Cerebrovascular diseases 2

Treatment of Ischemic Stroke :

Treatment of Ischemic Stroke Dr Rahul Chakor MD., DM Assoc Prof Dept of Neurology T. N. Medical College B. Y. L. Nair Hospital Mumbai

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Interruption of nutrient blood flow Cellular metabolic events Duration, severity & location of ischemia Severity of stroke .

Slide 3:

Loss of (ATP) Na/K pump failure Membrane depolarization ↑Na, ↑Ca Cell loses potassium Anaerobic glycotic pathways -damaging by-products, lactic acid and hydrogen ions Stimulates the massive release of the amino acids glutamate and aspartate, excitatory neurotransmitters in the brain. Calcium channels is the N-methyl-D aspartate (NMDA) channel. Na & Ca ions rapidly accumulate within the cells, inflow of water, cytotoxic edema of neurons and glia.

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↑Ca Activation of Phospholipases Proteases Lipases Nucleases NOS Arachidonic acid metabolites Oxygen free radicals, Damage cell membranes, Genetic material, Structural proteins Leading to cell death. Excitotoxicity NMDA receptors Non NMDA receptors Glutamate binds to the receptor Excites” the cells Depolarizes Moves positive ions into the cell

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Core - Infarct Penumbra – ischemic but viable Continuation of Ischemia converts penumbra to infarct Ischemic Penumbra

Treatment:

Treatment

Treatment:

Treatment Tests for the Emergent Evaluation of the Patient with Acute Ischemic Stroke CT of the brain without contrast Electrocardiogram Chest x-ray Hematologic studies (complete blood count, platelet count, prothrombin time, partial thromboplastin time) Serum electrolytes Blood glucose Renal and hepatic chemical analyses National Institutes of Health Scale (NIHSS) score

Thrombolysis:

Thrombolysis IV rt-PA for acute stroke thrombolysis is based on the NINDS rt-PA study, a two-part randomized, double blind, placebo-controlled trial.

IV rt – PA (alteplase, actylise):

IV rt – PA (alteplase, actylise) Inclusion Criteria Clearly defined time of onset <3 h Measurable stroke-related deficit No intracranial hemorrhage on CT Dose Total dose 0.9mg/kg (max 90mg) 10% of the total dose as bolus over 1min 90% of the remaining over 60 min Exclusion Criteria Stroke or head trauma within 3 months Major surgery within 14 days History of intracranial hemorrhage SBP > 185 mm Hg or DBP >110 mm Hg Rapidly improving or minor symptoms Symptoms suggestive of subarachnoid hemorrhage Gastrointestinal hemorrhage or urinary tract hemorrhage within the previous 21 days Arterial puncture at a noncompressible site within the previous 7 days Seizure at stroke onset Anticoagulant or heparin use <48 h before onset with elevated partial-thromboplastin time Prothrombin time >15 s Platelet count <100,000/mm3 Glucose concentration <50 mg/dL or >400 mg/dL 1995 NINDS rt-PA study

Intra-arterial Thrombolysis:

Intra-arterial Thrombolysis Microcatheter techniques Smaller dose of fibrinolytic agent More complete recanalization Complications reduced treatment window can be extended beyond the typical IV window of 3 hours Combined with mechanical manipulation of the clot,

Endovascular treatment:

Endovascular treatment Mechanical manipulation of the clot MERCI clot retrieval device Thrombectomy Thromboaspiration –Penumbra stroke system

Prevention:

Prevention Avoidance of risk factors Treatment of specific risk factors (HT,DM) Treatment to reduce coagulability Antiplatelet therapy Anticoagulation Carotid stenosis

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Primary prevention DM, HT, AF, Hypercholesterolemia, Lifestyle modification Secondary prevention Thrombosis

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HT Target 120/80 Depends on associated diseases DM As carefully as possible Cholesterol LDL <100 mg/dl, Ch <135mg/dl Statins

Antiplatelet:

Antiplatelet Aspirin – 50 to 325mg/day Clopidogrel 75mg/day Combination

Anticoagulation:

Anticoagulation Cardioembolism Major vessel occlusion – ICA, BA Arterial dissection – ICA, extra cranial VA Prothrombotic states Severe carotid stenosis Anti platelet failure Cerebral venous thrombosis

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Carotid artery endarterectomy Symptomatic > 70% Symptoms within 6 months Fit for surgery Expertise available Carotid artery stenting Selected patients

Thank You:

Thank You