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A Neurological Emergency
Acute Stroke
Acute stroke
Benefits of treatment
Acute therapy
Prevention
Acute Stroke
Acute Stroke
Medical Emergencies
Acute Stroke
A Medical Emergency
12% mortality at 7 days 19% at 30 days 31% at one year TIME = BRAIN
Is it a Stroke?
TACI
Large cortical stroke MCA +/- ACA territories Higher cerebral dysfunction
AND
And
PACI
2 out of 3 of TACI OR
motor/sensory deficit more restricted than LACI Higher centre dysfunction alone
OR
LACI
Pure motor stroke Pure sensory stroke Sensorimotor stroke Ataxic hemiparesis Dysarthria-clumsy hand syndrome
POCI
Ipsilateral cranial nerve lesion with contralateral motor/sensory deficit Bilateral motor/sensory deficits Conjugate gaze palsy Pure cerebellar deficit Isolated homonymous visual field defect
Investigations
Is it a stroke?
Investigations
CT
Fast Reliable Available Differentiates between ICH and ischaemic stroke May show alternate diagnosis
Investigations
CT
Investigations
Investigations
TACI
LACI
POCI
PACI
Emergency Management
Dr Christopher Trethewy
Clearly defined time of onset Less than 3 hours No contraindications to thrombolysis Stroke not too mild nor too severe
Recombinant tissue plasminogen activator Given within 3 hours To patients with appropriate stroke and CT REDUCES DEATH and DISABILITY at 3/12 NNT 18 NNH 34
rTPA
Stroke Units
Coordinated, goal directed rehabilitation Oxygenation Fever management Early mobilization BGL management PATHWAYS DON'T HELP
Aspirin
Started within 48 hours Reduces death, disability, recurrent stroke Improves recovery NNT 111 NNH
BP reduction
Neuroprotection
Prevention
BP lowering
Smoking cessation Lipid lowering (maybe) Anticoagulation for Afib if other risk factors Aspirin if other vascular disease
Secondary prevention
Aspirin (and modified release dipyridamole) Anticoagulation if Afib CEA if symptomatic stenosis >70% BP lowering Smoking cessation Lipid lowering
Stroke: an emergency
Early hospitalisation if moderate stroke Aspirin within 48 hours if not for TPA Stroke Unit Aspirin plus vascular risk management