
DIFFICULTIES IN SWALLOWING
BLOOD PRESSURE AND RESPIRATION
DYSFUNCTION
How do you know if someone is having a
stroke?
CONFUSSION OR
SEVERE, PROBLEM DROOPING OF
SUDDEN- UNDERSTANDING
UNCONCIOUSNESS THE MOUTH
ONSET WHAT IS BEING ON ONE SIDE
HEADACHE SAID

WEAKNESS
LOSS OF MOVEMENT
DIZZINESS AND/OR SENSATION
IN ONE OR MORE
LIMBS
DIFFICULTY
VISUAL
TALKING,
DISTURBANCE
FORMING
OR LOSS OF
WORDS OR
SIGHT IN ONE
SLURRING
OR BOTH EYES
WORDS
IMPORTANT
NOTE THE TIME AT WHICH THESE SYMPTOMS
STARTED AND CALL THE EMERGENCY SERVICES
IMMEDIATELY
Face Arm Speech Test (F.A.S.T.)
TO CHECK FOR STROKE SYMPTOMS, REMEMBER F.A.S.T.

FACE ARMS SPEECH TIME

112

FACE ARM SPEECH TIME TO CALL

DROOPING WEAKNESS DIFFICULTY the emergency
or asymmetry or paralysis on or slurring of services –
on smiling one side speech 102/112/0114277
6444
Manageme
nt of Acute
Stroke
YOU KNOW ITS STROKE -
NOW WHAT TO DO??
 Acute Ischaemic Stroke: Treatment
GOAL: A rapid vessel recanalisation with subsequent restoration of blood perfusion
into the ischaemic area aiming to salvage the penumbra
 “Time is Brain”
Estimated Pace of Neural Circuitry Loss In Typical Large-Vessel Supratentorial Acute Ischaemic
Stroke

Neurons Lost Synapses Lost Myelinated Fibres Lost Accelerated Aging

Per Stroke 1.2 billion 8.3 trillion 7140 km 36 y

Per Hour 120 million 830 billion 714 km 3.6 y

Per Minute 1.9 million 14 billion 12 km 3.1 wk

Per Second 32,000 230 million 200 m 8.7 h

Saver. Stroke 2006;37:263-266.

 Treatment strategies
SYSTEMIC REPERFUSION THERAPIES:
ALTEPLASE
TENECTEPLASE
ENDOVASCULAR TREATMENT
MECHANICAL THROMBECTOMY WITH MEDICAL DEVICES
INTRA-ARTERIAL (IA) THROMBOLYTICS ADMINISTRATION

20% - Spontaneous recanalization 60% - Recanalization after IA tPA

40% -Recanalization after IV tPA 80%- Mechanical recanalization

 What is rtPA?
• rtPA is a thrombolytic drug also known as Alteplase
• Used for Acute Ischemic Stroke (AIS), AMI, PE.
• The dosage for AIS is less than the dosing for AMI or
PE

• rtPA disrupts the integrity of a thrombus, plaque or

emboli within a blood vessel

• Other Thrombolytics had unacceptably high

hemorrhage rates or were not tested extensively to
establish risk versus benefits.
What has not changed since IVrt-PA
is on the stroke scene
Thrombolysis is still underused
The majority of patients who receive tPA have a DTN time ≥ 60 min

Reducing rtPA treatment times is the single most important

modifiable factor to improve patient outcomes from hyper-acute
stroke care
Problem
Overwhelming No. of Tasks to Complete in 60 Minutes
We need a team to Win
What to do when a patient
comes with suspected
stroke?
 Do as much as possible in Emergency Department!!
Rapidly admit patient
Oxygen saturation Blood pressure IV access Glucose test

Leaving as little as
possible to be done
before CT room
arrival!!
Deliver directly to CT scanner
 4-step process:
Selection for Alteplase treatment
4
3
Contra-
2 indications
Severity of stroke
1
Diagnosis

Exclude bleeding
 Step 1: Excluding bleeding
Intra-cerebral haemorrhage Sub-arachnoid haemorrhage

1. Rule out blood or other mass effect

 Step 2 : Diagnosis

1. Clinical diagnosis

2. Rule out Stroke mimics, e.g. tumour, SDH

3. Extensive ischaemic damage

 Step 3 : Stroke Severity

CLINICAL SEVERITY RADIOLOGICAL SEVERITY

• NIHSS score • ASPECTS score

• A score of zero indicates diffuse ischaemic

damage
• A score of ten indicates a normal CT scan

• Clinical studies have demonstrated that

patients with an ASPECTS score of >7 were
most likely to benefit from treatment
 NIHSS: National Institutes of
Health Stroke Scale
• Objectively quantify the impairment caused
by a stroke.
• The NIHSS is composed of 11 items, each of
which scores a specific ability between a 0
and 4.
• For each item, a score of 0 typically indicates
normal function in that specific ability, while
a higher score is indicative of some level of
impairment.
• The maximum possible score is 42, with the
minimum score being a 0
 Stroke severity and relative benefit

IVT
No treatment

Mishra/VISTA Stroke 2010 Ntaios, J Neurol 2011

Step 4: Exclude contraindications
Contraindications fall under the following broad categories 1, 2

Onset of symptoms
Increased bleeding
more than 4.5 hours
risk
ago

Severity

Aged
Unstable patient
<18 years
 Absolute contraindications
• Evidence of active bleeding on examination, acute bleeding
diathesis
• Blood glucose concentration ≤50 or > 400 mg/dl → Thrombolyse if acute
ischemia documented
• Elevated BP (systolic, ≥185 mm Hg, or diastolic, ≥110 mm Hg)
that has not responded to quite aggressive intravenous
antihypertensive treatment

→ But don’t wait for

• Platelet count ≤100,000/mm3 labs if no history of
• Heparin received within 48 hours, resulting in aPTT ≥upper - bleeding
limit of normal
- liver disorder
• LMWH in last 24 hours - hemodialysis
• Current use of anticoagulant, with INR ≥1.7 or PT ≥15 sec - anticoagulation Rx*
 Relative contraindications
• Only minor stroke symptoms
• Rapidly improving stroke symptoms
• Seizure at onset with postictal residual
neurologic impairments
• Incidental cerebral aneurysms
• Incidental venous angiomas
• Incidental arteriovenous malformations
 Thrombolyse if disabling deficit at
time of decision
→ Thrombolyse if acute ischemia
documented
→Urgent discussion with specialist
- bleeding risk ?
- treatable if bleeding
 Relative contraindications
Urgent discussion
• Major surgery or serious trauma <14 days
with specialist
• Gastrointestinal or urinary tract hemorrhage < 21 days - bleeding risk ?
- treatable if bleeding?

• Acute myocardial infarction < 3 months - C.I. if sub →Rather < 7 weeks
acute and trans mural, if high risk of hemopericardium
and pericardial rupture
Note : Concurrent MI: same dose as for AIS (0.9mg/kg for AIS & 1.1mg/kg for MI)
Final step: Treat the patient with
Alteplase
In acute ischaemic stroke, the recommended dose of Actilyse ® is 0.9 mg/kg body
weight (maximum 90 mg)1
• 10% of the 0.9 mg/kg dose is given as an initial intravenous bolus
• The remaining 90% are infused intravenously over 60 minutes
What can go
wrong
That’s why we need to be cautious
and vigilant!!
 1. Symptomatic Intra Cranial
Hemorrhage
• Risk factors for sICH after IVT
• Baseline symptom severity (NIHSS)
• Advanced age
• Thrombolysis protocol violations (BP, rtPA-dose, ...)
• Uncontrolled blood pressure
• Dual antiplatelet / high INR
• History of congestive heart failure or atrial
fibrillation Sugar
Early infarct signs
• Elevated serum glucose, Hx of diabetes Dense artery sign on CT
Age > 75 years
NIHSS > 9 points
SEDAN SCORE
 2. Lingual Edema
• 1-3%
• Associated with ACE-inhibitors
• Prepare intubation, but often not needed
• Adrenaline, antihistaminic, corticosteroids
What new things can we
offer?
The era of mechanical thrombectomy
 Endovascular treatment
• An intra-arterial method using catheter-guided devices to assist
restoration of blood flow in an occluded vessel.

• Either by
• providing a thrombolytic agent directly to the clot – INTRA
ARTERIAL THROMBOLYSIS
• removing the clot mechanically from the site of vessel occlusion –
MECHANICAL THROMBECTOMY
 Intra-arterial (IA) thrombolysis
• Catheter-based intervention
• Allows intra-arterial revasculariation
with rt-PA topically delivered direclty
to intracranial thrombus
• Proact I and II: first IA thrombolysis
trials (pro-urokinase compared to
placebo).
The trial showed superiority of iat
over placebo but higher haemorrhage
rate.
Mechanical Thrombectomy
 New recommendation
• Patients should receive endovascular therapy with a stent retriever if
they meet all the following criteria (class I; level of evidence A).
• Prestroke MRS Score : 0 TO 1,
• Acute ischaemic stroke receiving intravenous rt-PA WITHIN 4.5
hours of onset according to guidelines
• Causative occlusion of the ICA or proximal MCA (M1),
• Age ≥18 years,
• NIHSS score of ≥6,
• Aspects of ≥6, and
• Treatment can be initiated (groin puncture) within 6 hours of
symptom onset
New Recommendations: DON’T
WAIT!!!

STEP 1: STEP 2: STEP 3: STEP 4:

Plain CT rt-PA CT Angio Endovascular
 Mechanical Thrombectomy –
LATEST UPDATES!!
• LEVEL 1 RECOMMENDATION
• AIS within 6 to 16 hours of last known normal who have LVO in the anterior
circulation

• LEVEL 2A RECOMMENDATION
• within 6 to 24 hours of last known normal who have LVO in the anterior
circulation

• LEVEL 2B RECOMMENDATION
• M2/M3 BLOCK, ACA, VA, BA, PCA, Contraindications TO rt PA
What After IV
Thrombolysis??
CONSTANT VIGILANCE!!!
MONITORING!! MONITORING!! MONITORING!!

• Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10% of the dose given
as a bolus over 1 minute.

• Admit the patient to an Intensive care or Stroke unit for monitoring.

• Perform neurological assessments every 15 minutes during the infusion and every 30
minutes thereafter for the next 6 hours, then hourly until 24 hours after treatment.

• If the patient develops severe headache, acute hypertension, nausea, vomiting,

discontinue the infusion (if rtPA is being administered) and obtain an emergency CT
scan.
MONITORING!! AND MORE MONITORING!!

• Measure blood pressure every 15 minutes for the first 2 hours and subsequently
every 30 minutes for the next 6 hours, then hourly until 24 hours after treatment.

• If SBP > 180 mm Hg or if DBP > 105 mm Hg - administer antihypertensive

medications to maintain blood pressure below these levels

• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-

arterial pressure catheters.

• Obtain a follow-up CT scan at 24 h before starting anticoagulants or antiplatelet

agents.
What other
things
should we
take care of?
Antiplatelets
Anticoagulants
Nutrition Management
 Antiplatelet Treatment
• LEVEL 1
• Administration of aspirin is recommended in patients
with AIS within 24 to 48 hours after onset.
• For those treated with IV alteplase, aspirin
administration is generally delayed until 24 hours
• LEVEL 2A
• minor stroke, treatment for 21 days with dual
antiplatelet therapy (aspirin and clopidogrel) begun
within 24 hours
• LEVEL III HARM
• Abciximab, Ticagrelor
 Anticoagulants
• LEVEL III HARM
• Urgent anticoagulation, with the
goal of preventing early recurrent
stroke, halting neurological
worsening, or improving outcomes
 Management of complications
• Prophylactic administration of antibiotics is not recommended, and
levofloxacin can be detrimental in acute stroke (Class II,)
• Early rehydration and graded compression stockings are recommended to
reduce DVT
• Early mobilization is recommended to prevent aspiration pneumonia, and
pressure ulcers
• LMWH should be considered for patients at high risk of DVT or pulmonary
embolism (Class I)
• Prophylactic administration of anticonvulsants to patients with stroke who
have not had seizures is not recommended
 Management of complications
• Early commencement of nasogastric
(NG) feeding (within 48 hours) is
recommended in stroke patients with
impaired swallowing (Class II, Level B)

• Percutaneous enteral gastrostomy

(PEG) feeding should not be
considered in stroke patients in the
first 2 weeks (Class II, Level B)
 ? Stroke < 24 hours
Intimate neurologist on call immediately
NCCT HEAD Intracranial Hemorrhage Management
Bleed +
Bleed -

<4.5 Hours >4.5 Hours

Iv rTPA if no contraindication Is it large vessel occlusion (LVO)?

NIHSS>6, VAN +

Is it large vessel occlusion (LVO)? LVO - Admit ICU, Post

NIHSS>6, VAN + CT ANGIOGRAPHY
If C/I + stroke care
LVO +
LVO - LVO +
Admit ICU, Post CT ANGIOGRAPHY Mechanical Thrombectomy
stroke care
THANK
YOU Keep Lowering Our Times/Keep
Learning

Lower you go- the better you do.