Management &Complications of strokeMr.Abdulaziz R. AlanziMedical Student, Al-Imam UniversityRiyadh – Saudi Arabia
References UpToDate Electronic Medical Database Harrisons Principles of InternalMedicine Book,18e, Dan L. Longo,Anthony S. Fauci, Dennis L. Kasper,Stephen L. Hauser, J. Larry Jameson,Joseph Loscalzo, Eds.
Management: Acute Ischemic Strokefalls within six categories(1) Medical support: optimize cerebral perfusion in the surrounding ischemic penumbra(2) IV thrombolysis: recombinant tPA(3) Endovascular techniques: Intraarterial administration of a thrombolytic agent(4) Antithrombotic treatment: Platelet Inhibition & Anticoagulation(5) Neuroprotection: providing a treatment that prolongs the brains tolerance to ischemia(6) Stroke centers and rehabilitation
Management: Acute Ischemic Stroke Medical support:if blood pressure is >185/110 mm Hg –- B1-adrenergic blocker (esmolol)Fever –- antipyretics and surface coolingSerum glucose 6.1 mmol/L (110 mg/dL) –- insulin infusionCerebral Edema –- Water restriction and IV mannitolFeeding –- NGTSphincters –- Foleys Catheter
Management: Acute Ischemic Stroke IV thrombolysis:Administration of rtPAIntravenous access with two peripheral IV lines (avoid arterial or central lineplacement)Review eligibility for rtPAAdminister 0.9 mg/kg IV (maximum 90 mg) IV as 10% of total dose by bolus,followed by remainder of total dose over 1 hFrequent cuff blood pressure monitoringNo other antithrombotic treatment for 24 hFor decline in neurologic status or uncontrolled blood pressure, stop infusion,give cryoprecipitate, and reimage brain emergentlyAvoid urethral catheterization for 2 h
Management: Acute Ischemic Stroke Antithrombotic treatment:- Platelet inhibition: Aspirin is the only antiplatelet agent that has been proveneffective for the acute treatment of ischemic stroke; there are several antiplateletagents proven for the secondary prevention of stroke.- Anticoagulation: Trials generally have shown an excess risk of brain and systemichemorrhage with acute anticoagulation. Therefore, trials do not support the routineuse of heparin or other anticoagulants for patients with atherothrombotic stroke. Neuroprotection: Drugs that block the excitatory amino acid pathways havebeen shown to protect neurons and glia in animals. Hypothermia is a powerfulneuroprotective treatment in patients with cardiac arrest and is neuroprotectivein animal models of stroke, but it has not been adequately studied in patientswith ischemic stroke.
Management: Acute Ischemic Stroke Stroke centers and rehabilitation:Proper rehabilitation of the stroke patient includes early physical, occupational, andspeech therapy. It is directed toward educating the patient and family about thepatients neurologic deficit, preventing the complications of immobility (e.g.,pneumonia, DVT and pulmonary embolism, pressure sores of the skin, and musclecontractures).The goal of rehabilitation is to return the patient to home and to maximize recovery byproviding a safe, progressive regimen suited to the individual patient. Additionally, theuse of restraint therapy (immobilizing the unaffected side) has been shown to improvehemiparesis following stroke.
Complication PercentFallsUrinary tract infectionChest infectionPressure soresDepressionShoulder painDeep venous thrombosisPulmonary embolismMedical complications of stroke were frequent in a prospective multicenter study of 311 patients followedweekly through hospital discharge and again at 6, 18, and 30 months after stroke.Data from: Langhorne, P, Stott, DJ, Robertson, L, et al. Medical complications after stroke: a multicenterstudy. Stroke 2000; 31:1223.Complications of strokeCommon medical complications of stroke
Complications of strokeSerious medical complications of strokeIn a prospective study that analyzed the placebo group of the RANTTAS database (n = 279), at least one serious medicalcomplication (defined as prolonged, immediately life threatening, or resulting in hospitalization or death) occurred in 24percent of patients.Data from: Johnston, KC, Li, JY, Lyden, PD, et al. Medical and neurological complications of ischemic stroke: experiencefrom the RANTTAS trial. RANTTAS Investigators. Stroke 1998; 29:447.Complication PercentAll pneumoniasAspiration pneumonia aloneHeart failureGastrointestinal bleedingCardiac arrestAngina/MI/cardiac ischemiaDeep venous thrombosisPulmonary embolismHypoxiaUrinary tract infectionSepsisCellulitisPeripheral vascular disorderDyspneaPulmonary edemaDehydration