Recent Trends in Acute Stroke Treatment

Stroke treatment in coimbatore-sri Ramakrishna Hospital
  • Acute ischemic stroke is a medical emergency in which each minute is counted
  • 2 million neurons are lost each minute after ischemic injury
  • The therapeutic approach to acute stroke treatment has been deeply transformed over two decades
  • Nihilism on stroke treatment is long gone, it has been replaced by the excitement of proven treatment options
  • IV thrombolysis – IVT
  • Mechanical thrombectomy – EVT
  • These two options can reverse ischemia and bring back functions to the patients.
  • Without these options these patients will otherwise be destined to death or severe disability
  • The three main principles of acute stroke are
  • Achieve timely recanalization of the occluded artery and reperfusion of the ischemic tissue
  • Optimize collateral flow
  • Avoid secondary brain injury
  • Three zones of injury may occur the following LVO
  • Ischemic core zone (Tissue irreversibly injured)
  • Ischemic penumbra (Ischemic but still viable cerebral tissue
  • Benign oligemia zone (area with milder reduction in tissue

Perfusion that does not place the tissue at risk)

  • Ischemic penumbra,
  • Ischemic penumbra is an area of brain tissue that is viable but is critically hypoperfused and will progress to infarct in the absence of timely reperfusion.
  • Collateral circulation
  • Primary collaterals refers to circle ofwillis —ACOM and PCOM.
  • Secondary collaterals refers to Ophthalmic artery and Leptomeningeal arteries
  • Tertiary collaterals refers to newly developed vessels through angiogenesis – 1. But overtime thrombi tend to become more fibrin rich 2.Red blood cell rich thrombi are more permeable to blood flow and respond to thrombolytics
  • DSA is a gold standard to evaluate the collateral anatomy.
  • Both IVT and EVT are safe and effective for the right candidate
  • Patient selection is crucial to optimize outcomes
  • Attitude of the clinician should be the treatment should be given unless a solid contraindications exits
  • Expansion of therapeutic window for emergency reperfusion adds merit to these procedures
  • Therapeutic window for IV thrombolysis was extended from 3 to 4 1/2 hours and is has been extended now upto 6 hours.
  • T h e ra p e u t i c wi ndow to mechanical thrombectomy
  • Upto is for 24 hours
  • Upto 6 hours, we may try IVT (IV)

(Thrombolysis ) + EVT (Endovascular treatment)

  • After 6 hours are upto 24 hours mechanical thrombectomy can be done if collaterals are good and core volume is small and if it is LVO
  • Nature of Thrombus
  • Thrombi within the intracranial tree are either formed in situ or reach there as emboli. A freshly formed thrombus is red blood cell rich.
  • Hemodynamicaugmentation & BID Targets
  • Collateral flow can be protected by avoiding BP drops and supported by the administration of IV fluids.
  • If BP drop occurs keep the patient in a laying-flat position for 24 hours after admission (Head-post trial) — Head position stroke trial
  • Aspiration should be taken care of
  • Vasopressors may be beneficial in selected cases — such as patient with cervical ICA/ LV occlusion.
  • Keep the BP around 180/100 for 24 hours.

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