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CVA

  • Ischemic stroke = 87%
  • hemorrhagic stroke = 13%

Stroke managment Goals

  • blood pressure (BP) management
  • anticoagulation
  • thrombolytic therapy
  • catheter-based interventions
  • surgery.

Causes of Stroke

  1. Thrombotic
  2. Hypertension = Lacuanr stroke by small vessels obstruction
  3. cardiac afib
  4. Carotid and vertebral dissections

Blood SUpply

BV and lesion

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TIA

  • neurologic deficit that completely resolves within 24 hours;

Ischemic Stroke

  • Anterior BV stroke can progress for 24hrs
  • posterior Bv stroke can progress for upto 3days

Hemorrhagic stroke

  • mass effect , inflamation and BBB disruption
    • 50% mortality risk in 30days
      • half dead in 2days
    • 5% can live independantly
    • need airway mng

DXD for stroke and hemorrhage

  • extra axonal blood colection
  • epidural or subdural hematoma
  • Carotid dissection in neck trauma
  • aortic dissection that extends into the carotid arteries.
  • Hypo-glycemia altered mental status can be presentf or few days
  • Wernicke encephalopathy
  • Complex migraines
  • giant cell arteritis
  • brain tumor
  • head trauma
  • abscess
  • Hypertensive encephalopathy

Diagnosis

  • CT brain for ischemic vs Hemorrhagic
  • MRI for late cases

Investigations

  • PT/PTT inr
  • platelets

mng in Ischemic stroke

  • O2
  • prevent over hydration risk cerebral edema
  • prevent dehydration
  • no DNS in Normal patient
  • prevent aspiration
  • Hypertension

  • HTN drugs only if BP > 220mmhg/120mmhg

    • EXCEPT in CHF
    • MI
    • Aortic dissection
    • Anti-platelet theorpy indication

  • no thrombolysis in > 185/110mmhg patient

  • if thrombolysis then Control HTN => to prevent ICH after lysis
  • HTN drugs to reduce below < 185mmhg for thrombolysis - IV labetolol 10 t0 20mg over 2min - OR Nicardipine 5mh/hr
  • in Hypotension / Hyptensive pt with low bp and hypovolumia = Fluid bolus / vassopressor if unresponnsive
  • Glucose = Moratlity
  • maintain 140-180mg/dl
  • hypoglycemia with dextrose solution

Thrombolysis

  • if BP <185mmhg
  • tPA
    1. IV alteplase iv in 3 hours of clearly defined symptom onset to treatment
    2. IV tenecteplase.

Mng in Hemorrhagic stroke

MAss Effect problem

  • Stop all anti-coagualnts
  • Nasal O2
  • 16% Seizure risk
    • levetiracetam 1g IV
  • mannitol 20% 100–200 mL over 10 minutes followed by 100 mL every 8 hours & Hypertonic NS 3% 100ml in 30min to reduce cerebral edema
    • Early continuous infusion of 3% of HyperTonic Saline for sodium goal of 145 to 155 mmol/L => less cerebral edema and ICP elevations
  • prevent hyper and hypoglycemia