The document discusses recent developments in stroke management. It summarizes that (1) endovascular therapy plus usual care is more effective than usual care alone for acute ischemic stroke patients with proximal arterial occlusion within 6 hours of onset, (2) early intensive blood pressure lowering is safe and may improve outcomes for intracerebral hemorrhage patients presenting within 6 hours with systolic BP 150-220 mmHg, and (3) stroke rehabilitation involving early mobilization, drug therapy to enhance motor recovery, and robotic training can improve functional recovery.
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
I am a Neurosurgeon with advanced training in Interventional vascular Neurosurgery(FINR) from Zurich, Switzerland, and FMINS-Fellowship in minimally invasive and Endoscopic Neurosurgery from Germany.
I am presently working in Columbia asia hospitals, Bangalore.
My areas of interest are Vascular Neurosurgery, Stroke specialist, interventional neuroradiology.
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
I am a Neurosurgeon with advanced training in Interventional vascular Neurosurgery(FINR) from Zurich, Switzerland, and FMINS-Fellowship in minimally invasive and Endoscopic Neurosurgery from Germany.
I am presently working in Columbia asia hospitals, Bangalore.
My areas of interest are Vascular Neurosurgery, Stroke specialist, interventional neuroradiology.
This talk covers the most important aspects of treatment of acute ischemic stroke, such as thrombolysis, use of antiplatelets, BP and sugar control and general supportive care.
This talk covers the most important aspects of treatment of acute ischemic stroke, such as thrombolysis, use of antiplatelets, BP and sugar control and general supportive care.
Peripheral neuropathy (PN) is damage to or disease affecting nerves, which may impair sensation, movement, gland or organ function, or other aspects of health, depending on the type of nerve affected
The American College of Cardiology's (ACC) 2013 standards of primary care were created to reduce individual heart risk (heart attack, stroke or cardiac death event within 10 and 30 years) and obesity-based chronic disease risk, but if taken together, may also represent modifiable lab/exam levels that are more predictive of cost than claims-based billing code sets.
The research question is, how does the relationship between obesity and heart risk impact total medical costs? A clinical data set, representative of US “well-appearing” and impaired obese and atherosclerotic cardiovascular disease (ASCVD) adults alike, was used to determine prevalence, cost differences, and correlates per stage. This cross-sectional study used a public health data set to investigate the relationship between obesity and heart risk and their impact on treatment costs with general linear models.
This study uses consecutive National Health and Nutrition Examination Surveys (NHANES) data from 2003-2012 to concurrently model obese body size (c.f., normal weight) main effects, moderated by non-diabetic moderate 10-year ASCVD risk (c.f., 30-year and diabetic), on total medical cost outcomes. Minors, seniors 76+, outlier diseases, and pregnant women were excluded, resulting in 192,447,424 weighted or 22,510 unweighted participants. Findings are that obesity explains 2% of cost by itself, together with heart risk some 10% contribution is explained, and interaction effects at 0.2% has the least potency on costs. Heart risk, 10-year and 30-year alike, exponentially compound costs at the onset of diabetes and heart attack/stroke; this means the speed of heart disease progression in patients differs but mean costs rise identically with new diabetes or heart events.
an updated account on management of TIA, Ischemic and hemorrhagic stroke in Sri Lanka. This is based on American Stroke Association and NICE guidelines.
Sudden onset Neurological deficit (Focal/ Global) of vascular etiology motor weakness, sensory disturbance,visual disturbance, speech disturbance and Imbalance.
Every year 15 million people worldwide suffer a stroke
Stroke is second leading cause of death over the age of 60
Stroke is the second leading cause of disability, after dementia
15% - 30% of stroke survivors are permanently disabled.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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
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.
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.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
3. What's new
• Reperfusion therapy
• Endovascular therapy
• Mx of haemorhagic stroke/ICH
• Stroke rehabilitation
• Novel therapy
4. Epidemiology
• Annually 15 million people worldwide
suffer a stroke
–5 million die
–5 million are left permanently disabled.
• Top 4 leading causes of death in ASEAN
countries,
– death rate :
• 10.9/100 000 (Thailand)
• 54.2/100 000 (Singapore).
6. • In Kelantan, 158 stroke patients were admitted to HUSM
between January 1997 and December 1998.
– 56·3% ischemic stroke
– 36·1% primary intracerebral hemorrhage
– 7·6% subarachnoid hemorrhage.
• 246 stroke patients admitted to Penang Hospital from
December 1998 to November 1999
– 74·8% ischemic stroke
– 25·2% hemorrhagic stroke
Malaysia's data
7. • 163 ischemic stroke patients were admitted to HUKM
from June 2000 until January 2001
– 62·6% lacunar infarct
– 26·4% middle cerebral infarct
– 11·0% other manifestations
– The mortality rate: 11·7%, with a mean age of 62·2 years
• UMMC 83 ischemic stroke patients were admitted
between June 2000 and November 2000
– hyperhomocysteinemia was found to be a risk factor for ischemic
stroke (odds ratio 5·3)
– Depression was reported in (66%) 3-6 months poststroke
• It has been reported that six new stroke cases occur in
Malaysia every hour
Malaysia's data
10. Acute Stroke
• sudden non-convulsive, focal neurological
deficit resulting from vascular disease
• could be divided into
» Acute ischemia infarction
» Intraparenchymal hemorrhage
» Subarachnoid hemorrhage
**a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke
Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention
11. Transient Ischemic Attack
• Old definition - (Clinically-based)
– brief episode of neurologic dysfunction
< 24 hours resulting from focal temporary
cerebral ischemia
• New definition - (Tissue-based)
– transient episode of neurologic dysfunction
caused by focal brain, spinal cord, or
retinal ischemia, without acute infarction*
**a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke
Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention
13. Reperfusion therapy
• Intravenous rt-PA can be given only if the following is
available:
1. A physician with expertise in the diagnosis and mx of stroke.
2. Appropriate neuroimaging tests are available 24 hours a day
3. Capability to manage the complications of thrombolysis,
particularly intracranial haemorrhage.
• Onset:
– 4.5 hours
– 3 hours ( >80 y.o with DM)
• NIHSS 6-22 (some centre 4-22)
14. Tips to know the exact onset
• The exact time of “last seen well”
• What is the patient doing during the onset?
• Where does the patient stay?
• Challenge the eye witness regarding the time
15.
16. Candidate for thrombolysis
1. Diagnosis of ischaemic stroke causing measurable
neurological deficit.
2. The neurological signs should not be clearing
spontaneously.
3. The neurological signs should not be minor and isolated.
4. Caution should be exercised in treating a patient with
major deficits.
5. Onset of symptoms <4.5 hours before beginning
treatment.
17. Candidate for thrombolysis
6. No contraindication for thrombolytic therapy.
7. Blood pressure less than 185mm Hg systolic and/or less
than 110mm Hg diastolic.
8. Brain CT is normal or minimal change.
9. The patient or family understand the potential risks and
benefits from treatment.
*written consent
18. 1. Current use of oral anticoagulant or a promthrombin time (PT) > 15
seconds (INR > 1.7)
2. Use of heparin in the previous 48 hours and a prolonged partial
thromboplastin time (PTT)
3. A platelet count < 100,000/mm3
4. Another stroke or any serious head injury in the previous 3 months
5. Major surgery within the preceding 14 days
6. Arterial puncture at noncompressible site within the last 21 days
7. Pre-treatment systolic blood pressure > 185mmHg or diastolic blood
pressure > 110mmHg
Contraindication for thrombolysis (I)
19. 8. Neurological signs that are improving rapidly
9. Isolated mild neurological deficits, such as ataxia alone, sensory loss
alone, dysarthria alone or minimal weakness
10. Prior intracranial haemorrhage
11. A blood glucose < 2.7mmol/l or > 22.2mmol/l
12. Seizure at the onset of stroke
13. Gastrointestinal or urinary bleeding within the preceding 24 days
14. Recent myocardial infarction
Contraindication for thrombolysis (II)
24. Post thrombolysis care (I)
1. Admit to ICU or a stroke unit
2. Perform neurological assessments
• every 15 minutes during the infusion of rt-PA
• every 30 minutes for the next 6 hours
• every hour until 24 hours from treatment.
3. If the patient develops severe headache, acute hypertension,
nausea or vomiting --> discontinue the rt-PA, obtain a CT scan of
brain.
4. Measure blood pressure
• every 15 minutes for the first 2 hours
• every 30 minutes for the next 6 hours
• every hour until 24 hours from treatment.
25. Post thrombolysis care (I)
5. Increase blood pressure measurements if a systolic blood pressure
>180mmHg or diastolic blood pressure >105mmHg is recorded.
Administer anti-hypertensive
6. Delay placement of NG tube, CBD, arterial line.
7. Avoid antiplatelet drugs for the first 24 hours after rt-PA.
26. Neurology HKL experience
• Total of candidate thrombolysed: 30 pts
• Complicated by ICB : 6 pts
• Mortality: 6 pts (various reasons)
29. BackgroundBackground
• In patients with acute ischemic stroke caused by
a proximal intracranial arterial occlusion,
intraarterial treatment is highly effective for
emergency revascularization
• However, proof of a beneficial effect on
functional outcome is lacking
30. Limitation of IV AlteplaseLimitation of IV Alteplase
narrow therapeutic time window
Contraindications
recent surgery, coagulation abnormalities, and a
history of intracranial hemorrhage.
less effective at opening proximal occlusions of
the major intracranial arteries (1/3 in ICA
infarction)
31. Intraarterial therapyIntraarterial therapy
2 types
Intraarterial thrombolysis
clot retrieval with mechanical devices
Neutral results so far, probably due to
long interval before intraarterial treatment
absence of pretreatment vascular imaging to confirm
a proximal intracranial occlusion
Limited use of third-generation mechanical
thrombectomy devices
32. ObjectivesObjectives
• Assess whether intraarterial treatment plus usual
care would be more effective than usual care
alone
– in patients with a proximal arterial occlusion in the
anterior cerebral circulation
– could be treated intraarterially within 6 hours after
symptom onset
33. MethodologyMethodology
• Interventional group
– Intraarterial treatment (intraarterial
thrombolysis, mechanical treatment, or both)
plus usual care (which could include
intravenous administration of alteplase)
• Control group
– Patients who receives usual care only
35. Primary outcomePrimary outcome
• There was a shift in the distribution of the
primary-outcome scores in favor of the
intervention.
• The adjusted common odds ratio was 1.67
(95% confidence interval)
36. Secondary outcomeSecondary outcome
• The NIHSS score after 5 to 7 days was,
on average, 2.9 points (95% CI, 1.5 to
4.3) lower in the intervention group than in
the control group.
37. SafetySafety
• No significant between-group difference in the
occurrence of serious adverse events during the
90-day follow-up period (P = 0.31)
• 13 of the 233 patients (5.6%) in the intervention
group had clinical signs of a new ischemic stroke
in a different vascular territory within 90 days
• No significant difference in mortality at 7, 30, or
90 days of follow-up
39. ConclusionsConclusions
• Patients with acute ischemic stroke caused by a
proximal intracranial arterial occlusion of the
anterior circulation have a benefit with respect to
functional recovery when combination of
intravenous thrombolysis and intraarterial
treatment are administered within 6 hours after
stroke onset
43. Introduction
• This guideline serves :
– An update to previous AHA guideline 2010
– As a brief and useful guide on management of ICH
• Consist of 15 sections:
– Emergency diagnosis & assessment, causes of ICH, BP
management, in-patient management, mx of raised ICP, role of
surgical clot removal, outcome prediction, prevention of
recurrent ICH, rehabilitation and future considerations
44. MEDICAL TREATMENT FOR ICH
(Blood Pressure and Outcome in ICH)
• Elevated BP is very common in acute ICH
– Stress, pain, increased ICP, premorbid persistent high BP
– a/w hematoma expansion, neurological deterioration, death and
dependency after ICH
45. MEDICAL TREATMENT FOR ICH
(Blood Pressure and Outcome in ICH)
• Safety of Early Intensive BP-Lowering Treatment
– ATACH trial (Antihypertensive Treatment of Acute Cerebral
Hemorrhage)
• IV nicardipine-based BP lowering within 3 hrs of ICH
– INTERACT-1 trial (Intensive BP Reduction in Acute Cerebral
Hemorrhage) – pilot phase
• BP lowering within 6 hrs of ICH
– Both found rapid reduction of SBP < 140 to be safe
– INTERACT-2 – main phase
• No increase in death or serious adverse events from early intensive
BP lowering in eligible patients
46. MEDICAL TREATMENT FOR ICH
(Blood Pressure and Outcome in ICH)
• Efficacy of Early Intensive BP-lowering Treatment
– INTERACT-2
• Intensive BP lowering, n=2839 pts with SBP 150- 220 mmHg within
6 hours of ICH
• Two arms :
– A: intensive therapy ( BP lowered to target SBP<140 within 1 hr
of randomization , for 7 days)
– B: standard therapy ( SBP< 180 mmHg)
• Primary outcome : death / major disability (MRS > 3) : OR 0.87 (p=
0.06)
• Secondary end points
– Functional recovery : OR 0.87 (p = 0.04)
– Physical & mental-health QoL: OR 0.87 (p = 0.002)
47. MEDICAL TREATMENT FOR ICH
(Blood Pressure and Outcome in ICH)
• Efficacy of Early Intensive BP-lowering Treatment
– INTERACT-2
• no clear relationship between outcome and the time from onset of
ICH to commencing treatment
• no significant effect of intensive BP-lowering treatment on hematoma
growth.
48. MEDICAL TREATMENT FOR ICH
(Blood Pressure and Outcome in ICH)
• Recommendations, for ICH patients presenting with:
– SBP between 150 and 220 mmHg and without contraindication
to acute BP treatment, acute lowering of SBP to 140 mm Hg is
safe (Class I; Level of Evidence A) and can be effective for
improving functional outcome (Class IIa; Level of Evidence B).
(Revised from the previous guideline)
– SBP >220 mm Hg: to consider aggressive reduction of BP with
a continuous intravenous infusion and frequent BP monitoring
(Class IIb; Level of Evidence C). (New recommendation)
49. Inpatient mx (Seizures and AED)
• Frequency of early seizures after ICH ~ 16%
– Due to cortical involvement
• Epilepsy occurs in ~ 10%
– Risks include stroke severity, cortical location of hematoma, and
delayed initial seizures.
• Clinical seizures should be treated with AEDs (Class I; Level of
Evidence A).
• Pts with a change in mental status who are found to have
electrographic seizures on EEG should be treated with AEDs (Class
I; Level of Evidence C).
• Prophylactic AED is not recommended (Class III; Level of Evidence
B).
50. Inpatient mx and prevention of secondary brain
injury (Mx of medical complications)
• Frequency of medical complications after ICH is high
• Most common complications:
– Pneumonia (5.6%)
– Aspiration (2.6%)
– Respiration failure/distress (2%)
– PE (1.3%)
– Sepsis (1.7%)
• ~ 50% of death after stroke are related to medical
complications, usually after 7 days of hospitalization.
52. Stroke rehabilitation
1) Drug Therapy Options Evolving to Enhance
Motor Recovery :
– -ve study
– Fluoxetine for Motor Recovery in Acute Ischemic
Stroke (FLAME) study*:
• n = 118
• given within the first 10 days
• pt with moderate-to-severe motor deficit, the early
prescription of fluoxetine + physiotherapy enhances motor
recovery after 3 months.
Chollet F, Tardy J, Albucher JF, Thalamas C, Berard E, Lamy C, et al. Fluoxetine for motor recovery after acute ischaemic stroke
(FLAME): a randomised placebo-controlled trial. Lancet Neurol. 2011;10:123–130.
53. Stroke rehabilitation
2) Early Mobilization
• The A Very Early Rehabilitation Trial (AVERT) study*,**,
mobilization within the first 24 hours of stroke and at
regular intervals
– is safe, feasible, and fast-track return to walking unassisted,
– increasing the likelihood of milder stroke discharged home,
– good functional outcomes at 3 and 12 months.
– prevent poststroke complications i.e contractures and DVT.
*van Wijk R, Cumming T, Churilov L, Donnan G, Bernhardt J. An early mobilization protocol successfully delivers more and
earlier therapy to acute stroke patients: further results from phase II of AVERT. Neurorehabil Neural Repair. 2012;26:20–26.
**Cumming TB, Thrift AG, Collier JM, Churilov L, Dewey HM, Donnan GA, et al. Very early mobilization after stroke fast-tracks
54. Stroke rehabilitation
3) Ambulation With Body Weight Support Treadmill
Training (RCT, n=408)
– training on a treadmill with body weight support
• 2 months after the stroke (early locomotor training);
• 6 months after the stroke (late locomotor training)
• exercise program at home (2 months)
– After 1 year, 52.0% had increased walking ability.
– No significant differences in between groups
– All groups had similar improvements in walking speed, motor
recovery, balance, functional status, and QoF.
– early training of locomotion carried a higher risk for falls.
55. Stroke rehabilitation
4) Robotic
• Cochrane* systematic review 19 trials (n=666
participants).
• Electromechanical and robot-assisted arm training:
– did improve activities of daily living and arm function
– but not arm muscle strength
– did not increase the risk of patients to dropout and adverse
events were rare.
*Mehrholz J, Hädrich A, Platz T, Kugler J, Pohl M. Electromechanical and robot-assisted arm training for improving
generic activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst Rev.
2012;6:CD006876.
56. Stroke rehabilitation
5) Virtual Reality (Virtual reality and video game
applications)
• 12 studies, 195 participants
• 11 out of 12 studies identified showed a significant benefit toward
VR for the selected outcomes.
57. Stroke rehabilitation
6) Transcranial Magnetic Stimulation
• Meta-analysis*, the effects of repetitive transcranial magnetic
stimulation (rTMS) on upper limb motor function in patients with
stroke.
• Evaluating 18 randomized controlled trials published between 1990
and 2011
• Conclution:
– rTMS has a positive effect on motor recovery in patients with stroke,
especially for those with subcortical stroke
– low-frequency rTMS over the unaffected hemisphere may be more
beneficial than high-frequency rTMS over the affected hemisphere
Hsu WY, Cheng CH, Liao KK, Lee IH, Lin YY. Effects of repetitive transcranial magnetic stimulation on motor
functions in patients with stroke: a meta-analysis. Stroke. 2012;43:1849–1857.
59. Novel therapy
Stem cell therapy
• Repair of the infarcted area of brain through enhancing
neuroprotective and repair mechanisms
• Cell therapy promotes re-vascularization, and reduces cerebral
inflammation
• Phase II clinical trials of intravenous transplantation of autologous
bone-marrow stem cells have reported safety and tolerability in
stroke patients
• Pending the results of future larger trials
• PISCES study currently underway in Glasgow*
The PISCES Study. The PISCES Clinical Trial in Disabled Stroke Patients. http://www.reneuron.com/the-
piscesclinical-trial-in-disabled-stroke-patients (2 June 2012, date last accessed).