Download acute brain attach protocols

Guidelines in the acute
management of Ischemia
stroke 0-3 hrs.
INTRODUCTION
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Incidence of ABA :
2.4 per 1000 people per year
0.2 % per year between 55-64 yrs of age
2 % per year for persons >85 yrs.
1 per 1000 persons per year
10,00,000 strokes per year in India
3000 strokes a day
In Chennai alone, 1000 cases a month
2% of all admissions
Crude prevalence rate is 220/100000.
Impact of ABA and economic
burden
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Someone suffers a Brain Attack every 33
secs.
Every 3.3 mins., someone dies of a stroke
Atleast 50,00,000 Indians are Stroke
survivors
Stroke costs in India: Rs. 3000 – 4000
Crores a year
Rationale behind developing
ABA team
1. Targets the unique needs of the Stroke victim
2. A radical change has taken place in the way
stroke is managed. A ‘wait and hope’
approach has been replaced by a ‘rapid
diagnosis and intervention’ approach.
3. A protocol driven, appropriately equipped
Stroke program run by a well-trained
staff is an absolute necessity to implement
the newer stroke treatments.
4. Acute Stroke units decrease length of hospital
stay.
Rationale behind developing
ABA team
Time is Brain!
ABA teams provide the most efficient and
effective care during acute Hospitalization,
deliver thrombolytic therapy and improve
outcome.
0
10
90
20
30
40
50
minutes
60
70
80
Estimated thresholds
Core Penumbra
0
20
10
Infarct
Volume
0 30 60 120 180 240 360 480
min
720
1080
1440
Time
Oligemia
Normal range
40
60
Hyperperfusion
CBF ( ml/100g/min)
Ischaemic core and penumbra
Relationship of Ischemia over Time
One Hour from Onset
penumbra
core
3 Hours from Onset
6 Hours from Onset
Heterogeneous Disease: Infarction at different rates
1 Hr
average
slow
fast
3 Hr
6 Hr
Acute Brain Attack Team
Objectives:
1. To form a multi-disciplinary Stroke
team.
2. To implement new advances that
improve stroke outcome.
3. To train Medical, Neurological and
Neurosurgical residents.
4. To participate in International Clinical
Research and Stroke trials.
Acute Brain Attack Team
Requirements:
1. 6 beds in Neuro Critical Care and 6 beds in
Stroke Unit
2. E R Physicians interested in Stroke
3. 24 Hr/365 days ‘Full time’ Stroke/ Vascular
Neurologists
4. Nursing staff trained in stroke care
5. Stroke Rehab Programme
6. Physiotherapists
7. Speech Therapists
8. Dietitians
Anticoagulants and Antiplatelet Agents in
Acute
Ischemic Stroke
Report of the Joint Stroke Guideline Development
Committee of:
 American Academy of Neurology and the American
Stroke Association
(a Division of the American Heart Association)
B.M. Coull, MD; L.S. Williams, MD; L.B.
Goldstein, MD; J.F. Meschia, MD; D. Heitzman, M.S.
Chaturvedi, MD; K.C. Johnston, MD; S. Starkman,
MD; L.B. Morgenstem, MD; J.L. Wilterdink,MD; S.R.
Levine, MD &; J.L. Saver, MD.
Recommendations
A tale of two drugs
1. Patients with acute ischemic stroke presenting
within 48 hours of symptom onset should be given
aspirin (160 to 325 mg/day) to reduce stroke
mortality and decrease morbidity, provided
contraindications such as allergy and GI bleeding are
absent, and the patient has or will not be treated with
recombinant tissue-type Plasminogen Activator
(Grade A). The data are insufficient at this time to
recommend the use of any other platelet
antiaggregant in the setting of acute ischemic stroke.
Recommendations (Contd.)
2. Subcutaneous unfractionated heparin, LMW
heparins, and heparinoids may be considered
for DVT prophylaxis in at-risk patients with
acute ischemic stroke, recognizing that nonpharmacologic treatments for DVT prevention
also exist (Grade A). A benefit in reducing the
incidence of PE has not been demonstrated.
The relative benefits of these agents must be
weighed against the risk of systemic and intracerebral hemorrhage.
Recommendations (Contd.)
3. Although there is some evidence that fixed-dose,
subcutaneous, unfractionated heparin reduces early
recurrent ischemic stroke, this benefit js negated by a
concomitant increase in the occurrence of
hemorrhage. Therefore, use of cutaneous
unfractionated heparin is not recommended for
decreasing the risk of death or related morbidity or
for preventing early Stroke recurrence (Grade A).
Suspected Acute Ischemic Stroke/TIA
DAY 1---1st 24hrs
Emergency Department
Protocols
Acute Stroke Nursing
Protocol
t-PA reconstitution and
Neurologist Protocols
IV thrombolysis
administration instructions
IA thrombolysis
Acute Stroke Blood Draw and
ED Order Sheet
Acute stroke Patient Clinical
Examination Form
Stroke scales
Post-thrombolysis
Management
NINDS - Stroke evaluation targets for
potential Thrombolytic candidates
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Door to MD evaluation
10 min
Door to CT completion
25 min
Door to CT read
45 min
Door to treatment
60 min
Access to neurological expertise 15 min
Access to neurosurgical expertise
2 hrs
Admit to monitored bed
3 hrs
Acute Brain Attack Team
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OVERVIEW OF PROTOCOL:
1.Creation of Public awareness about ABA
2.Time 0 : Apollo Ambulance called for
3.Pre – arrival
4.First hour after patient arrives in EMR
5.Second Hour
6. First 2 days
7.Follow up.
Acute Brain Attack Team
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Education / Creation of awareness
among the Public that:
1. Stroke is called Acute Brain Attack and
is a medical emergency.
2. Effective treatment is available if rushed
to Apollo Hospitals within the first 3-6
hours, after an ABA.
CREATION OF AWARENESS AMONG THE
PEOPLE
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Stroke is “ACUTE BRAIN ATTACK"
Exposure in TV channels as a video skit, Stroke
information.
Slide projection in Cinema theatres & other
gatherings.
AIR (All India Radio) skits, small talks &
announcements.
Handouts in English,Tamil,Telugu & Hindi in
gatherings.
Posters in prominent places, road junctions &
public places.
Lectures - periodic at public places / functions /
health meetings.
Education / Creation of
awareness among the Public
Recognize the warning signs of Stroke like:
 1.Sudden numbness or weakness of the face,
arm or leg on one side of the body.
 2.Sudden confusion, trouble speaking or
understanding.
 3.Sudden trouble seeing in one or both eyes.
 4.Sudden trouble walking, dizziness, loss of
balance or Coordination.
 5.Sudden severe headache or coma.
The Chennai Acute Brain Attack
Consortium
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Formed on October 29, 2009, World
Stroke Day.
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Prof. M.R.SIVAKUMAR, MD, DM, FRCP,
FAAN, FAHA, is the Program Director
and Co-ordinator
ALL 95000 17893 IF ANY OF THE
ABOVE SYMPTOMS ARE NOTED(24x7).
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Time Zero - Ambulance is called
The ambulance operator will be asked to rush
the ambulance to the Stroke victim’s house.
The Stroke patient will be transported to the
nearest scan center where facilities for CT/MRI
Scans are available.
After the Neuroimaging, the patient will be
admitted to the nearest Hospital equipped with
Stroke Unit and Acute Stroke Protocols.
Pre -arrival: Before patient
arrives at the ER
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The ambulance operator should:
1.Dispatch the ambulance immediately.
2.Inform the Emergency Room/ Neurologist that
a Stroke victim is on the way.
EMR Medical Officer should:
1. Alert the Radiology Staff in the CT scan
area/Duty Radiologist.
2. Inform Stroke Neurologist
Pre-arrival
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Phone contact eye-witnesses or family members
to obtain:
- details of the event (time of onset)
- relevant medical history, medications, allergies
- open discussion about risk/benefit of potential
emergency therapies
- ensure open line of communication with next of
kin
Acute Stroke Nursing Protocol
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T-PA reconstitution and administration
instructions
Acute Stroke Blood Draw Order Sheet
Acute Stroke Patient Clinical Examination
Form
Acute Stroke Action Plan
Acute Stroke Nursing Protocol
Acute Stroke Nursing Protocol
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Record time of onset of symptoms
Note patient’s PCP and primary
neurologist
Notify ED attending
Notify Stroke Neurologist
Obtain vital signs
Ask the family medical history from patient
or family:
Acute Stroke Nursing Protocol
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Recent trauma, dates
Recent surgery, dates
Recent procedure, dates
Prior stroke/TIA, dates
HTN; DM; CAD; AF
Bleeding disorder; coumadin use
Aspirin use ; GI, GU, or pulmonary hemorrhage
Migraine;
Metal fragments, or pacemaker
First Hour - after the patient arrives in the ER:
The ER Medical Officer should note the time of
arrival of the patient and:
 1.Inform CT scan room, Stroke Neurologist
immediately.
 2.ABC - Resuscitation if needed.
 3.Quick History/Examination to confirm the initial
suspicion of ABA.
 4.Phlebotomy -->Send blood for Complete Blood
Count, glucose, Creatinine, Urea, Electrolytes, PT,
PTT. Leave IV plug in.
 5.Check bedside glucose with a drop of blood from
the phlebotomy. Treat
Hypoglycemia (<70mg/dl) immediately.
First Hour - after the patient arrives in the ER:
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6.Optimum MAP is 130 mm of Hg. If BP is low, start IV
Normal Saline and if BP is high
( > 180/110 mm/Hg.), place a Nitrodisc (40 mg).
7.ECG - If ischemic changes are noted, request
Cardiac Enzymes in addition to other tests.Treat
arrhythmias if noted.
8.Check vital signs every 10 minutes.
9.Wheel patient to CT scan area.
10. Perform Transcranial Doppler at bedside,
Carotid/Vertebral /TC Doppler and ECHO Cardiogram
in Vascular lab.
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Start collecting the result of investigations.
Transcranial Doppler in AIS
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Can help identify intracranial vascular disease
Useful to guide and monitor acute therapy
Useful for monitoring for emboli, and based on
location of MES (microembolic signals, nHITS), can
differentiate between cardioembolic, large artery,
medium vessel sources for stroke
TCD performed 6 hours after stroke onset, if normal
was predictive of early improvement, and if abnormal
was predictive of early deterioration.
TCD in Acute Stroke
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MES have been detected distal to intracranial
arterial occlusions, and when found in high
numbers appear to herald the break-up of the
thrombus.
Some experimental evidence suggests that
ultrasound (although at frequencies lower than
those used for TCD imaging) may enhance
thrombolysis of intra-arterial thrombi.
Microembolic Signals (HITS)
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High intensity
Transient
Unidirectional
Occur randomly in cardiac cycle
Characteristic chirping sound
MES have particular characteristics that
distinguish them from the waveform,
background, and artifacts that move across the
monitoring screen.
Sonothrombolysis(TCD monitoring with i.v. tPA)
TCD and Neuroimaging Data
Pre-Sonothrombolysis
49 yo presented
with Rt. Sided
Hemiplegia/
Dysphasia since
90 min.
Post-Sonothrombolysis
Acute Brain Attack Team
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The radiology technician should make
him/herself available immediately.
Should perform a non-contrast CT scan of the
Brain as the ‘next case’ and the films should be
printed out as soon as possible.
The stroke Neurologist should make him/herself
available with the first call and arrive in the ER
as soon as the patient gets there.
NCCT pre and post t-PA
CT Angiogram
Acute Brain Attack Team
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First Hour:
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The Stroke Neurologist would evaluate the clinical picture of the
patient, review the CT Head and the results of the
investigations.
If the patient turns out to have an intracerebral or subarachnoid
bleed, follow appropriate protocol.
If the patient has an infarct, a decision needs to be made if rTPA could be safely used in the patient.
The pharmacy needs to be alerted immediately once a decision is
made to use r-TPA
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Acute Brain Attack Team
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Intravenous r-TPA would be administered in the ER,
only after getting an informed consent and under the
direct supervision of the Neurologist.
The patient should be on ECG monitor and vital signs
should be checked every 10 minutes during the r-TPA
infusion.
The patient would be moved to the Acute Stroke Unit.
Second Hour:
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The Stroke Neurologist would evaluate the clinical
picture of the patient, review the CT Head and the
results of the investigations.
If the patient turns out to have an intracerebral or
subarachnoid bleed, follow appropriate protocol.
If the patient has an infarct, a decision needs to be
made if r-TPA could be safely used in the patient.
The pharmacy needs to be alerted immediately once a
decision is made to use r-TPA
TPA
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Intravenous r-TPA would be administered in
the ER, only after getting an informed consent
and under the direct supervision of the
Neurologist.
The patient should be on ECG monitor and vital
signs should be checked every 10 minutes
during the r-TPA infusion.
The patient would be moved to the Acute Stroke
Unit.
Exclusion Criteria for Thrombolytic
Therapy:
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Absolute:
1. CT or MRI evidence of hemorrhage
2. Complete resolution of symptoms
Relative:
1. CT changes > one-third of MCA territory
2. Hypertension (systolic > 185, diastolic > 110) that remains
unresponsive to antihyperstensive management .
3. History of GU or GI bleeding within three (3) weeks
4. History of CPR, extensive trauma, or surgery within 2 weeks
5. History of stroke within two (2) weeks
6. PT > 15, platelets < 100,000, INR > 1.7
7. LP or non-compressible arterial puncture within one week
8. History of seizure at time of onset
Clinical Cautions
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1. Clinical presentation suggestive of SAH,
even if CT is negative
2. Age > 80
3. Active pericarditis or pericardial infusion
4. Glucose < 50 or > 400
5. NIH Stroke Scale > 22
6. Rapidly improving symptoms
IV rt-PA reconstitution & Dosing
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Dose: 0.9 mg/Kg ( Maximum: 90 mg.)
10% bolus, rest as an infusion over 1 hour.
Intravenous/Intra-Arterial
Therapy:
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Consider for the following patients:
Patients with suspected large vessel occlusive
disease(carotid terminus, basilar artery, M1,
proximal M2)
Patients with a diffusion-perfusion mismatch on
MR
Patients being transferred from other institutions
Consent for IV/IA therapy should be obtained at
the institution initiating IV therapy.
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TIBI (Thrombolysis in Brain Ischemia)
Grade 0: Absent - absent flow signals are defined by
the lack of regular pulsatile flow signals despite
varying degrees of background noise.
Grade 1: Minimal - systolic spikes of variable velocity
and duration; absent diastolic flow during all cardiac
cycles based on a visual interpretation of periods of no
flow during end diastole(reverberating flow is a type of
minimal flow).
Grade 2: Blunted - flattened systolic flow acceleration of
variable duration compared to control; positive end
diastolic velocity and PI < 1.2.
TIBI (Thrombolysis in Brain Ischemia)
Grade 3: Dampened - normal systolic flow acceleration;
positive end-diastolic velocity; decreased MFVs by
>30% compared to control.
Grade 4: Stenotic - MFV >80 cm/s and velocity
difference >30% compared to control or; if both
affected and comparison sides have MFV <80 cm/s
due to low end-diastolic velocities, MFV >30%
compared to the control side and signs of turbulence.
Grade 5: Normal - <30% MFV difference compared to
control; similar waveform shapes compared to
controls.
Carotid Doppler
Flow Velocity Criteria
Peak Systolic Velocity
(cm/sec)
< 140
> 140
>> 140
Variable Velocities
No detectable flow
Diastolic Velocity
(cm/sec)
< 40
< 110
> 110
Variable
N/A
ICA/CCA
% Diameter
Ratio Stenosis
<2
< 50%
>2
50-75%
>3
75-95%
Variable
95-99%
(Subtotal occlusion)
N/A
Probable occlusion
Onset 3-6 hours: Intra-Arterial Thrombolysis
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ACT:
Baseline, 1 hour, 2 hours
1. Administer 2000 units heparin IV bolus if
thrombus is identified angiographically.
2. Start maintenance infusion of heparin at 450
units/hour.
3. Position 2.3 French microcatheter just distal to
occlusion.
4. Infuse 2 mg TPA (2 mg/2 cc NS) over 4
minutes distal to thrombus.
5. Retract catheter into thrombus.
Onset 3-6 hours: Intra-Arterial Thrombolysis
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6. Infuse 2 mg TPA (2 mg/2 cc normal saline) over 4
minutes into thrombus.
7. Start maintenance infusion of 10 mg/hr TPA using
infusion pump.
8. Perform control angiogram every 15 minutes (or as
needed) after start of maintenance TPA infusion
(option to mechanically disrupt every 15 min.).
9. Perform neurological examination every 15
minutes to assess level of consciousness and upper
extremity motor function
10. Infuse maintenance dose for a maximum of 2
hours to a maximum time after onset of 8 hours.
11. Consider more aggressive mechanical disruption
(i.e., snare) if clot has not resolved after 1 hour.
12. Terminate infusion prior to 2 hours if complete
clot lysis is achieved.
13. Total IA TPA dose = 24 mg.
tPA Dosing chart
Weight (Lbs)Conv. to Kg) Total Dose t-PA Bolus t-PA Bolus Discard Dose Infusion dose Inf.rate
Kg
( mg)
(mg)
(ml)
( mg)
(mg)
(ml/hr)
220+
100.0
90.0
9.0
9.0
10.0
81.0
81.0
210
95.5
85.9
8.6
8.6
14.1
77.3
77.3
200
90.9
81.8
8.2
8.2
18.2
73.6
73.6
190
86.4
77.7
7.8
7.8
22.3
70.0
70.0
180
81.8
73.6
7.4
7.4
26.4
66.3
66.3
170
77.3
69.5
7.0
7.0
30.5
62.6
62.6
160
72.7
65.5
6.5
6.5
34.5
58.9
58.9
150
68.2
61.4
6.1
6.1
38.6
55.2
55.2
140
63.6
57.3
5.7
5.7
42.7
51.5
51.5
130
59.1
53.2
5.3
5.3
46.8
47.9
47.9
120
54.5
49.1
4.9
4.9
50.9
44.2
44.2
110
50.0
45.0
4.5
4.5
55.0
40.5
40.5
100
45.5
40.9
4.1
4.1
59.1
36.8
36.8
Procedure consent form
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----------Hospitals, Chennai.
Patient’s name :
Unit No. :
Procedure:
I have explained to the patient / family / guardian the nature of the patient’s condition,
the nature of the procedure, the benefits to be reasonably expected compared with
alternative approaches. I have discussed the likelihood of major risks or
complications of this procedure including (if applicable) but not limited to loss of limb
function, brain damage, paralysis, hemorrhage, infection, complications from
transfusion of blood components, drug reactions, blood clots, and loss of life. I have
also indicated that with any procedure there is always the possibility of an unexpected
complication.
Dr.
has explained to me (or my family member) why
they believe a stroke is happening and which of the available methods would be most
likely to improve my condition. They have explained the risks and benefits of the
drugs and techniques available to dissolve blood clots in the brain and possible
alternative treatments. They have recommended use of the INTRAVENOUS DRUG,
recombinant Tissue Plasminogen Activator (clot – dissolver) to dissolve the blood
clot.
INTRAVENOUS THROMBOLYSIS:
Procedure consent ( contd.)
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The risks include: 1. Death, Stroke or permanent neurologic injury (paralysis,
coma,etc) 2. Worsening of stroke symptoms from swelling or bleeding in the brain 3.
Bleeding in other parts of the body 4. Need for blood transfusions to replace blood or
clotting factors 5. Other unexpected complications.
All questions were answered and the patient / family / guardian consents to the
procedure.
(Physician’s Signature)
Date :
Dr.
has explained the above to me and I consent to the
procedure. I understand that APOLLO HOSPITALS is an academic medical center
and that residents, registrars, fellows and students in medical and allied disciplines
may participate in this procedure. In addition, I understand that tissue, blood or other
specimens removed for necessary diagnostic or therapeutic reasons may
subsequently be used by the Hospital or members of its professional staff for
research or educational purposes.
( patient’s / family’s / guardian’s signature)
Symptomatic hemorrhage after t-PA
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STAT head CT, if ICH suspected
Consult Neurosurgery for ICH
Check CBC, PT, PTT, platelets, fibrinogen and D-dimer.
Repeat q 2 h until bleeding is controlled
Give FFP 2 units every 6 hours for 24 hours after dose
Give cryoprecipitate 20 units. If fibrinogen level < 200 mg/dL at
1 hr, repeat cryoprecipitate dose.
Give platelets 4 units
Give protamine sulfate 1 mg/100 U heparin received in last 3
hours (give inital 10 mg test dose. Maximum dose :50 mg)
Institute frequent neurochecks and therapy of acutely elevated
ICP, as needed
May give aminocaproic acid (Amicar) 5 g in 250 cc NS IV over
1 hr as a last resort.
NIH Stroke Scale
The NINDS t-PA Stroke Trial No. ___
 Pt. Date of Birth ___ ___/___ ___/___ ___
 Date of Exam ___ ___/___ ___/___ ___
 Intervals :
1[ ] Baseline
2[ ] 2 hours post treatment
3[ ] 24 hours post onset of symptoms ±20 mins.
4[ ] 7-10 days
5[ ] 3 months
6[ ] Other
Total Score : 42
1a. Level of
Consciousness
1b. LOC Questions
1c. LOC Commands
2. Best Gaze
3. Best Visual
4. Facial Palsy
5. Best Arm
Movement
6. Other Arm
7. Best Motor Leg
8. Other Leg
9. Limb Ataxia
10. Sensory
11. Neglect
12. Dysarthria
13. Best Language
14.
Change from
Previous Exam
Alert
Drowsy
Stuporous
Coma
Answers both correctly
Answers one correctly
Incorrect
Obeys both correctly
Obeys one correctly
Incorrect
Normal
Partial gaze palsy
Forced deviation
No visual loss
Partial hemianopia
Complete hemianopia
Bilateral hemianopia
Normal
Minor
Partial
Complete
No drift
Drift
Can’t resist gravity
No effort against gravity
No movement
For brainstem stroke
use same scale as
No
drift
above
Drift
Can’t resist gravity
No effort against gravity
No movement
For brainstem stroke
use same scale as
Absent
above
Present in upper or
lower
Present in both
Normal
Partial loss
Dense loss
No neglect
Partial neglect
Complete neglect
Normal articulation
Mild to moderate
dysarthria
Near
unintelligible or
worse
No
aphasia
Mild to moderate
aphasiaaphasia
Severe
Mute
Same
Better
Worse
0
1
2
3
0
1
2
0
1
2
0
1
2
0
1
2
3
0
1
2
3
0
1
2
3
4
0-4
0
1
2
3
4
0-4
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
3
S
B
W
Baseli
ne
30
Min.
1 hr
2 hr
24 hr
48 hr
7-10
days
Modified Rankin Scale
Patient Name: RANKIN Rater Name:
SCALE (MRS) Date: __
Score Description
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0 No symptoms at all
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1 No significant disability despite symptoms; able to carry out all usual duties
and activities
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2 Slight disability; unable to carry out all previous activities, but able to look after
own affairs without assistance
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3 Moderate disability; requiring some help, but able to walk without assistance
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4 Moderately severe disability; unable to walk without assistance and unable to
attend to own bodily needs without assistance
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5 Severe disability; bedridden, incontinent and requiring constant nursing care
and attention
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6 Dead
TOTAL (0–6): _______
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References

Rankin J. “Cerebral vascular accidents in patients over the age of 60.”
Scott Med J 1957;2:200-15

Bonita R, Beaglehole R. “Modification of Rankin Scale: Recovery of motor
function after stroke.”

Stroke 1988 Dec;19(12):1497-1500
Barthel Index
First day:
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Transcranial doppler repeated after 6 hours if
abnormal earlier.
Repeat CT Scan if I.V. r-TPA has been used.
Continuous ECG monitor. Hourly vital signs and
neurological status examination.
Swallowing/nutrition status assessed and treated
appropriately.
DVT prophylaxis instituted.
Physiotherapy/ Speech therapy started, if
condition is stable.
Acute Brain Attack Team


Second day:
Continue medical management and monitoring.
Ensure that detailed case evaluation notes,
NIHSS, mRS and Barthel Index are
documented.
Standard treatment with Alteplase to
Reverse Stroke ( STARS) study
No.
Mean age(yrs.)
Time to treatment(%)
0-90 mins.
91-180 mins.
180 - 270 mins.
Median time from stroke
onset to tPA Rx.
Median time from ER
arrival to tPA Rx.
STARS
389
69
CVRF
174
60.3(23-78)
4.2
82.3
13.5
21.40
75.00
3.60
2 h 44 m
2h,22m
1 h 36m
1h28m
Standard treatment with Alteplase to
Reverse Stroke ( STARS) study
Baseline NIHSS Score
Mean
Symptomatic ICH(%)
Asymptomaic ICH(%)
Outcome at 30 days(%)
MRSS 0-1
MRSS 0-2
Mortality rate
STARS
CVRF
14
3.3
8.2
12
10.71
7.14
35
43
13
53.57
39.28
2.34
STROKE package



Costs about Rs. 8 – 17000/- for investigations.
The cost of 50 mg of r-TPA is around
Rs.44,000/-( 0.9 mg/Kg. Body wt.).
The cost for stay in the Hospital for 1 week will
depend on the type of room and will be around
Rs. 5,000 to Rs.20,000.