1. PREHOSPITAL & ED MANAGEMENT OF STROKE

2. Principal Causes of Deaths In Government Hospitals Malaysia in 2002 1 Heart Diseases & Diseases of Pulmonary Circulation 15.99% 2 Septicemia 14.51% 3 Malignant Neoplasm 9.16% 4 Accident 6.76% 5 Perinatal Conditions 5.56% 6 Pneumonia 4.98% 7 Cerebrovascular Diseases 4.48% 8 Diseases of Digestive Systems 4.38% 9 Kidney Diseases 3.72% 10 Ill-Defined Conditions 2.74%

5. Stroke Chain of Survival and Recovery (7D's) 1. Detection - note the onset of signs and symptoms 2. Dispatch - call 9 99/991 and have EMS dispatched immediately 3. Delivery - transport patient to hospital with assessment and care 4. Door - immediate emergency department triage 5. Data - prompt laboratory and CT diagnostic studies 6. Decision - diagnosis and decision about appropriate therapy 7. Drug - administration of appropriate drugs or other intervention

6. DETECTION DISPATCH DELIVERY DOOR DATA DECISION DRUG Recognizing signs & symptoms Calling for help (999/991) Initial assessment & stabilization Appropriate hospital delivery Initial investigation Treatment modality Choosing appropriate drugs

7. DETECTION – PH Cincinnati Stroke Scale

9. ED Management of Acute Stroke

10. ED Management of Acute Stroke The completion of 4 D’s……… Door - immediate emergency department triage Data - prompt laboratory and CT diagnostic studies Decision - diagnosis and decision about appropriate therapy Drug - administration of appropriate drugs or other intervention

17. ED Management of Acute Stroke

21. ED Management of Acute Stroke III. Management of seizures - Life-threatening complication if recurs - Anticonvulsant recommended - Prophylaxis is not indicated - A,B,C, O2, Normothermia - Benzodiazepine, phenytoin, phenobarbitone Adams HJ et al. Stroke. 1994;25:1901-1914

28. Pharmacological & Interventional Therapies The National Institute of Neurological Disorders & Stroke rtPA Stroke Trial prospective,blinded RCT < 3 hours of stroke onset use of IV rtPA (0.9mg/kg 10% bolus over 1 min & the rest over 1 hour infusion) 30% more likely no/minimal disability BUT 10X more likely to get intracranial bleed overall mortality NOT increased

29. Pharmacological & Interventional Therapies The National Institute of Neurological Disorders & Stroke rtPA Stroke Trial Based on part I & II: IV administration of rtPA is recommended for carefully selected patients with acute ischemic stroke with no contraindications to fibrinolytic therapy & given within 3 hours of stroke onset (Class I)

30. Pharmacological & Interventional Therapies

31. Pharmacological & Interventional Therapies Characteristics of patients with ischemic stroke who Could be treated with rtPA: Diagnosis of ischemic stroke Measurable neurological deficit Hemorrhagic stroke excluded Onset of symptoms < 3 hours SBP<185mmHg & DBP<110mmHg CT does not show a multilobular infarction The patient & family understand the risk & benefits

32. Pharmacological & Interventional Therapies WHY LESS THAN 3 HOURS ???????? The ATLANTIS Trial: Recombinant Alteplase for ischemic stroke 3 to 5 hours after symptom onset (A RCT) No significant end points differences The benefit was not maintained at 30 days Increased rate of intracranial bleed Routine use of IN rtPA > 3 hours is not recommended (Class indeterminate) Clark W et al. Recombinant Alteplase for ischemic stroke 3 to 5 hours After symptom onset: the ATLANTIS study: a RCT. JAMA. 1999;282:2019-2026

35. Pharmacological & Interventional Therapies LOW MOLECULAR WEIGHT HEPARIN ???? Norwegian Trial Compare deltaparin & aspirin No significant differences in outcomes & recurrent Higher rate of bleeding in deltaparin group Aspirin group has fewer second stroke German Trial Use 4 different doses of certoparin No favourable outcome among the four groups High incidence of spontaneous bleed Berge E et al. Lancet;2000;355:1205-1210 Diener HC et al. Stroke;32:22-29

36. Pharmacological & Interventional Therapies OTHER TREATMENTS ???? Ca2+ channel blockers Volume expander Hemodilution Low molecular weight dextran NO FAVOURABLE OUTCOME Clark WM et al. Stroke.1999;31:2592-2597

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