Description
Acute stroke management requires a time-sensitive and multidisciplinary approach. Rapid recognition of stroke symptoms, such as sudden onset of facial droop, arm weakness, or speech difficulties, is crucial for activating emergency medical services. Intravenous administration of tissue plasminogen activator (tPA) within the first few hours of symptom onset remains a cornerstone of acute ischemic stroke treatment, aiming to dissolve the clot and restore blood flow to the brain. For eligible patients, mechanical thrombectomy, a procedure to physically remove the clot, has shown efficacy in improving outcomes. Alongside these interventions, supportive care, close monitoring, and post-stroke rehabilitation contribute to optimizing recovery and reducing the long-term impact of stroke on patients' lives.
Résumé
- Stroke demands immediate attention and a coordinated response. "Time is brain" underscores the need for rapid assessment and intervention to minimize neurological damage. The goal is to administer thrombolysis or perform a mechanical thrombectomy within 60 minutes of the patient's arrival at the hospital.
- A stroke team ideally comprises neurologists, radiologists, emergency physicians, stroke nurses, neurosurgeons (when needed), and cardiologists (for cardioembolic strokes). A dedicated stroke unit is crucial for specialized care and close monitoring of vital signs and neurological function, especially after thrombolysis.
- Factors delaying treatment include unavailable relatives, unknown symptom onset, incomplete medical history, elevated blood pressure, and lack of information on anticoagulant status. In-hospital delays can stem from misdiagnosis of stroke symptoms, manpower shortages, CT scan unavailability, technical issues, patient consent challenges, financial limitations, and inter-hospital transfers.
- Rapid assessment involves a B-FAST examination and a neurological assessment to evaluate the patient's balance, vision, facial symmetry, arm drift, and speech. NIH stroke score is also essential and ranges from 1-4 (minor) to 25+ (severe), and is useful for determining the treatment strategies.
- Imaging techniques such as CT scans and MRI are vital in stroke diagnosis. CT scans are used to rule out bleeding. MRI and MRA are also essential in detecting ischemia. MRI can also determine whether the patient is still in a golden period. CT scans also are a good way to detect dense MCA, where the arteries appear more dense.
- Thrombolysis is indicated for acute ischemic strokes within 3 hours, with certain conditions being met. Contraindications include active internal bleeding, blood pressure exceeding 180/100, recent major surgery or trauma, and known bleeding diathesis. Blood pressure control is essential prior to thrombolysis, often achieved with agents like labetalol. Hypoglycemia must be corrected first.
- Following thrombolysis, neurological assessment is crucial for a time period, with monitoring blood pressure, GCS, NIH, and motor power. Antiplatelets and anticoagulants are typically withheld for the first 24 hours. Follow-up CT scans or MRIs may be required, particularly if the patient experiences headaches or worsening symptoms.
- Strategies to reduce door-to-needle time (DTN) include pre-hospital notification from paramedics and direct patient transfer to the CT scan. Stroke bags containing checklists, forms, drugs, and TPA are effective for cutting down around 20 to 30 minutes of time. Be sure to check blood sugar.
- Do not miss posterior circulation strokes. Stroke mimics should be remembered to properly assess the patient and to prevent misdiagnosis. Check for MCA, look for hypertenseness, insula ribon signs, etc. New agents can also be used to treat strokes and help provide neuroprotection.
Exemple de certificat
À propos des intervenants
Dr Purusatyam Chakraborty
Consultant et chef du service de médecine d'urgence, hôpital CMRI, Kolkata
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