Acute treatment of stroke has been revolutionized over the last few years. Thrombolytic agents mainly involve intravenous tissue plasminogen activator and or occasionally intra-arterial TPA. Mechanical clot retrieval devices are used much more commonly these days. Also intracranial angioplasty and stents are used as well as neuroprotective agents as well as hypothermia and cooling devices. Over the last 10 to 20 years or so there have been the development of primary stroke centers and these focus on trying to provide patients with intravenous tissue plasminogen activator as long as they meet the criteria within a window now of 4.5 hours which has been extended from 3 hours. A primary stroke center needs to have a stroke team in place 24-7 which includes everything from emergency medicine professionals, stroke neurologists, neurosurgeons, interventional neuroradiologists, etc. Rapid standard CT scanning with interpretation needs to be done emergently and you need to have a close relationship and communication with your emergency medical service. In recent years the stroke unit has actually become mobile in some situations where you can have a CT scanner actually in the ambulance with close communication with the emergency department and vascular neurologists where in some situations you can actually provide intravenous TPA or tissue plasminogen activators in the ambulance. This has been a fairly new development. Let's talk about TPA, an acute ischemic stroke. It was approved by the FDA in 1996 for up to 3 hours after symptom onset but in recent years the window has increased to 4.5 hours. The FDA has not officially approved the intra-arterial route but it still is used at times for up to 6 hours after symptom onset. Functional recovery after TPA is superior to a placebo and it may help all ischemic stroke subtypes both small and large. The administration of TPA is not without its risks with an approximate 6.4% incidence of symptomatic brain hemorrhage. Despite that, TPA is underutilized generally throughout the country and we encourage patients if they think they have a stroke to play it safe, get to the emergency room hopefully in a stroke center to get the care that they may need. This is the National Institutes of Health Stroke Scale or NIHSS. This is utilized in a variety of settings, particularly in the acute care setting, the emergency room, also in the rehabilitative settings, both inpatient and outpatient. And it's important to quantify how impaired a person with a stroke is, particularly to guide management both in the acute phase and subsequently. Decision options, time is brain. As we said before, if someone has symptom onset of 0 to 4.5 hours and brain imaging reveal evidence of an acute ischemic stroke, the patient is generally a candidate for intravenous TPA within four and a half hours from symptom onset. Decision making for tissue plasminogen activator. All includes a documented time of onset within four and a half hours of ER arrival, moderate to severe non-resolving sensory motor deficits, including visual field cuts, significant aphasia, both expressive and receptive, well-controlled blood pressure, and an aspect score of eight to 10. Unfavorable factors in decision making for TPA include the onset of symptoms is unclear in terms of time, it's unclear if the patient has a stroke or not, very mild or rapidly resolving deficits, visible edema and or ischemia of large volume on brain imaging, uncontrolled and or labile hypertension, and no abnormalities seen on brain imaging. This is a brain CT perfusion scan of a patient with an acute right brain ischemia with the red showing areas of ischemia. This slide shows CT angiography of the brain where there is a right middle cerebral arterial occlusion. This is a follow-up MRI, MRA showing post-intervention reduced infarct size and a patent right middle cerebral artery as seen to the scan on the right with the red arrow. And these are criteria for the administration of TPA. The world of acute stroke management has been revolutionized over the last four or five years and this includes the use of mechanical clot retrieval devices. In emergent situations, these mechanical clot retrieval devices are actually being used within the first eight hours from zero to eight hours. This is an angiogram of a patient with left middle cerebral arterial stroke with a clot in that artery, pre-clot busting. And this shows post-treatment how the angiogram improves as the clot has been resolved. These are various types of mechanical clot retrieval devices post-stroke and in the lower right hand corner, you see evidence of a clot being removed by a device in one of the blood vessels of the brain. Just last year, in the New England Journal of Medicine, in a study of middle cerebral artery or internal carotid artery occlusion, mechanical thrombectomy at six to 16 hours post-symptom onset was combined with medical therapy, was superior to medical therapy alone without significant difference in brain hemorrhage. Intracranial stenting, just as you can put a stent in your coronary artery or in an artery in the lower extremity, this could be used as well in brain arteries. And this is a case of a stent. We have a baseline angiogram to the left, post-stenting showing improvement in collateral circulation and then showing an improvement on a CT scan post-intracranial arterial stenting. Let's talk about antiplatelet agents in strokes. Aspirin is the usual initial agent, and over the years we have realized that lower doses are equally effective to much higher doses with less side effects. Very often when used alone, when someone has had a stroke, patients will often have a 325 milligram per day dose of aspirin, but that varies. Clopidogrel also can be used with aspirin or with diperitamol in stroke patients. And these agents are preferred in patients with stroke, coronary artery disease, and peripheral vascular disease. Aspirin and diperitamol, their effects are additive, an appropriate secondary stroke prevention regimen. In the New England Journal of Medicine in 2018, when studying aspirin and clopidogrel, they may also provide an appropriate secondary stroke prevention regimen versus aspirin alone with a degree of increased risk of bleeding. But the key point for you to know is there is no single gold standard regimen for medical management in secondary stroke prevention. You should consult with a neurologist who manages stroke patients. There are indications for atrial fibrillation, recent myocardial infarction with left ventricular thrombus, patients with mechanical heart valves. Probable indications include left atrial or appendage clot, a large patent foramenal valley with shunted aneurysm, and hypercoagulable state. Possible indications for anticoagulants include a small patent foramenal valley without shunted aneurysm or a spontaneous echogram contrast showing smoke. Probably the prototypical anticoagulant medication is warfarin, which requires monitoring of internationalized normal ratio, or INR. This is used for secondary stroke prevention in patients with atrial fibrillation. However, there are more novel oral anticoagulants, or NOACs. Some of them are direct thrombin inhibitors, such as dabigatran and rivaroxaban, and the upside of that is that no blood work is required, unlike what you need for warfarin. There's also a direct factor XA inhibitor, such as ipixaban. Similarly, to dabigatran and rivaroxaban, no blood work is required. In terms of secondary stroke prevention, surgeries and procedures, carotid artery endarterectomy, carotid stenting, and closure of patent foramenal valley. In carotid artery disease, as discussed previously, you screen initially with the carotid duplex. If there's a greater than 50% stenosis, you want to verify this with further imaging. What's carotid endarterectomy? That's where, whether it's a vascular surgeon or a neurosurgeon, they will try to take out the plaque in the carotid artery to prevent further stroke. For symptomatic patients, if it's greater than 70% stenosis, if it's asymptomatic, the question is, do you operate if it's greater than 60% stenosis? That's something, again, that a vascular surgeon or a neurovascular neurosurgeon would need to clarify. When someone has total occlusion of their carotid artery, surgery generally is not indicated, and medical treatment is the course of action. Carotid stenting, not necessarily safer than endarterectomy, and the stroke risk may be related to catheterization or arch disease. So what do we do about this? Do we stent? Do we do medical therapy? Do we do endarterectomy? We don't know. Chymowicz in the New England Journal of Medicine in 2011, in their study, found that medical therapy was superior to intracranial stenting. It was a higher stroke risk in carotid stented patients. Brott's study in the New England Journal of Medicine in 2010 found a higher risk of myocardial infarction in endarterectomy patients. So more research is needed. So a pain in the fremental valley is an abnormal connection between your right atrium and your left atrium, and that could be a cause of turbulent flow and can predispose patients to stroke. Clinicians have included, back in the day, open surgical closure versus minimally invasive closure versus not performing closure at all. The New England Journal of Medicine published some articles in 2017 that talked about closure with antiplatelets could be superior to antiplatelets alone, but with a higher rate of atrial fibrillation and device complication. So once again, a physiatrist is not expected to make this decision. You should collaborate with your physician colleagues. Treatment of subarachnoid hemorrhage, controlled blood pressure, appropriate pain management, operative intervention as needed, including burr hole, craniotomy, aneurysm coiling, and or clipping of the aneurysm. Treatment of intracranial hemorrhage, blood pressure management, intracranial pressure management, operative intervention as needed. What's hemicraniectomy? That's when a neurosurgeon will remove half of the skull on the affected side that can often be implanted inside the patient's abdominal cavity in order to relieve increased intracranial pressure. In most cases, that skull is replaced and put back where it should be within three months. And during that time, a hard helmet is used in place of your skull. Sometimes what will happen is when, even if you have the half of the skull that's been removed, whether you have it in a bank or you have it in your abdominal cavity, when you sometimes try to replace it, it doesn't fit right. And if that's the case, you can provide a prosthetic skull that can be molded and applied. Treatment of arterial venous malformation. Operative intervention can include angioembolization is often done first. You could also do stereotactic proton beam therapy or microsurgical resection. Question. Guidelines for use of intravenous tissue plasminogen activator, TPA, in acute ischemic stroke includes a time frame from symptom onset within A, one hour, B, four and a half hours, C, nine hours, D, 18 hours. The answer is B, four and a half hours. Patients who qualify for the option of TPA must present within four and a half hours of symptom onset. The patient must have no history of head trauma, myocardial infarction, or stroke within the past three months. Having a systolic blood pressure greater than 185 millimeters of mercury is not necessarily a contraindication. The increased blood pressure may be managed with hydralazine, labanolol, or nalprol to reduce the risk of hemorrhagic stroke during TPA administrations.

acute treatment of stroke

thrombolytic agents

rapid CT scanning

tissue plasminogen activator (TPA)

secondary stroke prevention