Non-hemorrhagic Stroke Latest
Transcript of Non-hemorrhagic Stroke Latest
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NON-HEMORRHAGICSTROKE
GUIDELINES FOR TREATMENT
(Stroke Society of the Philippines Handbook, 6thed)
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OBJECTIVE
To present the guidelines for treatment of Acute Stroke and TransienIschemic Attack (TIA)
To discuss briefly the guidelines for Antiplatelet Therapy inNoncardioembolic Stroke or Transient Ischemic Attack (TIA)
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Outline
Stroke Scales (Glasgow Coma Scale, NIHSS)
Classification of Acute Stroke Based on Clinical Severity
Guidelines for Management of TIA, Mild -, Moderate -, and Severe
Early Specific Treatment of Ischemic Stroke
Management of Increased Intracranial Pressure
Guidelines for Antiplatelet Therapy in Noncardioembolic Stroke orTransient Ischemic Attack (TIA)
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GLASGOW COMA SCALE
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National Institute of HealthStroke Scale
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CLASSIFICATION OFACUTE STROKE
BASED ONCLINICAL SEVERITY
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TRANSIENT ISCHEMIC ATTACK (T
a transientepisode of neurological dysfunction caused by focal brain
or retinal ischemia, withoutevidence of acute infarction in which clinical symtypically last less than an hour
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MILD STROKE
Alert patients with any (or combination) of the ff:
Mild pure motor weakness of one side of the body
Pure sensory deficit
Slurred but intelligible speech
Vertigo with incoordination
Visual field defects alone
or NIHSS score: 0-5
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MODERATE STROKE
Awake patient with significant motor and/or sensory and/or languagand/or visual deficit
or
Disoriented, drowsy or light stupor with purposeful response to painstimuli
or
NIHSS score: 6-21
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SEVERE STROKE
Deep stupor or comatose patient with non-purposeful response, decor decerebrate posturing to painful stimuli
or
Comatose patient with no response to painful stimulior
NIHSS score: >22
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Recommended Place of Treatment
(TIA)OPD
Occurred >2 wks prior (work-upshould be done within 24-48hrs)
ASU w/in 48hrs
Crescendo TIAs (multiple & incsymptoms)
With known high-risk cardiac soembolism
Known hypercoagulable state orsymptomatic ICA stenosis
ABCD2score >3
High Risk
AF (valvular or non-valvular) Rheumatic MS Prosthetic heart valves Recent MI LV/LA thrombus Atrial myxoma Infective endocarditis Dilated cardiomyopathy Marantic endocarditis
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a risk assessment tool designed toimprove the prediction of short-termstroke risk after a transient ischemicattack (TIA)
to predict the risk of stroke within 2
days after a TIA, but also predictsstroke risk within 90 days
Higher ABCD2 scores are associatedwith greater risk of stroke during the2, 7, 30, and 90 days after a TIA
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Mild Stroke
ASU/ regular room
Moderate Stroke
ASU/ ICU
Severe Stroke
ICU
Recommended Place of Treatmen
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GUIDELINES
Management Priorities
Emergent Diagnostics
Early Specific Treatment
Delayed Management and Secondary Prevention
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GUIDELINES FOR THEMANAGEMENT OF
TRANSIENT ISCHEMIC ATTAC(TIA)
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Transient Ischemic Attack
Management Priorities Ascertain clinical dx of TIA
Exclude common TIA mimics
ID comorbidities
ABCs of resuscitation
Monitor the ff:
NVS, pupil size, BP, MAP, RR, temp, SO2
Perform stroke scales (NIHSS, GCS) and riskstratification using ABCD2scale
Treat BP if MAP >130
Avoid precipitous drop (not >15% of baselin
24 hrs
Do not use rapid-acting SL agents; when need
titratable IV or short-acting oral antihyperten
Ensure appropriate hydration
0.9% NaCl
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Emergent Diagnostics CBC
CBG or RBS
PT, aPTT ECG
Cranial MRI-DWI is preferred; may doNCCT scan if MRI is not available/possible
Transient Ischemic Attack
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Transient Ischemic Attack
Early Specific Treatment
Cardioembolism NOT suspected
ASA 160-325 mg/day as early aspossible & continue for 14 days
ASA 80mg + Clopidogrel 75mgmay be considered for short-termtreatment
Ensure neuroprotection*
Cardioembolism Suspected
IV heparin or SQ LMWH forindividuals at high risk of earlrecurrence (AF with thrombuor MI) or ASA 160-325mg/d
anticoagulation is not possiblecontraindicated)
If IE is suspected, give antibiDO NOT anticoagulate
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Transient Ischemic Attack
Delayed Management and Secondary Prevention
Cardioembolism NOT suspected
Give antiplatelets (ASA,clopidogrel, cilostazol, triflusal,dipyridamole + ASA)
Control/treat risk factors Carotid UTZ (extracranialstenosis)
TCD studies or CTA/MRA(intracranialstenosis)
Cardioembolism Suspected
Echocardiography and/or rcardiologist
NOACs > dose-adjusted w
ASA 160-325mg/day ifanticoagulation is contraind
ASA + Clopidogrel is reaso
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Transient Ischemic Attack
Delayed Management and Secondary Prevention
Screening for hypercoagulable states and drug/toxicology tests may beconsidered for young patients with TIA/stroke especially when no vrisk factors exist and no underlying cause is identified.
If vasculitis is suspected, may do ESR, ANA and lupus anticoagulan
TEE to rule out PFO in cryptogenic strokes
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GUIDELINES FOR THEMANAGEMENT OF
MILD STROKE
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Mild Stroke
Management Priorities Ascertain clinical dx of stroke
Exclude common stroke mimics
ID comorbidities
ABCs of resuscitation Monitor the ff:
NVS, pupil size, BP, MAP, RR, temp, SO2
Perform and monitor stroke scales(NIHSS, GCS)
Provide O2support to maintain SO
Treat BP if MAP >130
Avoid precipitous drop (not >15% of baselin
24 hrs
Do not use rapid-acting SL agents; when need
titratable IV or short-acting oral antihyperten
Ensure appropriate hydration
0.9% NaCl
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Emergent Diagnostics CBC
CBG or RBS
PT, aPTT
ECG
Cranial NCCT scan or MRI-DWI as soon aspossible
If ICH is evident, compute for the hematomavolume
Mild Stroke
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Mild Stroke
Early Specific Treatment(requires neuroimaging confirmation)
ISCHEMIC
ASA 160-325mg/day as early as possibleand continue for 14 days
ASA 80mg + Clopidogrel 75mg mayconsidered for short-term treatment
Ensure neuroprotection*
Consider IV heparin or SQ LMWindividuals at high risk of early r(AF with thrombus, VHD, or M160-325mg/day (if anticoagulati
possible or is contraindicated)
Ensure neuroprotection*
If IE is suspected, give antibiotiNOT anticoagulate
Cardioembolism SuspectedCardioembolism NOT suspected
(Thrombotic, Lacunar)
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Mild Stroke
Early Specific Treatment(requires neuroimaging confirmation)
HEMORRHAGIC Early neurology and/or neurosurgery consult for all ICH cases
Monitor and maintain target SBP 140mmHg during the first week
Ensure neuroprotection*
Early rehabilitation once stable within 72hrs
Give AEDs for clinical seizures and proven subclinical or electrographic seizures Prophylactic AEDs and steroids are generallynot recommended.
Monitor/ correct for metabolic parameters and coagulation/ bleeding abnormalities
Follow recommendations for neurosurgical intervention
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Mild Stroke
Delayed Management and Secondary PreventionISCHEMIC
Cardioembolism NOT suspected
(Thrombotic, Lacunar)
Give antiplatelets (ASA, clopidogrel,cilostazol, triflusal, dipyridamole, ER-dipyridamole + ASA)
Control/treat risk factors
Carotid UTZ (extracranialstenosis)
TCD studies or CTA/MRA (intracranialstenosis)
Cardioembolism Suspected
Echocardiography and/or refer cardiologist
NOACs > dose-adjusted warfari
ASA 160-325mg/day if anticoagcontraindicated
ASA + Clopidogrel is reasonabl
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Mild Stroke
Delayed Management and Secondary PreventionHEMORRHAGIC
Long-term strict BP control and monitoring
Contrast CT scan, 4-vessel cerebral angiogram, MRA or CTA if the is:
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GUIDELINES FOR THEMANAGEMENT OF
MODERATE STROKE
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Moderate Stroke
Management Priorities Ascertain clinical dx of stroke
Exclude common stroke mimics
ID comorbidities
ABCs of resuscitation Monitor the ff:
NVS, pupil size, BP, MAP, RR, temp, SO2
Perform and monitor stroke scales (NIHSS,GCS)
Provide O2support to maintain SO
Treat BP if MAP >130
Avoid precipitous drop (not >15% of baselin
24 hrs
Do not use rapid-acting SL agents; when need
titratable IV or short-acting oral antihyperten
Recognize and treat for early S/Sincreased ICP
Ensure appropriate hydration
0.9% NaCl
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Emergent Diagnostics CBC
CBG or RBS
PT, aPTT
Serum Na+ and K+
ECG
Cranial NCCT scan or MRI-DWI as soon aspossible
If ICH is evident, compute for the hematoma volume
Moderate Stroke
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Moderate StrokeEarly Specific Treatment
(requires neuroimaging confirmation)
ISCHEMIC
Cardioembolism NOT suspected
Refer to neurologist for evaluation anddecision
w/in 3-4.5hrs of stroke onset:
IV thrombolysis (rt-PA)
w/in 6hrs:
Intra-arterial thrombolysis (in specialized
centers)
ASA 160-325mg/day 24 hrs aftetreatment and continue for 14 da
Ensure neuroprotection*
Early rehabilitation once stable whrs
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Moderate StrokeEarly Specific Treatment
(requires neuroimaging confirmation)
ISCHEMIC
Cardioembolism Suspected
Refer to neurologist for evaluation anddecision
w/in 3-4.5hrs of stroke onset:
IV thrombolysis (rt-PA)
w/in 6hrs:
Intra-arterial thrombolysis (in specialized
centers)
If px is ineligible for thrombolyticor 24hrs post-rt-PA treatment:
IV heparin or SQ LMWH for indhigh risk of early recurrence; or
ASA 160-325mg/day if anticoagnot possible or is contraindicated
Ensure neuroprotection*
if IE is suspected, give antibioticsNOT anticoagulate
Early rehabilitation once stable wi
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Moderate StrokeEarly Specific Treatment
(requires neuroimaging confirmation)
HEMORRHAGIC Early neurology and/or neurosurgery consult for all ICH cases
Monitor and maintain target SBP 140mmHg during the first week
Ensure neuroprotection*
Early rehabilitation once stable within 72hrs
Give AEDs for clinical seizures and proven subclinical or electrographic seizures
Prophylactic AEDs and steroids are generallynot recommended.
Monitor/ correct for metabolic parameters and coagulation/ bleeding abnormalities
Follow recommendations for neurosurgical intervention
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Moderate Stroke
Delayed Management and Secondary PreventionISCHEMIC
Cardioembolism NOT suspected
(Thrombotic, Lacunar)
Give antiplatelets (ASA, clopidogrel,cilostazol, triflusal, dipyridamole, ER-dipyridamole + ASA)
Control/treat risk factors
Carotid UTZ (extracranialstenosis)
Cardioembolism Suspected
Echocardiography and/or refer cardiologist
NOACs > dose-adjusted warfari ASA 160-325mg/day if anticoag
contraindicated
ASA + Clopidogrel is reasonabl
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Moderate Stroke
Delayed Management and Secondary PreventionHEMORRHAGIC
Long-term strict BP control and monitoring
Contrast CT scan, 4-vessel cerebral angiogram, MRA or CTA if the is:
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GUIDELINES FOR THEMANAGEMENT OF
SEVERE STROKE
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Severe Stroke
Management Priorities Ascertain clinical dx of stroke
Exclude common stroke mimics
ID comorbidities
ABCs of resuscitation
Monitor the ff:
NVS, pupil size, BP, MAP, RR, temp, SO2
Perform and monitor stroke scales (NIHSS,GCS)
Provide O2support to maintain SO
Treat BP if MAP >130
Avoid precipitous drop (not >15% of baselin
24 hrs
Do not use rapid-acting SL agents; when need
titratable IV or short-acting oral antihyperten
Recognize and treat for early S/Sincreased ICP
Ensure appropriate hydration
0.9% NaCl
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Emergent Diagnostics CBC
CBG or RBS
PT, aPTT
Serum Na+ and K+ ECG
Cranial NCCT scan or MRI-DWI as soon aspossible
If ICH is evident, compute for the hematoma volume
Severe Stroke
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Severe StrokeEarly Specific Treatment
(requires neuroimaging confirmation)
ISCHEMIC
Cardioembolism NOT suspected
Refer to neurologist for evaluation anddecision
w/in 3-4.5hrs of stroke onset:
IV thrombolysis (rt-PA)
w/in 6hrs:
Intra-arterial thrombolysis (in specialized
centers)
ASA 160-325mg/day 24 hrs aftetreatment and continue for 14 da
Ensure neuroprotection*
Early rehabilitation once stable whrs
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Severe StrokeEarly Specific Treatment
(requires neuroimaging confirmation)
ISCHEMIC
Cardioembolism Suspected
May give ASA 160-325mg/day
Ensure neuroprotection*
Refer to a neurologist for cases ofposterior circulation strokes within 12 hrsof onset for evaluation and decisionregarding thrombolytic therapy
For cases of cerebellar infarct, reneurosurgeon as soon as possibl
Early supportive rehabilitation
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Severe StrokeEarly Specific Treatment
(requires neuroimaging confirmation)
HEMORRHAGIC
Supportive treatment: Mannitol 20% 0.5-1g/kg BW q 4-6h for 3-7days
Ensure neuroprotection*
Give AEDs for clinical seizures and proven subclinical or electrographic seizures
Prophylactic AEDs and steroids are generallynot recommended.
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Severe StrokeEarly Specific Treatment
(requires neuroimaging confirmation)
HEMORRHAGIC Neurosurgical consult if:
Px is not herniated
Location of bleed is lobar, putamen, pallidum, or cerebellum
Pxsfamily is willing to accept consequences of irreversible coma or persistent vegetative state
ICP monitoring is contemplated and salvage surgery is considered
Early supportive rehabilitation
GOAL IS REDUCTION OF MORTALITY
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Severe StrokeDelayed Management and Secondary Prevention
ISCHEMIC
Cardioembolism NOT suspected
(Thrombotic, Lacunar)
Give antiplatelets (ASA, clopidogrel,cilostazol, triflusal, dipyridamole, ER-dipyridamole + ASA)
Control/treat risk factors
Cardioembolism Suspected
Echocardiography and/or refer cardiologist
NOACs > dose-adjusted warfari ASA 160-325mg/day if anticoag
contraindicated
ASA + Clopidogrel is reasonabl
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Severe StrokeDelayed Management and Secondary Prevention
HEMORRHAGIC
Long-term strict BP control and monitoring
Contrast CT scan, 4-vessel cerebral angiogram, MRA or CTA if the is:
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EARLY SPECIFIC TREATMENT OISCHEMIC STROKE
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ANTITHROMBOTIC THERAPYIN ACUTE STROKE
Aspirin (ASA)
[Clopidogrel + ASA] vs ASA alone
ClopidogrelASA vs ASA alone
Cilostazol vs ASA
LMWH
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NEUROPROTECTION
The Five H Principle:
AVOID
Hypotension, Hypoxemia, Hyperglycemia, Hypoglycemia andHypertherm
during acute stroke in an effort to salvage the ischemic penum
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Neuroprotective Interventions
1. Avoid HYPOTENSION and allow permissive hypertension dthe first (7) days.
Mean Arterial Pressure (MAP) = 2 (DBP) + SBP3
Cerebral Perfusion Pressure (CPP) = MAP - ICP
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Check if Px has any condition that may increase BP and address acc
Treat if SBP >220 mmHg or DBP >120 mmHg, or MAP >130.
Defer E BP therapy if MAP is within 110-130, or SBP = 185-220mor DBP = 105-120mmHg, UNLESS:
Px is a candidate for thrombolytic therapy
Presence of AMI, CHF, aortic dissection, acute pulmonary edema, ARF, andhypertensive encephalopathy
Neuroprotective InterventionsBP Management in Acute Ischemic Stro
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The use of IV Nicardepine is reasonable, readily available, easy to adand titrate, has short duration of action, and does not significantly af
Although rare in acute ischemic stroke, arterial hypotension (a baselineSBP
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In acute ischemic stroke, autoregulation is paralyzedin the affected tissues with
passively following MAP. Rapid BP lowering further decrease in perfus
penumbra.
Hypertension is typically present in acute stroke, with spontaneous decline in the 7days with attainment of neurological stability. SBP dropped by 28% du
first day whether or not medications were given.
SBP and DBP drops of >20mmHg were associated with early neurological
worsening, high rates of poor outcome or death, and larger volumes of inf
Rationale for Permissive Hypertension
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Treat if SBP > 180 mmHg
Acute lowering of SBP to 140mmHg within 7 days is safe and imp
outcome in patients with small-moderate size ICH not requiring surgintervention
If ICP monitor is available, keep CPP >70mmHg
Neuroprotective InterventionsBP Management in Acute Hypertensive I
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Treat hypertension with modest reductions in BP to minimize vasospand delayed cerebral ischemia
Preoperatively, for unsecured aneurysms, the use of IV Nicardepine target SBP
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1. Avoid HYPOTENSION and allow permissive hypertension during the first (7) days.
2. Avoid HYPOXEMIA
Routine O2is not warranted for all stroke patients unless theres evidence of h
or desaturation (target SO2>94%)
Monitor oxygenation via pulse oximeter and/or determine ABG Provide ventilator support if the upper airway is threatened, sensorium is imp
ICP is increased.
Neuroprotective Interventions
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1. Avoid HYPOTENSION and allow permissive hypertension during the first (7) days.
2. Avoid HYPOXEMIA
3. Avoid HYPERGLYCEMIA or HYPOGLYCEMIA
Hyperglycemia causes lactic acidosis, increases free radical production, worsens cerebral weakens blood vessels
Hypoglycemia can mimic a stroke
Achieve glucose targets of 140-180mg/dl if the FBS is >140mg/dl or RBS isconsistently >180mg/dl
Neuroprotective Interventions
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1. Avoid HYPOTENSION and allow permissive hypertension during the first (7) days.
2. Avoid HYPOXEMIA
3. Avoid HYPERGLYCEMIA or HYPOGLYCEMIA
Use an established and standardized IV insulin protocol for pxs who present extreme or persistent hyperglycemia, are critically ill, or who have received thr
therapy for at least the first 24-48hrs of hospitalization SQ basal long-actin+ rapid-acting insulin
For pxs who are feeding, add rapid-acting prandial (meal) insulin
Avoid D5 IV fluids
Neuroprotective Interventions
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1. Avoid HYPOTENSION and allow permissive hypertension during the first (7) days.
2. Avoid HYPOXEMIA
3. Avoid HYPERGLYCEMIA or HYPOGLYCEMIA
4. Avoid HYPERTHERMIA
Associated withpoor outcome metabolic demand, free radical production, enh
neurotransmitter release RR of 1-year mortality by 3.4 times
Treat fever with antipyretics and cooling blankets. Investigate for source of feverinfection)
Neuroprotective Interventions
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Neuroprotective and Neurorestorative Dru
Cerebrolysin
Citicoline
NeuroAID
The use of drugs with neurorestorative andneuroprotective properties in acute stroke remains as a
matter of preference of the attending physician.
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ANTICOAGULATION INACUTE CARDIOEMBOLIC STRO
Sources of Cardioembolic Stroke
Low or Uncertain Risk High Risk
MVP Mitral annular calcification Patent Foramen Ovale (PFO) Atrial Septal Aneurysm
Calcific aortic stenosis Mitral valve strands
AF (valvular or non-valvular) Rheumatic MS Prosthetic heart valves Recent MI
LV/LA thrombus Atrial myxoma IE Dilated cardiomyopathy Marantic endocarditis
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ANTICOAGULATION INACUTE CARDIOEMBOLIC STRO
Features Suggestive of Cardioembolic Stroke
Sudden onset of maximal deficit (
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ANTICOAGULATION INACUTE CARDIOEMBOLIC STRO
Features Suggestive of Cardioembolic Stroke
Onset of symptoms after a Valsalva-provoking activity (e.g., coughing, bending)
Infratentorial ischemic stroke (cerebellar, PCA, and multi-level infarcts, top-of-thsyndrome)
Hemorrhagic transformation and early recanalization of occluded intracranial ves
Neuroimaging finding of acute infarcts involving multiple vascular territories in t(predominantly carotid and MCA territories), or multiple levels of the posterior c
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ANTICOAGULATION INACUTE CARDIOEMBOLIC STRO
Indications and Contraindications for Anticoagulation in Patients with
Cardioembolic Stroke
Probably Indicated Contraindicated
Intracardiac thrombus Mechanical prosthetic valve
Recent MI CHF Bridging measure for long-term
coagulation
Bleeding diathesis Non-petechial intracranial
hemorrhage Recent major surgery or trauma Infective endocarditis
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ANTICOAGULATION INACUTE CARDIOEMBOLIC STRO
How to anticoagulate
Heparin 600-800 units per hour TIV via infusion pump. Heparin bolus IS NOT rec
Perform aPTT as often as necessary, every 4-6hrs after dose adjustments, to keeplevels at 1.5-2.5x the control
Infusion may be discontinued once oral anticoagulation with warfarin has reached
therapeutic levels or once antiplatelet medication is initiated for secondary preven
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ANTICOAGULATION INACUTE CARDIOEMBOLIC STRO
The benefits of reducing early stroke recurrence should be weighed against the rihemorrhagic transformation
higher in patients with large infarction, severe strokes or neurologic deficits, uncontrolled hypertension
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MANAGEMENT OF
INCREASED INTRACRANIALPRESSURE
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MANAGEMENT OF INCREASED
Signs and Symptoms of Increased ICP
Deteriorating level of sensorium
Cushings triad: hypertension, bradycardia, irregular respiration
Anisocoria
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MANAGEMENT OF INCREASED
General
Control agitation and pain with short-acting medications, such as NSAIDs an
Treat fever aggressively. Avoid hyperthermia.
Control seizures if present.
Phenytoin 18-20mg/kg LD slow IV, then maintained at 3-5 mg/kg; or
Levetiracetam 500mg IV q12
Strict blood glucose control between 140-180mg/dl
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MANAGEMENT OF INCREASED
General
Maintain normal fluid and electrolyte balance
Avoid excessive free water or any hypotonic fluids such as D5W
Maintain normal volume status
Encourage hyperosmolar state with hypertonic saline and/or induce free water clwith mannitol or diuretics
Use stool softeners to prevent straining
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MANAGEMENT OF INCREASED
Specific
Elevate the head at 30-45 degrees to assist venous drainage.
Do CSF drainage in the setting of hydrocephalus.
Administer osmotic therapy:
Give Mannitol 20% IV infusion: 0.5-1.5g/kg q 3-6h Hypertonic saline is an option
Always maintain serum osmolality at 300-320mosmol/kg
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MANAGEMENT OF INCREASED
Specific
Hyperventilate only in impending herniation by adjusting tidal volume (targetlevels of 30-35mmHg)
Carefully intubate patients with respiratory failure defined as:
SO2< 90% by pulse oximeter
By ABG: PaO2 < 60 mmHg, and/ or PaCO2> 55mmHg
Consider surgical evacuation or decompressive hemicraniectomy if indicated
ICP catheter insertion
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GUIDELINES FORANTIPLATELET THERAPY INNONCARDIOEMBOLIC
STROKE OR TRANSIENTISCHEMIC ATTACK
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GUIDELINES FOR ANTIPLATELET THERAPY IN
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GUIDELINES FOR ANTIPLATELET THERAPY INNONCARDIOEMBOLIC STROKE OR TRANSIENT ISCHE
ATTACK
Although often considered for patients who have an ischemic strokewhile already on ASA, there is insufficient evidence to show that swian alternative antiplatelet agents or the use of antiplatelet combinatioreduces the risk for subsequent events.
It is recommended that patients who develop recurrent stroke while
antithrombotic therapy be re-evaluated for pathophysiology and risk
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A good history and physical examination of patients could not beoveremphasized.
Identification of stroke mimickers should be facilitated to rule outpossible diagnoses.
Comorbid conditions should be addressed adequately.
In our setting, there should be a conscious effort in the judicious usediagnostic examinations to maximize our resources in the managemestroke patients.
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Care of critically ill patients is a TEAM EFFORT.
Guidelines are guidelines. Management of patients should be individdepending on the patients clinical profile.
Talk to your patients and their relatives.
We are not GOD but we can be ANGELS.
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