ISCHEMIC STROKE PALITA KAJARERN 580710220 - PowerPoint Presentation

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ISCHEMIC STROKE

PALITA KAJARERN 580710220

Slide2

OBJECTIVE

นักศึกษาแพทย์ทราบแนวทางการประเมินและวินิจฉัยผู้ป่วยโรคหลอดเลือดสมองเบื้องต้นได้

นักศึกษาแพทย์ทราบแนวทางการรักษาและส่งต่อผู้ป่วยโรคหลอดเลือดสมองตีบเฉียบพลัน

(stroke fast track)

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IDENTIFICATION DATA

ผู้ป่วยชายไทยคู่

อายุ 61 ปี

ภูมิลำเนาอำเภอเมือง จังหวัดเชียงราย

อาชีพ ทำนา

สิทธิการรักษา บัตรประกันสุขภาพบัตรทอง

Slide4

หมดสติ 2 hrs PTA

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HISTORY TAKING

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PRESENT ILLNESS

14.00

น. ขณะผู้ป่วยกำลังเกี่ยวข้าว บ่นอ่อนไม่มีแรง ลงนอนกับพื้น เพื่อนร่วมงานของผู้ป่วยสังเกตว่าผู้ป่วยมีปากเบี้ยวน้ำลายไหลมุมปาก ปฏิเสธชักหรือเกร็ง ไม่มีปัสสาวะอุจจาระราด เรียกไม่รู้สึกตัว ผู้ป่วยไม่มีบ่นปวดศีรษะ หรือเจ็บอกใจสั่น หรือมีไข้นำมาก่อน ญาติโทรเรียกรถพยาบาล

รพช

.

At

scene E4V1M

5

, Drowsiness

Slide7

PAST HISTORY

Underlying disease : HTN, DLP, Left RC, L-S

spondylosis

with

rediculopathy

Current medication :

ชาชงหญ้าหนวดแมว

Gabapentin(100) 1x3

po

pc

Orkelax

1x3

Amlodipine(10) 1x1

po

pc

Enalapril

(5) 0.5x2

po

pc

Simvastatin(20)1x1

po

hs

Allergy :

ปฏิเสธประวัติแพ้ยาแพ้อาหาร

Personal history :

สูบบุหรี่ทุกวัน 50 ปี

,

ดื่มสุราทุกวัน 50 ปี

,

ปฏิเสธประวัติใช้สารเสพติด

Previous hospitalization :

16/06/2563

hypertensive urgency with complicated UTI

Surgery history and trauma : no record

Family history : no data

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PHYSICAL EXAMINATION

Vital

sign :

BT

37

c, BP

144/90

mmHg, PR

120/min

,

RR18/min

,

O2sat 100% (on mask with bag 10 LPM), DTX 164, BW 46

kg

Ht

160cm, BMI 17.96

General

appearance :

a thin old age men with

drowsiness, stridor

HEENT

: No pale conjunctivae, No icteric

sclera,

No wound at scalp

Skin

: No external wound, No swelling, No

ecchymosis, No rash

CVS

: Normal chest wall contour,

Regular rhythm

,

Normal S1

S2,

No

murmur

, No

heaving, No

thrill,

No carotid bruit

, No JVD, No differentiated pulse, Pulse 2+ all Extremities

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PHYSICAL EXAMINATION

Respiratory

:

Symmetrical

chest movement, No

deformities, transitional secretion sound equal both lung

Abdomen

:

Scaphoid abdomen,

Normoactive

bowel sound,

Soft, Non

palpable

mass

Genitourinary

: C

annot evaluated CVA

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PHYSICAL EXAMINATION

Neurology:

Drowsiness, poor cooperative, E4V1M4, pupil 4 mm RTLBE

,

Eye deviate to Left in primary position

, Facial weakness, reflex, BBK sign, clonus not examined

Normal gag reflex, stiff neck negative, Can't

evaluate orientation

, EOM,

speech, language,

sensation Pronator drip, cerebellar sign

III

III

I

I

I

I

III

III

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PROBLEM LIST

An old age man 61 years old with …..

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PROVISIONAL DIAGNOSIS

“…………………………”

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DIFFERENTIAL DIAGNOSIS

…..

…..

…..

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INVESTIGATION

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EKG 12 lead

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CXR

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Electrolyte, BUN, Cr, Glucose

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CBC, PT, PTT, INR

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LFT

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CT brain Fast track

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MANAGEMENT

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At Scene and ER

Control BP with

nicardipine

Initiate

rTPA

41.22mg - 4.1mg IV in 1 min

then

37.12mg IV in 24

hrs

PE post

rTPA

: E2VTM5, pupils 4mm SRTLBE

Slide23

Progression 17/11/2563

17/11/63

F/U CT brain post

rTPA

24

hrs

20%Mannital 250ml IV drip in 1

hr

then 100 ml IV q 6

hrs

Lasix 40 mg IV

Keep BP 160/90 mmHg

Consult neurosurgery for

Craniectomy

Emergency

at

Left FTP

to

decompression

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Progression 18/11/2563

Principle diagnosis

:Malignant MCA infarction due to

thrombosis with cerebral edema

18/11/2563

S/P

Craniectomy

Fever + GCS drop-> septic W/U, step ATB to

Tazocin

+ notify

Neuro

Sx

NeuroSx

ประเมิน

poor prognosis +advice

ญาติ

ญาติปฏิเสธการรักษาขอนำผู้ป่วยกลับบ้าน

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ISCHEMIC STROKE

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OUTLINE

01

02

03

04

Basic anatomy and pathophysiology

Initial assessment

Ischemic stroke management

Acute management

for stroke fast track

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ISCHEMIC STROKE

  

1. Large

vessel  cerebral

infarction

              

1.1

Thrombotic cerebral infarction

              

1.2

Embolic cerebral infarction

              

1.3

Hypoperfusion

(low flow) or water-shed

infarction

  

2. Small

vessel  cerebral infarction (Lacuna infarction)

     

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ISCHEMIC STROKE

1. Anterior

circulation (internal carotid system)

Hemiparesis

Hemiparesthesia

Aphasia

 

(Dominant hemisphere)

Amaurosis

fugax

(

ตา

มืดบอด

ชั่วขณะ

)

Apraxia

 

2. Posterior

circulation (

vertebro

-basilar system)

C

ortical

 

blindness

Vertigo

Nystagmus

Drop attack

Horner’s

syndrome

Tetraparesis

Crossed neurologic deficit(แขนขาอ่อนแรงตรงข้ามกับ 

CN deficit)Severe headache,

Vomiting & Nausea are more common chief complaint      

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BASIC ANATOMY

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BASIC ANATOMY

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BASIC ANATOMY

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BASIC ANATOMY

Slide33

BASIC ANATOMY

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INITIAL ASSESSMENT

ABC – avoid hypoventilation, keep oxygen saturation > 94%

History taking, Physical examination and Investigation

Route out stroke mimic

Ischemic

stroke VS ICH or SAH – Early

neuroimaging

(CT or MRI)

Candidated

Intravenous thrombolytic therapy

Slide35

History taking and Physical examination

O

nset or last seen normal

- <4.5hrs (

rTPA

), <24hrs (mechanical

thrombolectomy

)

ICH or SAH

– acute onset headache and vomiting, abrupt onset of impaired cerebral function without focal symptom, take anticoagulant drugs

CVS

-

carotid bruit , palpation

of pulses

at neck

, arms, and

legs, murmur auscultation

Respiratory

- abnormal

breath sounds, bronchospasm, fluid

overload, stridor

Skin

- signs

of endocarditis, cholesterol emboli,

ecchymoses

,

surgical scar

HEENT

- signs

of trauma.

tongue laceration

Neurological examination

- NIHSS (National Institutes of Health Stroke Scale) 5-9

in moderated risk

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History taking and Physical examination

Artery involved

Syndrome

Anterior cerebral artery

Motor and/or sensory deficit (leg > face, arm)

Grasp, sucking reflexes

Abulia

,

paratonic

rigidity, gait apraxia

Middle cerebral artery

Dominant hemisphere: aphasia, motor and sensory deficit (face, arm > leg > foot), may be complete hemiplegia if internal capsule

involved

, homonymous hemianopia

Non-dominant hemisphere: neglect,

anosognosia

, motor and sensory deficit (face, arm > leg > foot), homonymous hemianopia

Posterior cerebral artery

Homonymous hemianopia; alexia without agraphia (dominant hemisphere); visual hallucinations, visual perseverations (

calcarine

cortex

); sensory loss,

choreoathetosis

, spontaneous pain (thalamus); III nerve palsy, paresis of vertical eye movement, motor

deficit

(cerebral peduncle, midbrain)

Penetrating vessels

Pure motor hemiparesis (classic lacunar syndromes)

Pure sensory deficit

Pure sensory-motor deficit

Hemiparesis, homolateral ataxia

Dysarthria/clumsy hand

Vertebrobasilar

Cranial nerve palsies

Crossed sensory deficits

Diplopia, dizziness, nausea, vomiting, dysarthria, dysphagia, hiccup

Limb and gait ataxia

Motor deficit

Coma

Bilateral signs suggest basilar artery disease

Internal carotid artery

Progressive or stuttering onset of MCA syndrome, occasionally ACA syndrome as well if insufficient collateral flow

Slide37

Investigation

Laboratory studies in

all

patients

Brain imaging : CT

/ MRI

Blood

tests = BS, CBC,

BUN

, Cr,

E’lyte

, LFT, PT, PTT,

   

INR

, lipid profiles

CXR

,  EKG

Laboratory

studies in selected patients

Carotid

Duplex scan

MRA

   CTA   4-vessels Angiography

Echocardiography

ESR

, ANA,  protein C, S,  

antithrombin

III,  antiphospholipid Ab

HIV

, syphilis

Slide38

Acute stroke differential diagnosis

Migraine aura

Seizure with postictal paresis (Todd paralysis), aphasia, or neglect

Central nervous system tumor or abscess

Cerebral venous thrombosis

Functional deficit (conversion reaction)

Hypertensive encephalopathy

Head trauma

Mitochondrial disorder (

eg

, mitochondrial encephalopathy with lactic acidosis and stroke-like episodes or MELAS)

Multiple sclerosis

Posterior reversible encephalopathy syndrome (PRES)

Reversible

cerebral

vasoconstriction syndromes (RCVS)

Spinal cord disorder (

eg

, compressive myelopathy, spinal

dural

arteriovenous fistula)

Subdural hematoma

Syncope

Systemic infection

Toxic-metabolic disturbance (eg, hypoglycemia, exogenous drug intoxication)

Transient global amnesia

Viral encephalitis (eg, herpes simplex encephalitis)

Wernicke encephalopathy

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Imaging in ischemic stroke

large vessel

stroke

Early phase (first 24

hrs

) -

MRI diffusion weighted image

(

DWI) 

Cord sign

DDx

slow flow,

polycytemia

BG obscuration

Gray-white

indifferentiation

Loss of insula ribbon

Loss of sulci gyri

Slide40

Imaging in ischemic stroke

Late phase (after 48

hrs

)

:

hypodensity

of brain parenchyma

ACA infarction

MCA infarction

(Most common)

P

CA infarction

Slide41

Imaging in ischemic stroke

CT brain NC Emergency

– small vessel stroke or lacuna infarction (size<1.5cm)

Small penetrating arteries located deep in brain

Putamen, Thalamus, Pons, Posterior limb internal capsule

No headache, good conscious, on cortical signs

Good prognosis

Common lacuna syndrome

Pure motor hemiparesis - Ataxia hemiparesis

Pure sensory stroke - Clumsy hand syndrome

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Criteria for the treatment of Acute

ischemic stroke with

rTPA

Inclusion criteria

Clinical diagnosis of ischemic stroke causing measurable neurologic deficit

Onset of symptoms <4.5 hours before beginning treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal or at neurologic baseline

Age ≥18 years

Exclusion criteria

Patient history

Ischemic stroke or severe head trauma in the previous three months

Previous intracranial hemorrhage

Intra-axial intracranial neoplasm

Gastrointestinal malignancy

Gastrointestinal hemorrhage in the previous 21 days

Intracranial or intraspinal surgery within the prior three months

Clinical

Symptoms suggestive of subarachnoid hemorrhage

Persistent blood pressure elevation (systolic ≥185 mmHg or diastolic ≥110 mmHg)

Active internal bleeding

Presentation consistent with infective endocarditis

Stroke known or suspected to be associated with aortic arch dissection

Acute bleeding diathesis, including but not limited to conditions defined under 'Hematologic'

Hematologic

Platelet count <100,000/mm

3

*

Current anticoagulant use with an INR >1.7 or PT >15 seconds or aPTT >40 seconds*

Therapeutic doses of low molecular weight heparin received within 24 hours (eg, to treat VTE and ACS); this exclusion does not apply to prophylactic doses (eg, to prevent VTE)

Current use (ie, last dose within 48 hours in a patient with normal renal function) of a direct thrombin inhibitor or direct factor Xa inhibitor with evidence of anticoagulant effect by laboratory tests such as aPTT, INR, ECT, TT, or appropriate factor Xa activity assays

Head CT

Evidence of hemorrhage

Extensive regions of obvious

hypodensity

consistent with irreversible injury

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STROKE MANAGEMENT

BP control

Fluid management – isotonic saline without dextrose

T

reatment

of abnormal blood glucose levels

rapidly correct low sugar for route out stroke mimic hypoglycemia

If hyperglycemia – keep 140-180mg%

Swallowing

assessment

– assess prior to administering oral medication or food for prevent aspiration pneumonia

Head and body position – recommend keeping head in neutral position, elevate head 30 degrees in who risk of IICP, aspiration, chronic cardiopulmonary disease

Treatment

of fever

(BT>37.5c) and infection

Slide44

STROKE MANAGEMENT

BP control

BP > 220/140 mmHg 

Sodium nitroprusside    0.25-10 µg/ kg/ min IV

Nitroglycerine                5 mg IV   and 1-4 mg/

hr

Hydralazine      5-10mg IV

BP 185-220 /105-120 mmHg with…

LV failure

Aortic dissection

Acute MI

Acute renal failure

Hypertensive encephalopathy

r-TPA  (keep SBP < 185 mmHg)

 

Slide45

ACUTE MANAGEMENT

Recanalization (stroke

fast

track)

r-TPA  0.9mg/kg(max=90mg) in first 4.5

hrs

10%

iv push then 90%  iv drip in 1

hr

Aspirin in first

48

hours -

extend if use r-TPA

ASA

60-325 mg PO  

Indication of

Decompressive

Craniectomy

C

linical worsening

Impending

uncal

herniation

Midline

shift > 5 mm.

Slide46

THANK YOU