Stroke is the third leading cause of death in Malaysia. The document defines stroke, classifies its types, and outlines its diagnosis and management. Key points include that stroke is caused by blocked blood flow to the brain, and risk factors include age, gender, family history, hypertension, diabetes, atrial fibrillation, smoking, and high cholesterol. Diagnostic tests include CT/MRI scans and angiograms to determine the cause. Treatment focuses on rehabilitation, managing risk factors, and preventing future strokes.
Stroke is a disease that affects the arteries within the brain.
It is the 5th cause of death and a leading cause of disability in the United States.
A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures). When that happens, part of the brain cannot get the blood (and oxygen) it needs,and brain cells die.
Stroke is a disease that affects the arteries within the brain.
It is the 5th cause of death and a leading cause of disability in the United States.
A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures). When that happens, part of the brain cannot get the blood (and oxygen) it needs,and brain cells die.
Is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke.
It can occur
in the carotid
artery of the
neck as well as
other arteries.
When an artery is acutely occluded by thrombus or embolus, the area of the CNS supplied by it will undergo infarction if there is no adequate collateral blood supply.
Surrounding a central necrotic zone, an ‘ischemic penumbra’ remains viable for a time, i.e. it may recover function if blood flow is restored.
CNS ischemia may be accompanied by swelling for two reasons:
● cytotoxic oedema – accumulation of water in damaged glial cells and neurones,
● vasogenic oedema – extracellular fluid accumulation as a result of breakdown of the blood–brain barrier.
In the brain, this swelling may be sufficient to produce clinical deterioration in the days following a major stroke, as a result of a rise in intracranial pressure and compression of adjacent structures.
In this presentation, I have described stroke and its subtypes, the ischemic stroke and the hemorrhagic stroke, their diagnosis, clinical manifestations and treatments.
Is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke.
It can occur
in the carotid
artery of the
neck as well as
other arteries.
When an artery is acutely occluded by thrombus or embolus, the area of the CNS supplied by it will undergo infarction if there is no adequate collateral blood supply.
Surrounding a central necrotic zone, an ‘ischemic penumbra’ remains viable for a time, i.e. it may recover function if blood flow is restored.
CNS ischemia may be accompanied by swelling for two reasons:
● cytotoxic oedema – accumulation of water in damaged glial cells and neurones,
● vasogenic oedema – extracellular fluid accumulation as a result of breakdown of the blood–brain barrier.
In the brain, this swelling may be sufficient to produce clinical deterioration in the days following a major stroke, as a result of a rise in intracranial pressure and compression of adjacent structures.
In this presentation, I have described stroke and its subtypes, the ischemic stroke and the hemorrhagic stroke, their diagnosis, clinical manifestations and treatments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. Stroke in Malaysia
Definition of stroke
Classification of stroke
Diagnosis of stroke
Cause & pathophysiology
Risk factors
Stroke investigations
Stroke Management
3. Stroke is the third largest cause of death in
Malaysia. Only heart diseases and cancer kill
more. It is considered to be the single most
common cause of severe disability, and every
year, an estimated 40,000 people in Malaysia
suffer from stroke. Anyone can have a
stroke, including children, but the vast majority of
the cases affect adults.
4. A stroke is a clinical
syndrome characterized
by rapidly developing
clinical symptoms
and/or signs of
focal, and at times
global, loss of cerebral
function, with
symptoms lasting more
Functions of the brain than 24 hours or
leading to death, with no apparent cause other that of
vascular origin
5. Total Anterior Circulation Stroke ( TAC)
All of
• Hemiplegia contralateral to the cerebral lesion , usually with
ipsilateral hemisensory loss
• Hemianopia contralateral to cerebral lesion
• New diturbance of higher cerebral function ( dysphasia
, visuospatial )
Lacunar Stroke ( LAC )
• Pathological definition
• Occlusion of a single deep ( LS ) perforating artery
• 5% can be due to haemorrhage
• Occurs at strategic sites
• More likely seen on MRI than CT scan
• Classical lacunar syndromes correlated with relevant lacunes at
autopsy
6. Partial Anterior Circulation Stroke ( PAC )
Any of
• Motor / sensory deficit + hemianopia
• Motor / sensory deficit + new higher cerebral dysfunction
• New higher cerebral dysfunction + hemianopia
• New higher cerebral dysfunction alone
• A pure motor / sensory deficit less extensive than for LAC ( eg.
confined to one limb, or to face and hand but not to whole arm)
Posterior Circulation Stroke ( POC )
Any of
• Ipsilateral cranial nerve palsy ( single / multiple ) with
contralateral motor and/or sensory deficit
• Bilateral motor and/or sensory deficit
• Disorder of conjugate eye movement (horizontal/vertical)
• Cerebellar dysfunction without ipsilateral long tract sign
• Isolated hemianopia or cortical blindness
• Other signs include Horner‟s sign
, nystagmus, dysarthria, hearing loss, etc.
7. Anterior ( carotid ) artery circulation Posterior ( vertebrobasilar ) artery
circulation
Middle cerebral artery • Homonymous hemianopia
• Aphasia ( dominant hemisphere) • Cortical blindness
• Hemiparesis/plegia • Ataxia
• Hemisensory loss/disturbance • Dizziness or vertigo
• Homonymous hemianopia • Disarthria
• Parietal lobe • Diplopia
dysfunction, e.g.astereognosis, agraph • Dysphagia
aesthesia, impraired two-point • Homer‟s syndrome
discrimination, sensory and visual • Hemiparesis or hemisensory loss
inattention, left-right dissociation and contralateral to the cranial nerves
acalculia palsy
Anterior cerebral artery • Cerebellar signs
• Weakness of lower limb more than
upper limb
9. Ischaemic stroke :
• Atherothromboembolism (50%)
• Intracranial small vessel
disease(penetrating artery disease) (25%)
• Cardiogenic embolism(20%)
• Other causes include:
arterial dissection
trauma
vasculitis (primary/secondary)
A blood clots get stuck in an
metabolic disorders artery and blocks the blood
congenital disorders flow.
And other less common causes such as
migraine, pregnancy, oral contraceptives, etc.
10. Ischaemic stroke
Atherothrombotic Penetrating Other
Embolism
cerebrovascular artery disease causes
disease (“lacunes”)
Cardiogenic Atrial
Large artery fibrillation
atheroma Hypoperfusion Valve disease
Venticular thrombi
PFO and ASA
Intracardiac tumour
Extracranial
Intracranial Prothrombotic
Artery to artery
Carotid stenosis states:Dissection,Arteritis,
AorticArchAtheroma Migraine, Drug abuse
11. Haemorrhagic stroke :
• An intracerebral
haemorrhage.
• A subarachnoid
haemorrhage.
When an artery bursts blood is
forced into the brain
tissue, damaging cells so that area
of the brain can't function.
12.
13. Age. Strokes are more common in people over 55, and
the incidence continues to rise with age.
Gender. Men are at a higher risk of stroke than
women, especially under the age of 65.
Family history. Having a close relative with a stroke
increases the risk, possibly because factors such as high
blood pressure and diabetes tend to run in families.
14. High Blood Pressure ( systolic and diastolic)
Cigarette smoking
Diabetes mellitus
Atrial Fibrillation
Coronary heart disease
Hyperlipidaemia
Obesity & physical inactivity
Raised Homocysteine levels
High dietary salt intake
Heavy alcohol consumption
Previous stroke
15. The following investigations for patients with
ischaemic stroke are recommended in order to
achieve the following objectives:
1. Confirm the diagnosis
2. Determine the stroke mechanism
3. Risk stratification and prognostication
4. Identify potentially treatable large obstructive
lesions of the cerebrovascular circulation
16. ON ADMISSION
Full blood count ( Exclude
anaemia, polycythaemia, thrombocytosis, thrombocytopenia, etc.)
Random blood glucose (Exclude hypoglycemia, new diagnosis of diabetes
mellitus)
Urea & electrolytes (Hydration status, excludes electrolyte imbalances)
Clotting profile (if thrombosis is considered) (Baseline)
NEXT DAY
Lipid profile(fasting)
Glucose (fasting)
OPTIONAL TESTS ( in selected patients)
VDRL
Autoimmune screen (ESR, antinuclear Factor, Rheumatoid Factor, anti double
stranded DNA antibodies, C3 C4 levels, etc.)
Thrombophilia screen & lupus anticoagulant (Serum fibrinogen, Anti-
thrombin III, Protein C, Protein S, Factor V-Leyden, anti-phospholipid
antibodies)
Homocysteine (fasting)
C reactive protein
17. 12 lead ECG ( Mandatory)
Ambulatory ECG ( for suspected
arrhythmias or sinoatrial node disease)
18. FOR ALL SUSPECTED STROKE
Chest x-ray ( Mandatory)
CT brain ( The emergency neuroimaging scan of choice for all
patients.
Differentiates haemorrhage from infarction.
Confirm site of lesion, cause of lesion, extent
of brain affected)
IN SELECTED PATIENTS
ECHO cardiography ( For suspect cardioembolism, assess cardiac
function)
MRI(magnetic resonance imaging) (Sensetive. Not available in
emergency setting, limited by expense. Useful tool to selecct
patients for thrombolysis where available)
Carotid duplex Ultrasound (Allows identification of extracranial
vessel disease)
Transcranial Doppler Ultrasound (Identifies intracranial vessel
disease with prognostic and therapeutic implications)
19. MR angiography(MRA) (Non invasive tool to assess intra- and extra-
cerebral circulation. Objective assessment of vessel stenosis)
CT angiography( multislice CT scan)( Non invasive tool to assess intra-
and extra-cerebral circulation. Involves intravenous contrast injection)
MR venography ( In suspected cerebral venous thrombosis)
Contrast angiogram ( Gold standard assessment of cerebral vasculature.
Reserved for patients planned for intervention)
MR angiography showing blockage
Areas of the brain affected with
of the artery in the brain (arrow)
stroke ( circled red circles)
20. Symptoms & signs suggestive of Stroke
Symptoms & signs persist > 1 hour
Acute Care
Urgent Clinical Evaluation
Urgent brain CT
Blood tests
ECG
Ischaemic Stroke
Brain CT normal or shows Haemorrhagic Stroke
acute infarction ( ICH / SAH )
Brain CT shows haemorhage
Specific Stroke therapy
Thrombolytic therapy ( if no
contraindications Neurosurgical Evaluation
, Antiplatelet therapy & Treatment
21. Acute Stroke Care
Stroke Unit ( if available )
Airway , Breathing , Circulation
Hydration.
Blood Pressure monitoring
Neurological Status monitoring
Anticipate & treat complications
Begin rehabilitation
Neurorehabilitation
Multidisciplinary Team Approach Further Investigations
Education
Proper Positioning Establish Stroke
Patient &
Early mobilization subtype and underlying
Caregiver
Physiotherapy cause
Occupational therapy Cardio &
Speech therapy Cerebrovascular Risk
Treat spasticity Assessment
Treat depression
Secondary Prevention
Antiplatelet therapy
Treat risk factors
Treat specific underlying cause
22. Factors recommendation
Hypertension Treat medically if BP>140mmHg systolic
and/or>90mmHg diastolic.
Lifestyle changes if BP between 130-139mmHg systolic
and/or 80-89mmHg diastolic.
Target BP for diabetics is <130mmHg systolic and
<80mmHg diastolic.
Hypertension should be treated in the very elderly(age
>70yrs) to reduce risk of stroke.
Diabetes mellitus Strict blood pressure control is important in diabetics.
Maintain tight glycaemic control.
Hyperlipidaemia High risk group keep LDL<2.6mmol/l.
1 or more risk factors: keep LDL<3.4mmol/l.
No risk faktor: keep LDL<4.2mmol/l.
Smoking Cessation of smoking.
23. Aspirin therapy 100mg aspirin every other day may be useful in women
above the age of 65
Post menopausal Oestrogen based HRT is not recommended for primary
Hormone stroke prevention
Replacement
therapy
Alcohol Avoid heavy alcohol consumption.
24. Factors Recommendation
Airway &Breathing Ensure clear airway and adequate oxygenation.
Elective intubation may help some patients with severely
increased ICP.
Mobilization Mobilize early to prevent complications
Blood Pressure Do not treat hypertension if<220mmHg systolic
or<120mmHg diastolic. Mild hypertension is desirable at
160-180/90-100mmHg.
Blood pressure reduction should not be drastic.
Proposed substances: Labetolol 10-20 mg boluses at 10
minute intervals up to 150-300 mg or 1 mg/ml infusion,
1-3 mg/min or Captopril 6.25-12.25 mg orally.
Blood Glucose Treat hyperglycaemia (Random blood
glucose>11mmol/l) with insulin.
Treat hypoglycaemia (Random blood glucose<3mmol/l)
with glucose infusion.
25. Nutrition Perform a water swallow test.
Insert a nasogastric tube if the patient fails the swallow test.
PEG is superior to nasogastric feeding only if prolonged
enteral feeding is required.
Infection Search for infection if fever appears and treat with
appropriate antibiotics early.
Fever Use anti-pyretics to control elevated temperatures.
Raised Hyperventilate to lower intracranial pressure.
Intracranial Mannitoll (0.25 to 0.5 g/kg) intravenously administered
Pressure over 20 minutes lowers intracranial pressure and can be
given every 6 hours.
If hydrocephalus is present, drainage of cerebrospinal fluid
via an intraventicular catheter can rapidly lower
intracranial pressure.
Hemicraniectomy and temporal lobe resection have been
used to control intracranial pressure and prevent herniation
among those patients with very large infarctions of cerebral
hemisphere.
Ventriculostomy and suboccipital craniectomy is effective
in relieving hydrocephalus and brain stem compression
caused large cerebellar infarctions.
26. Treatment Recommendations
rt-Pa In selected patients presenting within 3 hours: IV rt-Pa
(0.9mg/kg, maximum 90mg ) with 10% given as a bolus
followed by an infusion over one hour.
Aspirin Start aspirin within 48 hours of stroke onset.
Use of aspirin within 24 hours of rt-Pa is not recommended
Anticoagulants The use of heparins (unfractionated heparin, low molecular
weight heparin or heparinoids) is not routinely
recommended as it does not reduce the mortality in
patients with acute ischaemic stroke.
Neuroprotective A large number of clinical trials testing a variety of
Agents neuroprotective agents have been completed. These trials
have thus far produced negative results.
To date, no agent with neuroprotective effects can be
recommended for the treatment of patient with acute
ischaemic stroke at this time.
27. Treatment Recommendations
Aspirin All patients should be commenced on aspirin within 48
hours of ischaemic stroke
Warfarin Adjusted-dose warfarin may be commenced within 2-4 days
after the patient is both neurologically and medically stable.
Heparin Adjusted-dose unfractionated heparin may be sterted
(unfractionated) concurrently for patients at very high risk of embolism.
Anticoagulation Anticoagulation may be delayed for 1-2 weeks if there has
been substantial haemorrhage.
Urgent routine anticoagulation with the goal of improving
neurological outcomes or preventing early recurrent stroke
is not recommended.
Urgent anticoagulation is not recommended for treatment of
patients with moderate-to-large cerebral infarcts because of
a high risk of intracranial bleeding complications
28. Major risk Additional risk Recommendation
conditions factors
Atrial High risk:
Fibrillation Age>75years; Long-term warfarin for patients with 1 or
Previous stroke/TIA; more high-risk factors
Mitral valve disease;
Congestive heart
failure; hypertension
Moderate risk:
Age 65-75 years; Long-term warfarin for patients with 2 or
Coronary artery more moderate risk factors
disease, peripheral Warfarin or aspirin for patients with 1
artery disease; moderate risk factor
Diabetes; Aspirin 75-325mg daily is sufficient for
Active thyroid patients<65years of age with „lone‟ AF
disease. and no additional risk factors present
29. Prosthetic Moderate risk:
Heart Valves Bileaflet or tilting
(Mechanical) disk aortic valves in Life-long warfarin
NSR
High risk:
Bileaflet or tilting Life-long warfarin (target INR 3.0;
disk aortic valves in range 2.5-3.5)
AF or NSR
Very high risk:
Caged-ball and
caged-disk designs; Life-long warfarin (target INR 3.0;
documented range 2.5-3.5)
stroke/TIA despite plus aspirin 75-150mg daily
adequate therapy
with warfarin
Bioprosthetic High risk:
heart valves AF; left atrial If high risk factors present, consider
thrombus at surgery; warfarin for 3-12 months or longer
previous CVA/TIA For all other patients, give warfarin
or systemic embolism for 3 months post-op, then aspirin 75-
150mg daily
30. Mitral High risk:
Stenosis AF; previous If high risk factors present, consider
stroke/TIA; left atrial long-term warfarin
thrombus; left atrial For all other patients start aspirin 75-
diameter>55mm on 150mg daily
echo.
MI and LV High risk:
dysfunction Acute/recent MI(<6 If risk factors present without LV
mos); extensive thrombus: consider warfarin for 3-6
infarct with anterior months followed by aspirin 75-150mg
wall involvement; daily
previous stroke/TIA
Very high risk:
Severe LV
dysfunction If LV thrombus is present, consider
(EF<28%); LV warfarin for 6-12 month
aneurysm ;
spontaneous echo
contrast; LV For dilated cardiomyopathies
thrombus; dilated including peripartum, consider long-
non-ischaemic term warfarin
cardiomyopathies.
Recomended warfarin dose INR target 2.5(range2.0-3.0)unless stated otherwise
31. Factors Recommendations
Treatment
Antiplatelets
Single agent
Aspirin The recommended dose of aspirin is 75mg to 325mg
daily.
Alternatives:
Clopidogrel The recommended dose is 75mg daily.
Ticlopidine The recommended dose is 250mg twice a day.
Double therapy
Aspirin+clopidogrel In selected high risk patients only when benefit
outweighs risk
Anti-hypertensive ACE-inhibitor based therapy should be used to
treatment reduce recurrent stroke in normotensive and
hypertensive patients.
ARB-based therapy may benefit selected high risk
populations.
32. Lipid lowering Lipid reduction should be considered in all subjects
with previous ischaemic strokes.
Diabetic control All diabetic patients with previous stroke should
improve glycaemic control.
Cigarette smoking All smokers should stop smoking.
33. Treatment Recommendations
Carotid Indicated for most patients with stenosis of 70-99% after a
Endarterectomy recent ischaemic event in centres with complication rates
(CEA) less than 6%
Earlier invention (within 2 weeks) is more beneficial.
May be indicated for patients with stenosis of 50-69% after
a recent ischaemic event in centres with complication rates
of less than 6%
CEA is not recommended for patients with stenosis of less
than 50%
Patients should remain on antithrombotic therapy before
and after surgery.
Carotid CAS represents a feasible alternative to carotid
angioplasty & endarterectomy for secondary stroke prevention when
stenting (CAS) surgery is undesirable, technically difficult or inaccessible.
Distal protection devices should be used during the
procedure and anti-platelet agents such as clopidogrel be
intiated.
The long-term safety and efficacy of CAS is not known
Intracranial Role of AS in intra-cranial stenoses, asymptomatic
Angioplasty & Stenoses and acute stroke is unclear and not recommended
stenting ( IAS)
34. Treatment Recommendations
Aspirin Young Ischaemic stroke
If the cause is not identified, aspirin is usually given.
There are currently no guidelines on the appropriate
duration of treatment.
Cerebral Venous thrombosis
Heparin Anticoagulation appears to be safe, and cerebral
haemoffhage is not a contra-indication for
anticoagulation.
Warfarin Simultaneous oral warfarin should be commenced.
The appropriate length of treatment is unknown.
Endovascular It is currently considered for patients with extensive
thrombolysis disease and clinical deterioration