1. Acute Ischemic Stroke First Eight Hours Dr. Mohammed Ateequr Rahman
MD, DNB(Neuro), FINS.
Interventional Neurologist.
Care Hospital Nampally.

2. Acute Ischemic Stroke – The Burden
Third leading cause of death
Leading cause of disability
Permanent disability 15-30%
Stroke Burden – India
Prevalence per 100, (Anand et al 2001)
Incidence 105 per 100, (Benerjee et al 2001)

3. Case 1
A 55 yrs male presented to the emergency with acute onset of left side weakness of 80 minutes duration. He was hypertensive. No history of headache, vomiting, and seizures.
Exam: BP: 190/110, Pulse: 78/min and regular, Temp: 980F, Left motor hemiparesis, left homonimous hemianopia, brisk left sided reflexes and left plantar up going (NIHSS: 18)
Blood sugar: 120 mg/dL Platelets: 1.5 lakhs, PT: 14 sec

4. Loss of Insular with obliteration of sulcal and gyral spaces
Case 1
Loss of Insular with obliteration of sulcal and gyral spaces

5. Time is Brain

9. Therapeutic Strategies in Acute Ischemic Stroke
Reperfusion - Recanalization.
Neuroprotection – No effective drug.
Avert clot propagation – Efficacy of anticoagulants is still controversial.
Prevent complications.

10. Acute ischemic stroke – Reperfusion Strategies.
Recanalization or antegrade reperfusion approaches
Intravenous and or Intra arterial Thrombolysis.
Thrombolytic agents
Plasminogen activators, direct fibrinolytics, fibrinogenolytic agents.
Adjunctive therapy: heparin, direct thrombin inhibitors, GP IIb/IIIa antagonist
Endovascular thrombectomy
Distal devices: Merci, Phenox, Solitaire, Trevo, Neuronet, Catch, Attracter-18.
Proximal devices: Alligator, In-time retriever, Snares.
Endovascular thromboaspiration
Pneumbra, Possis AngioJet, F.A.S.T. Funnel Catheter.
Mechanical thrombus disruption
Microguidewire, Snares, Balloon angioplasty, Omni Wave.
Endovascular thrombus entrapment.
Self expanding and balloon expandable stents.
Temporary endovascular bypass
Resheathable (closed-cell) stents, Solitaire, Trevo, Re Vasc.
Alternate Reperfusion Approaches
Global reperfusion ( flow augmentation or transarterial retrograde reperfusion)
Pharmacological: Vasopressors
Mechanical: NeuroFlo
Transvenous retrograde reperfusion (flow reversal)
Partial: Retrograde transvenous neuroperfusion
Complete: ReviveFlow

11. Acute Ischemic Stroke: Intravenous tPA Treatment
Window period < 4.5 hrs
Normal CT or infarct less than 1/3 rd of MCA territory
Moderate stroke (NIHSSS 4-20)

12. Ischemic Stroke – Intravenous tPA
1 in 10 more will be independent
1 in 14 will suffer symptomatic hemorrhage
1 in 100 fewer may die as a result of the treatment
The success rates of the IV rt-PA treatment, based on anatomical location, are:
Saqqur M et al. Clinical detrioration after intravenous rt-PA treatment, Stroke 2007;38
Alexandrov AV . Current and future recanalisation strategies for acute ischemic stroke.
J. Intern. Med. 267,
Artery
% Recanalisation
Basilar 30
Terminal part of ICA 6
M1 part of MCA
M2 part of MCA 44
Tandem ICA and MCA 27

14. Earlier The Treatment: Better The Outcome
Time of Onset
NNT
<60mnts
1:2
60-90
1:4
90-180
1:9
1:21
Will likely become symptom free or have minimal residual symptoms if treated with IV Thrombolysis.
Marler JR et al: Early stroke treatment associated with better outcome: NINDS rt-PA stroke study. Neurology 55,

15. Intravenous tPA – Outcome: CARE ExperienceH S

16. Acute Ischemic Stroke – Thrombolysis
Intra-arterial Thrombolysis
Window periods: hrs
Stroke severity: NIHSS > 10
Vessel occluded: Mid to large size

18. Intra-arterial Thrombolysis

19. Intra-arterial Thromobolysis

21. Stroke Subtypes – Anticoagulation

22. Acute Ischemic Stroke: Antiplatelet Therapy
IST and CAST - Aspirin
Reduction in recurrent stroke: 7 per 1000
(p < )
Reduction of death or dependency: 12 per (p<0.01)
(Chen et al 2000)

24. Acute Ischemic Stroke: First Eight Hours Take Home Message
Time window determines appropriate treatment and outcomes.
Intravenous tPA is the treatment of choice in patients with onset <4.5hrs, moderate stroke (NIHSSS 4-20) and normal CT or infarct less than 1/3 rd of MCA territory. Intra-arterial therapy is feasible in appropriate condition and in failure of IV tPA cases.
Judicious management of BP & blood sugar is of great importance during acute phase. Control of elevated temperature is essential as it is detrimental to injured brain.
Care in the stroke unit is associated with better outcomes.

25. THE ORGAN THAT MAKES YOU WHAT YOU ARE.
Thank you