Management of Stroke-Mei2012

MANAGEMENT OF MANAGEMENT OF STROKESTROKE

Abdul GofirAbdul GofirNeurology Department of Neurology Department of Medical Faculty Medical Faculty Gadjah Mada UniversityGadjah Mada University

Stroke: DefinitionStroke: Definition

Stroke is clinically defined as a Stroke is clinically defined as a neurologic syndrome characterized neurologic syndrome characterized by acute disruption of blood flow to by acute disruption of blood flow to an area of the brain and an area of the brain and corresponding onset of neurologic corresponding onset of neurologic deficits related to the concerned deficits related to the concerned area of the brainarea of the brain

Nurs Clin N Am 2002;37:35-57

Causes of StrokeCauses of Stroke

1

Definition of Ischemic StrokeDefinition of Ischemic Stroke

Almost 80% of Almost 80% of strokes are from strokes are from an emboli or a an emboli or a thrombusthrombus

Embolic & Embolic & Thrombotic Thrombotic strokes are strokes are ISCHEMICISCHEMIC

< 15% of strokes < 15% of strokes are from are from hemorrhage, with hemorrhage, with an even smaller an even smaller percentage percentage caused by caused by hypoperfusionhypoperfusion

Dr.J.Husada 11-2003

Apoptotic Cell Death

NecroticCell Death

Ischemic Injury

Aterosclerotic is a normal response to arterial endotel injuryAterosclerotic plaque forming, start in youngClinical manifestation : acute and tent to occur one time because sudden plaque rupture

1. Vascular : Aterosclerotic process2. Biochemistry change /cellular

chemist

2 process in ischemic stroke:2 process in ischemic stroke:

Causes of Ischaemic STROKE

Blockade of blood flow by ateroma, emboli, and ateroscelerotic

EmbolicEmbolic Once in your Once in your

brain, the brain, the embolus embolus eventually travels eventually travels to a blood vessel to a blood vessel small enough to small enough to block its passageblock its passage

The embolus The embolus lodges there, lodges there, blocking the blocking the blood vessel and blood vessel and causing a strokecausing a stroke

Adapted from Goldstein, et al. Circulation 2001;103:163-182.

68% (warfarin)68% (warfarin)21% (aspirin)21% (aspirin)

Atrial Atrial fibrillation fibrillation

(non-valvular)(non-valvular)

20-30% with statins in patients 20-30% with statins in patients with known coronary heart diseasewith known coronary heart disease

HyperlipidemiaHyperlipidemia

44% reduction in hypertensive 44% reduction in hypertensive diabetics with tight blood pressurediabetics with tight blood pressure controlcontrol

DiabetesDiabetes

50% within 1 year, baseline 50% within 1 year, baseline after 5 yearsafter 5 years

SmokingSmoking

30% - 40%30% - 40%HypertensHypertensionion

Risk reduction with Risk reduction with treatmenttreatment

FactorFactor

Potential Stroke Risk Reduction for IndividualsPotential Stroke Risk Reduction for IndividualsAHA GuidelinesAHA Guidelines

Stroke: ClassificationStroke: ClassificationIschemic strokeIschemic stroke : Account for 80%. Results from : Account for 80%. Results from

occlusion in the blood vessel supplying the brainocclusion in the blood vessel supplying the brain– ThromboticThrombotic: Occlusion due to atherothrombosis : Occlusion due to atherothrombosis

of small/large vessels supplying the brainof small/large vessels supplying the brain– EmbolicEmbolic: Occlusion due to embolus arising : Occlusion due to embolus arising

either from heart (e.g. atrial fibrillation, valvular either from heart (e.g. atrial fibrillation, valvular disease) or blood vesseldisease) or blood vessel

Classification (cont.)Classification (cont.)

Hemorrhagic strokeHemorrhagic stroke: Account for 20%. Results from : Account for 20%. Results from rupture of blood vessels leading to bleeding in brainrupture of blood vessels leading to bleeding in brain

– Intracerebral: Intracerebral: Bleeding within the brain due to Bleeding within the brain due to rupture of small blood vessels. Occurs mainly due rupture of small blood vessels. Occurs mainly due to high blood pressureto high blood pressure

– Subarachnoid: Subarachnoid: Bleeding around the brain; Bleeding around the brain; commonest cause is rupture of aneurysm. Other commonest cause is rupture of aneurysm. Other causes: Head injurycauses: Head injury

Stroke: Predisposing factorsStroke: Predisposing factors Age (risk doubles for Age (risk doubles for

every decade > age 55)every decade > age 55) Gender (males>females)Gender (males>females) Family history of Family history of

stroke/TIAstroke/TIA HypertensionHypertension DiabetesDiabetes HyperlipidemiaHyperlipidemia HyperhomocysteinemiaHyperhomocysteinemia

ObesityObesity SmokingSmoking Atrial fibrillationAtrial fibrillation Sedentary lifestyleSedentary lifestyle Drug abuse (e.g. Drug abuse (e.g.

cocaine use)cocaine use) Hormone replacement Hormone replacement

therapytherapy Oral contraceptiveOral contraceptive

Risk Factors for StrokeRisk Factors for Stroke

Non-Modifiable Risk Factors for Stroke• Age • Sex • Race/ethnicity • Family history

Modifiable Risk Modifiable Risk Factors for StrokeFactors for Stroke6

HypertensionHypertensionDiabetesDiabetesSmokingSmokingHyperlipidemiaHyperlipidemiaCarotid stenosisCarotid stenosisAtrial fibrillationAtrial fibrillation

Stroke: SymptomsStroke: Symptoms

Onset of stroke symptoms Onset of stroke symptoms varies as per type of stroke:varies as per type of stroke:– Thrombotic strokeThrombotic stroke: Develop : Develop

more graduallymore gradually– Embolic strokeEmbolic stroke: Hits suddenly: Hits suddenly– Hemorrhagic strokeHemorrhagic stroke: Hits : Hits

suddenly and continues to suddenly and continues to worsenworsen

Stroke: Symptoms Stroke: Symptoms (cont.)(cont.)

DizzinessDizziness Confusion Confusion Loss of balance/coordinationLoss of balance/coordination Nausea/vomitingNausea/vomiting Numbness/weakness on one side of the bodyNumbness/weakness on one side of the body SeizureSeizure Severe headacheSevere headache Movement disorder/speech disorder/blindness etc Movement disorder/speech disorder/blindness etc

(depending on the area of brain affected)(depending on the area of brain affected)

Symptom and SignSymptom and Sign

Consider stroke in any patient presenting with acuteConsider stroke in any patient presenting with acuteneurological deficit or any alteration in level ofneurological deficit or any alteration in level ofconsciousness.consciousness.Common signs of stroke include the following:Common signs of stroke include the following: Acute hemiparesis or hemiplegia Acute hemiparesis or hemiplegia Complete or partial hemianopia, monocular or Complete or partial hemianopia, monocular or

binocular visual loss, or diplopia binocular visual loss, or diplopia Dysarthria or aphasia Dysarthria or aphasia Ataxia, vertigo, or nystagmus Ataxia, vertigo, or nystagmus Sudden decrease in consciousnessSudden decrease in consciousness

Transient Ischemic Attack (TIA)Transient Ischemic Attack (TIA)

““Mini stroke”Mini stroke” Stroke symptoms last for less than 24 hours Stroke symptoms last for less than 24 hours

(usually 10 to 15 mins)(usually 10 to 15 mins) Result as a brief interruption in blood flow to Result as a brief interruption in blood flow to

brainbrain Every TIA is an emergencyEvery TIA is an emergency TIA may be a warning sign of a larger strokeTIA may be a warning sign of a larger stroke Patients with possible TIA should be evaluated Patients with possible TIA should be evaluated

by a physicianby a physician

Diagnosis of acute ischemic Diagnosis of acute ischemic strokestroke

Physical examinationPhysical examination & Neurological Examination & Neurological Examination Brain imaging (cranial CT and/or MRI): Detect small Brain imaging (cranial CT and/or MRI): Detect small

vessel disease. Helps to effectively discriminate vessel disease. Helps to effectively discriminate between ischemic and hemorrhagic stroke, and between ischemic and hemorrhagic stroke, and stroke from brain tumoursstroke from brain tumours

Doppler ultrasonography/Angiography: Detect large Doppler ultrasonography/Angiography: Detect large vessel atherosclerosisvessel atherosclerosis

ECG/Echocardiography: Detect cardiac embolismECG/Echocardiography: Detect cardiac embolism Exclusion of conditions mimicking stroke Exclusion of conditions mimicking stroke

(hypoglycemia, migraine, seizure)(hypoglycemia, migraine, seizure)

Ischemic stroke diagnostic Ischemic stroke diagnostic algorithmalgorithm

Acute focal brain deficit

Head CT

Ischemic Stroke

ECGEcho

CARDIACEMBOLISM

LARGE ARTERYATHEROSCLEROSIS

SMALLVESSEL DISEASE

OTHER DETERMINEDCAUSE

DopplerMRAAngiogram

MRICT

VasculopathyCoagulopathy

CRYPTOGENICSTROKE

Excluded hypoglycemia, migraine

with aura, post-seizure deficit

TIA (if CT/MR brain imagingwithout ischemic lesion)

< 1 hour

Lacunar syndromeCortical syndrome

Acute Acute TreatmentTreatment

T-PAT-PA

If a 3-hour window of treatment can If a 3-hour window of treatment can be met, thrombolytic therapy with be met, thrombolytic therapy with intravenous t-PA can be beneficial for intravenous t-PA can be beneficial for each of the major categories of each of the major categories of ischemic stroke: ischemic stroke: atherothrombotic/atheroembolic, atherothrombotic/atheroembolic, cardioembolic, and small vessel cardioembolic, and small vessel occlusive (lacunar) strokeocclusive (lacunar) stroke

t-PA Protocolt-PA Protocol

.9 mg/Kg, 10% as bolus of t-PA, 90% .9 mg/Kg, 10% as bolus of t-PA, 90% over 60 minutesover 60 minutes

no anticoags or antiplatelet agents no anticoags or antiplatelet agents for 24 hrsfor 24 hrs

maintain bp in normal rangemaintain bp in normal range repeat CT in 24 hours and stop if ICH repeat CT in 24 hours and stop if ICH

suspectedsuspected

T-PA After Three Hours

1 Not proven Beneficial

2 European Cooperative Acute Stroke Study (ECASS): no benefit of later treatment

3 Patients with CT evidence infarction of more than one third of the territory of MCA had

excess risk of hemorrhagic stroke and death when treated with a higher dose of t-PA

Heparin for Cardioembolic Heparin for Cardioembolic Stroke:Stroke:

Stroke recurrence is low, much less Stroke recurrence is low, much less than 1%/day in first 2 weeksthan 1%/day in first 2 weeks

Large stroke: wait 48-72 hours and Large stroke: wait 48-72 hours and repeat CTrepeat CT

Small stroke: use judgmentSmall stroke: use judgment

Heparin

There is no large clinical trial in the literature comparing i.v. heparin as

traditionally administered to placebo

International Stroke Trial: compared s.q. heparin at comparable doses to asa and neither in 19435 patients: result: heparin

was not beneficialLancet. 1997;349:1569-81

Heparinoids

TOAST trial: indicated no benefit for a LMW heparinoid in stroke (ORG 10172)

Stroke. 1998;29:286

Management of acute Management of acute ischemic strokeischemic stroke

Systemic thrombolysisSystemic thrombolysis: Intravenous : Intravenous recombinant tissue plasminogen activator recombinant tissue plasminogen activator (rt-PA): Within 3 hrs of onset of stroke. (rt-PA): Within 3 hrs of onset of stroke. Dose 0.9 mg/kg, max 90 mg.Dose 0.9 mg/kg, max 90 mg.

Antiplatelet agentsAntiplatelet agents: Aspirin 160-300 mg : Aspirin 160-300 mg within 24- 48 hrs (not during first 24 hrs within 24- 48 hrs (not during first 24 hrs following thrombolytic therapy). following thrombolytic therapy). Clopidogrel a potential alternative. Clopidogrel a potential alternative. Combination of clopidogrel and aspirin Combination of clopidogrel and aspirin currently being evaluatedcurrently being evaluated

Management of acute Management of acute ischemic stroke (contd.)ischemic stroke (contd.)

AnticoagulantsAnticoagulants: Heparin/LMWH are not : Heparin/LMWH are not recommended in acute treatment of recommended in acute treatment of ischemic stroke. ischemic stroke. Recommended in setting Recommended in setting of of atrial fibrillationatrial fibrillation, acute MI risk, , acute MI risk, prosthetic valves, coagulopathies and prosthetic valves, coagulopathies and for prevention of DVTfor prevention of DVT. .

Intra-arterial thrombolyticsIntra-arterial thrombolytics: An option : An option for treatment of selected patients with for treatment of selected patients with major stroke of < 6 hrs duration due to large major stroke of < 6 hrs duration due to large vessel occlusion. vessel occlusion.

Emergency Medical Care for Neurologic Emergencies

• Provide reassurance.• Ensure proper airway and breathing.• Place the patient in a position of comfort.• If you suspect stroke, transport immediately and

notify hospital.• Assess and care for any injuries if you suspect any

type of trauma.

Management of acute Management of acute ischemic stroke (contd.)ischemic stroke (contd.)

BP managementBP management: Should be kept within higher : Should be kept within higher normal limits since low BP could precipitate normal limits since low BP could precipitate perfusion failure. Markedly elevated BP perfusion failure. Markedly elevated BP (>220/110mmHg) managed with nitroglycerin, (>220/110mmHg) managed with nitroglycerin, clonidine, labetalol, sodium nitroprusside. More clonidine, labetalol, sodium nitroprusside. More aggressive approach is taken if thrombolytic aggressive approach is taken if thrombolytic therapy is institutedtherapy is instituted

Blood glucose managementBlood glucose management: Should be kept : Should be kept within physiological levels using oral or IV within physiological levels using oral or IV glucose (in case of hypoglycemia)/insulin (in glucose (in case of hypoglycemia)/insulin (in case of hyperglycemia)case of hyperglycemia)

Elevated body temperature managementElevated body temperature management: : Antipyretics and use of cooling device can Antipyretics and use of cooling device can improve the prognosisimprove the prognosis

UPDATE ON MANAGEMENT OF UPDATE ON MANAGEMENT OF ICH ICH (Pouratian 2003)(Pouratian 2003)

Medical interventionsMedical interventions- Cardiopulmonary optimization - Cardiopulmonary optimization

(ABCSS)(ABCSS)

- Blood pressure control- Blood pressure control

- ICP reduction- ICP reduction

- - UltraUltra--early hemostatic therapyearly hemostatic therapy

Surgical interventionsSurgical interventions

MEDICAL MANAGEMENT OF ICH MEDICAL MANAGEMENT OF ICH (Pouratian 2003)(Pouratian 2003)

Cardiopulmonary optimization ( Airway, Breathing, Cardiopulmonary optimization ( Airway, Breathing, CirculationCirculation,skin, seizures,skin, seizures))

Reversing coagulation defects (coagulopathies and platelet Reversing coagulation defects (coagulopathies and platelet disorders)disorders)

Blood pressure control (Labetolol & nicardipine IV, Blood pressure control (Labetolol & nicardipine IV, nitroprusside not often usednitroprusside not often used brain edema). brain edema).

ICP reduction:ICP reduction: - Ventriculostomy as therapeutic means of reducing ICP- Ventriculostomy as therapeutic means of reducing ICP - Head-of-bed elevated at 30- Head-of-bed elevated at 3000, patient’s neck in neutral , patient’s neck in neutral

position position maxmaximize imize venous outflow.venous outflow. - Minimize agitation: sedatives- Minimize agitation: sedatives - Hyperosmolar fluids (mannitol, hypertonic saline)- Hyperosmolar fluids (mannitol, hypertonic saline) - Hyperventilation used only as temporary measures- Hyperventilation used only as temporary measures - Barbiturate-induced coma : rarely- Barbiturate-induced coma : rarely - Vasogenic edema with mass effect: corticosteroids - Vasogenic edema with mass effect: corticosteroids

(controversial)(controversial) Ultra-early hemostatic therapy:Ultra-early hemostatic therapy: - Antifibrinolytic tranexamic acid, aprotinin, activated - Antifibrinolytic tranexamic acid, aprotinin, activated

recombinantrecombinant factorfactor VIIVII (rFVIIa)(rFVIIa)

BLOOD PRESSURE MANAGEMENT IN ICHBLOOD PRESSURE MANAGEMENT IN ICH (Broderick 1999)(Broderick 1999)

- If SBP > 230 mm Hg or DBP >- If SBP > 230 mm Hg or DBP > 140 mm Hg on 2 140 mm Hg on 2 readings 5 minutes apart readings 5 minutes apart nitroprusside 0.5-10 nitroprusside 0.5-10 g/kg/min.g/kg/min.

- - If SBP is 180-230 mm Hg, DBP 105-140 mm Hg, or If SBP is 180-230 mm Hg, DBP 105-140 mm Hg, or mean arterial BP mean arterial BP 130 130 mm Hgmm Hg on 2 readings 20 on 2 readings 20 minutes apart minutes apart labetolol, esmolol, enalapril, or labetolol, esmolol, enalapril, or other smaller doses other smaller doses of titrabble IV medications of titrabble IV medications eg diltiazem, lisinopril, or verapamil.eg diltiazem, lisinopril, or verapamil.

- If SBP is < 180 mm Hg and DBP < 105 mm Hg, - If SBP is < 180 mm Hg and DBP < 105 mm Hg, defer antihypertensive therapy.defer antihypertensive therapy.

- - If ICP monitoring is available, cerebral perfusion If ICP monitoring is available, cerebral perfusion pressure should be kept at pressure should be kept at > 70 mm Hg. > 70 mm Hg.

Labetolol: 5-100 mg/h by intermittent bolus doses of 10-40 mg or continuous drip (2-Labetolol: 5-100 mg/h by intermittent bolus doses of 10-40 mg or continuous drip (2-8 mg/min).8 mg/min).

Esmolol: 500 Esmolol: 500 g/kg as a load, maintenance use, 50-200 g/kg as a load, maintenance use, 50-200 g/kg/min.g/kg/min. Hydralazine: 10-20 mg Q 4-6 hHydralazine: 10-20 mg Q 4-6 h Enalapril: 0.625-1.2 mg Q 6 h as needed.Enalapril: 0.625-1.2 mg Q 6 h as needed.

Management of Acute Management of Acute hemorrhagic strokehemorrhagic stroke

Analgesics/AntianxietyAnalgesics/Antianxiety agentsagents: To relieve : To relieve headache. Analgesics having sedative headache. Analgesics having sedative properties are beneficial for patients having properties are beneficial for patients having sustained trauma (e.g. morphine sulphate)sustained trauma (e.g. morphine sulphate)

AntihypertensivesAntihypertensives:(e.g. sodium :(e.g. sodium nitroprusside, labetolol) nitroprusside, labetolol)

HyperosmoticHyperosmotic agentsagents (e.g. mannitol, (e.g. mannitol, glycerol, furosemide): To reduce cerebral glycerol, furosemide): To reduce cerebral edema, and raised intracranial pressure.edema, and raised intracranial pressure.

Adequate hydration is necessaryAdequate hydration is necessary Surgical intervention may occasionally Surgical intervention may occasionally

be life savingbe life saving

RECOMMENDATIONS FOR RECOMMENDATIONS FOR SURGICAL TREATMENT OF ICH SURGICAL TREATMENT OF ICH

(Broderick 1999)(Broderick 1999)NON SURGICAL CANDIDATESNON SURGICAL CANDIDATES1. Small hemorrhages (<10 cm3) or minimal 1. Small hemorrhages (<10 cm3) or minimal

neurological deficits.neurological deficits.2. GCS score 2. GCS score 4. Except for cerebellar hemorrhage 4. Except for cerebellar hemorrhage

with brainstem compression for livesaving surgery.with brainstem compression for livesaving surgery.

SURGICAL CANDIDATESSURGICAL CANDIDATES1. Cerebellar hemorrhage > 3 cm who are 1. Cerebellar hemorrhage > 3 cm who are

neurologically deteriorating or who have brainstem neurologically deteriorating or who have brainstem compression and hydrocepahalus from ventricular compression and hydrocepahalus from ventricular obstruction.obstruction.

2. ICH with structural lesion eg aneurysm, AVM, or 2. ICH with structural lesion eg aneurysm, AVM, or cavernous angioma.cavernous angioma.

3. Young patients with a moderate or large lobar 3. Young patients with a moderate or large lobar hemorrhage who are clinicallyhemorrhage who are clinically deteriorating. deteriorating.

PREDICTORS OF EARLY PREDICTORS OF EARLY NEUROLOGICNEUROLOGIC

DETERIORATION IN ICH (Leira DETERIORATION IN ICH (Leira 2004)2004)

Early neurologic deterioration (END) occurred in 22.9 % patients.Early neurologic deterioration (END) occurred in 22.9 % patients.

On admission:On admission:Body temperature > 37.5Body temperature > 37.5º C (37.3 ± 0.7 vs 36.4 ± 0.5)º C (37.3 ± 0.7 vs 36.4 ± 0.5)

Neutrophil count by 1000-unit increase (10.8 ± 2.9 vs 6.3 ± 4.3)Neutrophil count by 1000-unit increase (10.8 ± 2.9 vs 6.3 ± 4.3)

Serum fibrinogen > 525 mg/dL (546 ± 126 vs 396 ± 119)Serum fibrinogen > 525 mg/dL (546 ± 126 vs 396 ± 119)

Within 48 hours:Within 48 hours:Early ICH growth (48.2 vs 20.7)Early ICH growth (48.2 vs 20.7)

Intraventricular bleeding (46.4 vs 29.5)Intraventricular bleeding (46.4 vs 29.5)

High systolic blood pressure (192 ± 21 vs 179 ± 27)High systolic blood pressure (192 ± 21 vs 179 ± 27)

Source : Neurology 2004; 63: 461-467

POOR OUTCOME IN ICHPOOR OUTCOME IN ICH

Pouratian 2003Pouratian 2003

Volume of the hematomaVolume of the hematoma ( (≥ 30 cc)≥ 30 cc)

Neurologic status (GCS scoreNeurologic status (GCS score ≤ 8≤ 8))

Intraventricular extension of the clotIntraventricular extension of the clot

HydrocephalusHydrocephalus

Subarachnoid extensionSubarachnoid extension

Anticoagulation agentsAnticoagulation agents

Relative edema Relative edema

Davis WSC 2004Davis WSC 2004

● ● Infratentorial lesionInfratentorial lesion

● ● Coronary heart diseaseCoronary heart disease

● ● HyperthermiaHyperthermia

Management of TIAManagement of TIA

Evaluation within hours after onset Evaluation within hours after onset of symptomsof symptoms

CT scan is necessary in all patientsCT scan is necessary in all patients Antiplatelet therapy with aspirin Antiplatelet therapy with aspirin

(50-325 mg/d), consider use of (50-325 mg/d), consider use of clopidogrel, ticlopidine, or aspirin-clopidogrel, ticlopidine, or aspirin-dipyridamole in patients who are dipyridamole in patients who are intolerant to aspirin or those who intolerant to aspirin or those who experience TIA despite aspirin useexperience TIA despite aspirin use

Hypertension/treatment

In general, antihypertensive drugs should be withheld unless the calculated mean blood pressure (the sum of the systolic pressure plus double the diastolic pressure, divided by three) is greater than 130 mm Hg or the systolic blood pressure is greater than 220 mm Hg

Elevated blood pressure usually declines spontaneously over the first 24 hours after stroke onset and overzealous use of a calcium antagonist and other antihypertensive drugs should be avoided because they can further reduce cerebral perfusion.

Antithypertensive Antithypertensive TreatmentTreatment

Indicated for:Indicated for:– aortic dissectionaortic dissection– acute myocardial infarctionacute myocardial infarction– heart failureheart failure– acute renal failureacute renal failure– hypertensive encephalopathyhypertensive encephalopathy– thrombolytic therapy thrombolytic therapy

When systolic pressure is 180 mm Hg or When systolic pressure is 180 mm Hg or higher or the diastolic pressure 105 mm higher or the diastolic pressure 105 mm Hg or higher. Hg or higher.

Blood Pressure and hemorrhage

Control of elevated blood pressure has never been shown to decrease the risk

of ongoing or recurrent bleeding in patients with intracerebral hemorrhage.

Recommend treatment of moderate and severe elevations of blood pressure

(systolic blood pressure of greater than 180 mm Hg or mean arterial pressure of

greater than 130 mm Hg).

GlucoseGlucose Elevated levels enhance neuronal Elevated levels enhance neuronal

injuryinjury Human studies >180 increases infarct Human studies >180 increases infarct

volumevolume Maintain levels betw 60 and 180Maintain levels betw 60 and 180

Blood Glucose

There is general agreement to recommend control of hypoglycemia or hyperglycemia after stroke (Levels of

Evidence III through V, Grade C).

Do not use D5W – free water and Incr glucose. Use 0.5 NS or NS i.v.

TemperatureTemperature Increase temp increases percentage Increase temp increases percentage

of poor outcome in strokeof poor outcome in stroke Increase cerebral oxygen/substrate Increase cerebral oxygen/substrate

consumptionconsumption– Lancet 1996:422Lancet 1996:422

Fever

There is general agreement to recommend treatment of the sources of fever and use of antipyretics to control

an elevated body temperature (Levels of Evidence III through V, Grade C). There

are insufficient clinical data about the use of hypothermia to recommend this

therapy.

Fever: Treatment

Treat any temperature elevations

Data is not in as to whether hypothermia may be protective

CEREBRAL EDEMA

Hypo-osmolar fluids, such as 5% dextrose in water, may worsen edema.

1/2NS or NS recommended

Mannitol

Mannitol (0.25 to 0.5 g/kg IV) given over 20 minutes rapidly lowers intracranial

pressure and can be given every 6 hours.57 The usual maximum daily dose

is 2 g/kg.57

MannitolMannitol Dose: - 25 to 50 g I.v. q 3-5 hrs.Dose: - 25 to 50 g I.v. q 3-5 hrs. Maximal dose of 2 g /KG/D. Maximal dose of 2 g /KG/D. Furosemide I.v. 20 to 80 mg q 4 to 12 Furosemide I.v. 20 to 80 mg q 4 to 12

hours to supplement mannitol.hours to supplement mannitol. Replacement fluids to maintain the Replacement fluids to maintain the

calculated serum osmolality at 300 to calculated serum osmolality at 300 to 320 mOsm per kilogram of water. 320 mOsm per kilogram of water.

Aspirin Plus Dipyridamole Versus Aspirin for Prevention of Vascular

Events After Stroke or TIA

Aspirin Plus Dipyridamole Versus Aspirin for Prevention of Vascular

Events After Stroke or TIA

The combination of aspirin plus dipyridamole is more effective than aspirin alone in preventing stroke and other serious vascular events in patients with minor stroke and TIAs. The risk reduction was greater and statistically significant for studies using primarily

extended release dipyridamole, which may reflect a true pharmacological effect or lack of statistical power in

studies using immediate release dipyridamole

The combination of aspirin plus dipyridamole is more effective than aspirin alone in preventing stroke and other serious vascular events in patients with minor stroke and TIAs. The risk reduction was greater and statistically significant for studies using primarily

extended release dipyridamole, which may reflect a true pharmacological effect or lack of statistical power in

studies using immediate release dipyridamole

This meta-analysis systematically reviewed randomized controlled trials comparing aspirin plus dipyridamole with aspirin alone in patients with stroke and TIA to determine the efficacy of these

agents in preventing recurrent cerebral and systemic vascular events

This meta-analysis systematically reviewed randomized controlled trials comparing aspirin plus dipyridamole with aspirin alone in patients with stroke and TIA to determine the efficacy of these

agents in preventing recurrent cerebral and systemic vascular events

Secondary prevention of Secondary prevention of strokestroke

Recurrence: Annual risk is 4.5 to 6%. Five Recurrence: Annual risk is 4.5 to 6%. Five year recurrence rates range from 24 to 42%; year recurrence rates range from 24 to 42%; one-third occur within first 30 days, hence one-third occur within first 30 days, hence high priority should be given to secondary high priority should be given to secondary prevention.prevention.

Patients with TIA or stroke have an increased Patients with TIA or stroke have an increased risk of MI or vascular event.risk of MI or vascular event.

Management of hypertension Management of hypertension (goal <140/85 (goal <140/85 mm Hg)mm Hg)

Diabetes control (goal<126 mg/dL)Diabetes control (goal<126 mg/dL)

Rehabilitation Rehabilitation Program: Program:

Physical therapy :Physical therapy : MobilizationMobilization WalkingWalking Major motor or sensory impairment of the Major motor or sensory impairment of the

limbslimbs Prescription of devices, such as a cane or Prescription of devices, such as a cane or

walkerwalker

Occupational Therapy :Occupational Therapy :• Fine movements of the handFine movements of the hand• Arm function Arm function • Utilization of toolsUtilization of tools• Assistive devicesAssistive devices• Ability to function independentlyAbility to function independently