This document summarizes the management and complications of stroke. It discusses the medical management of acute ischemic stroke, which falls into six categories: medical support, IV thrombolysis, endovascular techniques, antithrombotic treatment, neuroprotection, and stroke centers and rehabilitation. It also outlines common complications of stroke seen in studies such as falls, urinary tract infections, chest infections, pressure sores, and depression. Serious complications discussed include various types of pneumonia, heart failure, gastrointestinal bleeding, cardiac arrest, and deep venous thrombosis.

1. Management &
Complications of stroke
Mr.Abdulaziz R. Alanzi
Medical Student, Al-Imam University
Riyadh – Saudi Arabia

2. References
 UpToDate Electronic Medical Database
 Harrison's Principles of Internal
Medicine Book,18e, Dan L. Longo,
Anthony S. Fauci, Dennis L. Kasper,
Stephen L. Hauser, J. Larry Jameson,
Joseph Loscalzo, Eds.

3. Management
Medical management of stroke
and TIA. Rounded boxes are
diagnoses; rectangles are
interventions. Numbers are
percentages of stroke overall. ABCs,
airway, breathing, circulation; BP,
blood pressure; CEA, carotid
endarterectomy; ICH, intracerebral
hemorrhage; SAH, subarachnoid
hemorrhage; TIA, transient ischemic
attack.

4. Management: Acute Ischemic Stroke
falls 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 brain's tolerance to ischemia
(6) Stroke centers and rehabilitation

5. Management: Acute Ischemic Stroke
 Medical support:
if blood pressure is >185/110 mm Hg –- B1-adrenergic blocker (esmolol)
Fever –- antipyretics and surface cooling
Serum glucose 6.1 mmol/L (110 mg/dL) –- insulin infusion
Cerebral Edema –- Water restriction and IV mannitol
Feeding –- NGT
Sphincters –- Foleys Catheter

6. Management: Acute Ischemic Stroke
 IV thrombolysis:
Administration of rtPA
Intravenous access with two peripheral IV lines (avoid arterial or central line
placement)
Review eligibility for rtPA
Administer 0.9 mg/kg IV (maximum 90 mg) IV as 10% of total dose by bolus,
followed by remainder of total dose over 1 h
Frequent cuff blood pressure monitoring
No other antithrombotic treatment for 24 h
For decline in neurologic status or uncontrolled blood pressure, stop infusion,
give cryoprecipitate, and reimage brain emergently
Avoid urethral catheterization for 2 h

8. Management: Acute Ischemic Stroke
 Endovascular techniques :

9. Management: Acute Ischemic Stroke
 Antithrombotic treatment:
- Platelet inhibition: Aspirin is the only antiplatelet agent that has been proven
effective for the acute treatment of ischemic stroke; there are several antiplatelet
agents proven for the secondary prevention of stroke.
- Anticoagulation: Trials generally have shown an excess risk of brain and systemic
hemorrhage with acute anticoagulation. Therefore, trials do not support the routine
use of heparin or other anticoagulants for patients with atherothrombotic stroke.
 Neuroprotection: Drugs that block the excitatory amino acid pathways have
been shown to protect neurons and glia in animals. Hypothermia is a powerful
neuroprotective treatment in patients with cardiac arrest and is neuroprotective
in animal models of stroke, but it has not been adequately studied in patients
with ischemic stroke.

10. Management: Acute Ischemic Stroke
 Stroke centers and rehabilitation:
Proper rehabilitation of the stroke patient includes early physical, occupational, and
speech therapy. It is directed toward educating the patient and family about the
patient's neurologic deficit, preventing the complications of immobility (e.g.,
pneumonia, DVT and pulmonary embolism, pressure sores of the skin, and muscle
contractures).
The goal of rehabilitation is to return the patient to home and to maximize recovery by
providing a safe, progressive regimen suited to the individual patient. Additionally, the
use of restraint therapy (immobilizing the unaffected side) has been shown to improve
hemiparesis following stroke.

11. Complication Percent
Falls
Urinary tract infection
Chest infection
Pressure sores
Depression
Shoulder pain
Deep venous thrombosis
Pulmonary embolism
Medical complications of stroke were frequent in a prospective multicenter study of 311 patients followed
weekly 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 multicenter
study. Stroke 2000; 31:1223.
Complications of stroke
Common medical complications of stroke

12. Complications of stroke
Serious medical complications of stroke
In a prospective study that analyzed the placebo group of the RANTTAS database (n = 279), at least one serious medical
complication (defined as prolonged, immediately life threatening, or resulting in hospitalization or death) occurred in 24
percent of patients.
Data from: Johnston, KC, Li, JY, Lyden, PD, et al. Medical and neurological complications of ischemic stroke: experience
from the RANTTAS trial. RANTTAS Investigators. Stroke 1998; 29:447.
Complication Percent
All pneumonias
Aspiration pneumonia alone
Heart failure
Gastrointestinal bleeding
Cardiac arrest
Angina/MI/cardiac ischemia
Deep venous thrombosis
Pulmonary embolism
Hypoxia
Urinary tract infection
Sepsis
Cellulitis
Peripheral vascular disorder
Dyspnea
Pulmonary edema
Dehydration

13. Thank You
d0pa@hotmail.com
@AbdulazizEnazi
http://imamu.academia.edu/AbdulazizAlanzi