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Cornerstones of acute ischaemic stroke therapy?

- rapid recanalisation
- stroke unit
- hemicraniectomy
- preventing secondary stroke


Cornerstones of intracerebral haemorrhage therapy?

- prevent haematoma growth
- stroke unit
- [additional measures]


Imaging modality of choice for stroke?


(fast and widely available)


What to do if neuro symptoms in clinical exam and no intracranial haemorrhage?

[if persisting deficit <4.5hr/<6hr OR CCT early infarct signs <1/3
- IV thrombolysis
- mechanical thrombectomy


What to do with unknown symptom onset w/ neuro symptoms in clinical exam?

- multimodal MRI/CT based thrombolysis


What is IV thrombolysis (rtPA) and dosage?

[<4.5 hrs]
Only licensed medical therapy of acute ischaemic stroke in 4.5hr time window

0.9 mg/kg BW over 60 mins
10% of this dose given as bolus over 1 min

MAX dose = 90mg


Most important primary outcome measure in stroke?

Modified Rankin Scale

[see lecture]


Experimental effect of thrombolysis?

Increased proportion of pts w/ good functional outcome (mRS)

(the further from symptom onset that tPA is given, the less of a +ve effect it has)


What is perfusion-DWI mismatch?

Perfusion-weighted imaging (PWI) - Diffusion-weighted imaging = DWI/PWI mismatch

This shows us the area of brain that is salvageable.


Experimental evidence of DWI/PWI mismatch imaging?

[ECASS-4/ EXTEND trials]

IV thrombolysis of patitents w/ perfusion-DWI mismatch in 4.5-9hr time window improves outcome

[WAKE-UP trial]

IV thrombolysis of patients with DWI-FLAIR mismatch in 4.5hr time window after awakening improves outcome


List some methods of interventional recanalisation in stroke?

- ultrasound (EKOS)
- shock wave/ vacuum: angiojet
- retrieval devices (MERCI, penumbra)
- laser devices (EPAR)
- stentretrievers


Results of mechanical thrombectomy vs rTPA?

Numbers needed to treat to achieve:

- 1 more independent patient: 5
- a reduction in disability by 1 mRS point: 2.7

[to compare: 21 for PCI in MI to prevent 1 death]

In other words. For 100 patients: 20 more will be independent and 38 more will be less disabled


Importance of rapid administration of mechanical thrombectomy and rTPA?

30 min delay: 12% less chance of good clinical outcome


NICE recommendations of thrombectomy?

Recommended in selected patients up to 24 hours after symptom onset


ESO recommendations for mechanical thrombectomy?

Within 4.5 hrs to treat acute stroke patients w/ large artery occlusions in anterior circulation up to 6hrs after symptom onset

Mechanical thromb shouldn't prevent initiating IV thromb and vice versa when indicated

Mech thromb should be performed ASAP after its indication


Clinical features of basilary artery thrombosis?

sudden onset/initial fluctuating symptoms (treacherous)

- vertigo
- brainstem signs

- spontaneous course (50-90% mortality)
- severe morbidity (e.g. locked in syndrome)


Diagnostic workup of basilar artery thrombosis?

- CCT plus CT angio

- multimodal stroke MRI (DWI, MRA)

- Digital subtraction angiography


Therapy of basilar artery thrombosis?

Early recanalisation is KEY (time window for thrombolysis is longer than MCA stroke)

Assess prognosis (use clinical findings, pt age, symptom duration, MRI findings)


Neuroprotective methods to treat stroke?

Surgery (severe cases)
Physical (hypothermia)
Pharmacological (energy failure, peri-infarct depolarisation, excitotoxiticity, microglial activation, inflammatory infiltrate)


Members of a stroke unit?

Interdisciplinary team:
- vasc surgery
- neuroradiology/surhery
- cardiology
- speech + lang therapist
- occup therapist
- phys therapist


Causes on non-traumatic intracerebral haemorrhage

70%: hypertensive arteriolopathy

20%: cerebral amyloid angiopathy


Overview of management for intracerebral haemorrhage?

- haemostatic therapy
- minimise risk in pts taking oral anticoag
- anti-hypertensives
- surgery


E.g.s of haemostatic therapy for intracerebral haemorrhage?

- recombinant factor VIIa (activates tissue factor -> coag cascade)
- tranexamic acid


How to minimise risk in pts taking oral anticoagulants?

INR reversal
- Prothrombin concentrate

Reverse NOAC effects
- Idarucizumab
- Andexanet-alfa