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The recommendations contained in this document are intended to merely guide practitioners in the prevention, treatment and rehabilitation of patients
with stroke. In no way should these recommendations be regarded as absolute rules, since nuances and peculiarities in individual patients, situations or
communities may entail differences in specific approaches. The recommendations should supplement, not replace, sound clinical judgments on a case-
to-case basis.
Acute Stroke Treatment
Admit to Hospital (Stroke Unit) Urgent Outpatient Work-up
Place of 1. TIA within 48 hours TIA >2 weeks (but work-ups should be
Treatment 2. Crescendo TIAs (multiple & increasing done within 24 – 48 hours)
symptoms)
3. TIA with known high risk cardiac source of
embolism, known hypercoagulable state
or symptomatic ICA stenosis
4. Patient with ABCD2 score of >3
Non-cardioembolic
(Thrombotic/Lacunar) Cardioembolic Others
Guidelines for Mild Stroke
Ascertain clinical diagnosis of stroke (history and physical exam are very important)
Management • Exclude common stroke mimickers
Priorities • Provide basic emergent supportive care (ABCs of resuscitation)
• Monitor neuro-vital signs, BP, MAP, RR, temperature, pupils, O2 saturation
• Perform and monitor stroke scales (NIHSS, GCS)
• Provide O2 support to maintain O2 saturation >95%
• Monitor and manage BP; treat if MAP >130
Precautions:
• Avoid precipitous drop in BP (not >15% of baseline MAP). Do not use rapid-acting
sublingual agents; when needed use easily titratable IV or oral antihypertensive
medication.
• Ensure adequate hydration. Recommended IVF - 0.9% NaCl.
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Acute Stroke Treatment
Ischemic Hemorrhagic
Follow recommendations
for neurosurgical interven-
tion
Ischemic Hemorrhagic
Delayed Non-cardioembolic
Management (Thrombotic, Lacunar) Cardioembolic
and Treatment
(Secondary Antiplatelets (aspirin, clopidogrel, Echocardiography and/ Long-term strict BP control
Prevention) cilostazol, triflusal, dipyridamole, or cardiology consult and monitoring
extended-release dipyridamole +
aspirin combination) If age <75 and PT/INR Consider contrast CT
available, anticoagula- scan, 4 vessel cerebral
Control of risk factors tion with warfarin angiogram, MRA or CTA
(target INR: 2-3) if patient is:
Recommended vascular studies
such as carotid ultrasound to If age >75, warfarin 1) <45 years old,
document extracranial stenosis. (target INR: 2.0 [1.6-2.5]) 2) normotensive
If this reveals >70% stenosis, refer 3) has lobar ICH
to neurologist/neurosurgeon/vascular If anticoagulation is 4) uncertain cause of ICH
surgeon for decision-making contraindicated, give 5) suspected to have
regarding CEA or stenting antiplatelets (ASA 160 aneurysm, AV malformation
mg-325 mg) or vasculitis
To document intracranial stenosis,
recommend either TCD or MRA
or CTA
Acute Stroke Treatment
Guidelines for Moderate Stroke
Ascertain clinical diagnosis of stroke (history and physical exam are very important)
Management • Exclude common stroke mimickers
Priorities Basic emergent supportive care (ABCs of resuscitation)
Neuro-vital signs, BP, MAP, RR, temperature, pupils, oxygen saturation
Perform and monitor stroke scales (NIHSS, GCS)
Monitor and manage BP. Treat if MAP >130
Provide O2 support to maintain O2 saturation >95%
• Precaution: Avoid precipitous drop in BP (not >15% of baseline MAP). Do not use rapid-acting
sublingual agents; when needed use easily titratable IV or oral antihypertensive medication.
Identify comorbidities (cardiac disease, diabetes, liver disease, gastric ulcer, etc.)
Recognize and treat early signs and symptoms of increased ICP
Ensure adequate hydration. Recommended IVF-0.9% NaCl
Ischemic Hemorrhagic
Delayed Non-cardioembolic
Management (Thrombotic, Lacunar) Cardioembolic
and Treatment
(Secondary Antiplatelets (aspirin, clopidogrel, Echocardiography and/ Long-term strict BP control
Prevention) cilostazol, triflusal, dipyridamole, or cardiology consult and monitoring
extended-release dipyridamole +
aspirin combination) If age <75 and PT/INR Consider contrast CT scan,
available, anticoagu- 4 vessel cerebral angio-
Control of risk factors lation with warfarin gram, MRA or CTA if
(target INR: 2-3) patient is:
Recommended vascular studies
such as carotid ultrasound to If age >75, warfarin 1) <45 years old,
document extracranial stenosis. (target INR: 2.0 [1.6-2.5]) 2) normotensive
If this reveals >70% stenosis, refer 3) has lobar ICH
to neurologist/neurosurgeon/ If anticoagulation is 4) uncertain cause of ICH
vascular surgeon for decision- contraindicated, give 5) suspected to have
making regarding CEA or stenting antiplatelets aneurysm, AV
(ASA 160-325 mg) malformation or
To document intracranial stenosis, vasculitis
recommend either TCD or MRA
or CTA.
Guidelines for Severe Stroke
Ascertain clinical diagnosis of stroke (history and physical exam are very important)
Management • Exclude common stroke mimickers
Priorities Basic emergent supportive care (ABCs of resuscitation)
Neuro-vital signs, BP, MAP, RR, temperature, pupils, oxygen saturation
Perform and monitor stroke scales (NIHSS, GCS)
Monitor and manage BP; treat if MAP >130
Provide O2 support to maintain O2 saturation >95%
• Precaution: Avoid precipitous drop in BP (not >15% of baseline MAP). Do not use rapid-
acting sublingual agents; when needed use easily titratable IV or oral antihypertensive
medication.
Identify comorbidities (cardiac disease, diabetes, liver disease, gastric ulcer, etc.)
Recognize and treat early signs and symptoms of increased ICP
Ensure adequate hydration. Recommended IVF-0.9% NaCl
10
Acute Stroke Treatment
Ischemic Hemorrhagic
Early supportive
rehabilitation
Delayed Discuss prognosis with relatives of the patient in a most compassionate manner
Management
and Ischemic Hemorrhagic
Treatment
(Secondary Non-cardioembolic
Prevention) (Thrombotic, Lacunar) Cardioembolic
Antiplatelets (Aspirin, clopidogrel, Echocardiography and/ Long-term strict BP control
cilostazol, triflusal, dipyridamole, or cardiology consult and monitoring
extended-release dipyridamole +
aspirin combination) If age <75 and PT/INR Consider contrast CT scan,
available, anticoagula- 4 vessel cerebral angio-
Control of vascular risk factors tion with warfarin (target gram, MRA or CTA
INR: 2-3) if patient is:
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Acute Stroke Treatment
Early Specific Treatment for Ischemic Stroke
International Stroke Trial 19,435 patients with acute Aspirin treated patients had
(IST, Lancet 1997; 349: ischemic stroke were slightly fewer deaths at 14 days,
1569-1581) randomized within 48 hrs to significantly fewer recurrent
Aspirin 300 mg day, subcuta- ischemic strokes at 14 days
neous heparin 5000 units BID and no excess of hemorrhagic
or 12,500 units BID, Aspirin strokes
plus heparin or neither
For patients receiving heparin,
there were fewer deaths or
recurrent strokes; however
Aspirin
Chinese Acute Stroke Trial 21,106 patients with acute Aspirin significantly reduced
(CAST, Lancet 1997;449: ischemic stroke within 48 hours the risk of recurrent stroke or
1641-1649) were randomized to Aspirin vascular death
160 mg OD or placebo for up
to 4 weeks
Fast assessment of Stroke 392 patients with TIA or minor The trial was prematurely
and Transient Ischemic Attack stroke within 24 hours were terminated because of failure
to Prevent Early Recurrence, randomized to Clopidogrel to recruit patients at the pre-
Clopidogrel-ASA vs Aspirin
(FASTER, Lancet Neurology (300 mg loading dose then specified recruitment rate
2007; 6:961-969) 75 mg/day plus Aspirin 81 mg because of increased use
or Aspirin 75 mg alone, with or of statins
without Simvastatin (in factorial
design) and followed up for Recurrent stroke at 90 days
90 days) were: Clopidogrel-ASA (7.1%),
Aspirin alone (10.1%),
absolute risk reduction of
3.8% p=0.19
Recent MI Atrial septal aneurysm 1. Adams H. Emergent use of anticoagulation for treatment of patients with
ischemic stroke. Stroke 2002;33:856-861.
LV/LA thrombus Calcific aortic stenosis 2. Hart R, Palacio S, Pearce L. Atrial fibrillation, stroke and acute
Atrial myxoma Mitral valve strands antithrombotic therapy. Stroke 2002;33:2722-2727.
3. Moonis, M, Fisher M. Considering the role of heparin and low-molecular
Infective Endocarditis weight heparin in acute ischemic stroke. Stroke 2002;33:1927-1933.
4. Paciaroni M, Agnelli G, Micheli S. et al. Efficacy and safety of
Dilated cardiomyopathy anticoagulant treatment in acute cardioembolic stroke: A meta-analysis
of randomized controlled trials. Stroke 2007; 38: 423-430.
Marantic endocarditis
14
Acute Stroke Treatment
IV. ADIMINITRATION of rt-PA to ACUTE ISCHEMIC STROKE PATIENTS
NINDS tPA trial: National Institute 291 patients with acute ischemic No difference in neurologic
of Neurological Disorders and stroke <3 hours were randomized improvement at 24 hours, but
Stroke tPA trial (N Eng J Med to tpa (0.9 mg/kg IV) or placebo patients given IV rt-PA were
1995;333:1581 - 1587) and assessed for 4-point 30% more likely than controls to
improvement in NIH stroke scale have minimal or no disability at
or the resolution of neurological 3 months, despite more symp-
deficit within 24 hours; 333 tomatic ICH (6.4% vs 0.6%).
patients received IV rt-PA within Overall, there was no difference
3 hours of symptom onset and in mortality in 3 months.
were assessed for functional and
clinical outcome for 3 months
ECASS: European Australasian 620 patients with acute ischemic No difference in disability using
Cooperative Acute Stroke Study stroke <6 hours were randomized intention to treat analysis.
(JAMA 1995;274:1017-1025) to tPA 1.1 mg/kg or placebo However, there were 109 major
protocol violations. Post hoc
analysis excluding these patients
indicated better recovery for tPA
group at 90 days
ECASS II: Second European 800 patients with acute ischemic No significant difference was
Australasian Cooperative Acute stroke <6 hours were randomized seen in the rate of favorable
Stroke Study (Lancet 1998;352: to tPA 0.9 mg/kg or placebo outcome at 3 months between
1245-1251) rt-PA and placebo treated group
ATLANTIS A: Alteplase 142 patients with acute ischemic No significant difference was
Thrombolysis for Acute stroke <6 hours were randomized seen on any of the planned
Non-interventional Therapy in to tPA 0.9 mg/kg or placebo efficacy endpoints at 30 and
Ischemic Stroke 90 days between groups. The
(Stroke 2000;31:811-816) risk of symptomatic ICH was
increased with rt-PA treatment
particularly in patients treated
between 5 to 6 hours
EMS: Emergency Management 35 patients with acute ischemic IV/IA treatment resulted in
of Stroke Bridging Trial stroke <3 hours were randomized higher recanalization rate but
(Stroke 1999;30:2598-2605) to IV plus local intra-arterial (IA) no difference in outcome at 7
tPA vs intra-arterial tPA alone days or 3 months. The rate of
symptomatic intracerebral
hemorrhage was similar between
groups
ECASS III: European Australasian 821 patients with acute ischemic Significantly more patients in
Cooperative Acute Stroke Study stroke within 3 to 4.5 hours were the rt-PA treated group had
(N Eng J Med 2008; 359: randomized to tPA 0.9 mg/kg or favorable outcome at 3 months
1317-1329) placebo (52.4% vs 45.2%, p = 0.04). The
incidence of intracranial
hemorrhage was higher with
rt-PA but mortality did not
significantly differ between the
2 groups.
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Acute Stroke Treatment
Administration of rt-PA to Acute Ischemic Stroke lets, Blood glucose, PT or aPTT (in patients with
Patients (0-3 hours) recent use of oral anticoagulants or heparin)
• Review patient selection criteria
1. Eligibility for IV treatment with rt-PA • Infuse rt-PA.
• Age 18 or older. • Give 0.9 mg/kg, 10% as a bolus, intravenously.
• Clinical diagnosis of ischemic stroke causing a • Do not use the cardiac dose.
measurable neurological deficit. • Do not exceed the 90 mg maximum dose.
• Time of symptom onset well established to be less • Do not give aspirin, heparin or warfarin for 24
than 180 minutes before treatment would begin. hours.
• Monitor the patient carefully, especially the blood
2. Patient Selection: Contraindications and Warnings pressure. Follow the blood pressure algorithm (see
• Evidence of intracranial hemorrhage on pretreat- below and sample orders).
ment CT. • Monitor neurological status.
• Only minor or rapidly improving stroke symptoms.
• Clinical presentation suggestive of subarachnoid 5. Adjunctive Therapy
hemorrhage, even with normal CT. • No concomitant heparin, warfarin, or aspirin during
• Active internal bleeding. the first 24 hours after symptom onset. If heparin or
• Known bleeding diathesis, including but not limited any other anticoagulant is indicated after 24 hours,
to: consider performing a non-contrast CT scan or
♦ Platelet count <100,000/mm other sensitive diagnostic imaging method to rule
♦ Patient has received heparin within 48 hours and out any intracranial hemorrhage before starting an
has an elevated aPTT (greater than upper limit anticoagulant.
of normal for laboratory)
♦ Current use of oral anticoagulants (e.g., war- 6. Blood Pressure Control
farin sodium) or recent use with an elevated Pretreatment
prothrombin time >15 seconds • Monitor blood pressure every 15 minutes. It should
• Patient has had major surgery or serious trauma be below 185/110 mm Hg.
excluding head trauma in the previous 14 days. • If over 185/110, BP may be treated with nitroglycerin
• Within 3 months any intracranial surgery, serious paste and/or one or two 10-20 mg doses of labetalol
head trauma, or previous stroke. given IV push or Nicardipine infusion of 5 mg/hour
• History of gastrointestinal or urinary tract hemor- titrate up by 2.5 mg every 5 - 15 mins interval. If
rhage within 21 days. these measures do not reduce BP below 185/110
• Recent arterial puncture at a non-compressible and keep it down, the patient should not be treated
site. with rt-PA.
• Recent lumbar puncture.
• On repeated measurements, systolic blood pres- During and after treatment.
sure greater than 185 mm Hg or diastolic blood
pressure greater than 110 mm Hg at the time treat- • Monitor blood pressure for the first 24 hours after
ment is to begin, and patient requires aggressive starting treatment:
treatment to reduce blood pressure to within these ♦ Every 15 minutes for 2 hours after starting the
limits. infusion, then
• History of intracranial hemorrhage. ♦ Every 30 minutes for 6 hours, then
• Abnormal blood glucose (<50 or >400 mg/dL). ♦ Every hour for 18 hours.
• Post myocardial infarction pericarditis.
• Patient was observed to have seizures at the • If systolic BP >230 mm Hg and/or diastolic BP is
same time the onset of stroke symptoms were 121-140 mm Hg, give labetalol 20 mg intravenously
observed. over 1 to 2 minutes. The dose may be repeated
• Known arteriovenous malformation, or aneurysm. and/or doubled every 10 minutes, up to 150 mg.
Alternatively either an intravenous infusion of 2 to 8
3. Treatment mg/min labetalol may be initiated after the first bolus
• 0.9 mg/kg (maximum of 90 mg) infused over 60 of labetalol or Nicardipine infusion 5 mg/hr infusion
minutes with 10% of the total dose administered is started and titrated up by 2.5 mg/hr every 5 - 15
as an initial intravenous bolus over 1 minute. mins interval until the desired BP is reached.
If satisfactory response is not obtained, use sodium
4. Sequence of Events nitroprusside.
• Draw blood for tests while preparations are made • If systolic BP is 180 to 230 mm Hg and/or diastolic
to perform non-contract CT scan. BP is 105 to 120 mm Hg on two readings 5 to 10
• Start recording blood pressure minutes apart, give labetalol 10 mg intravenously
• Neurological examination. over 1 to 2 minutes. The dose may be repeated
• CT scan without contrast. or doubled every 10 to 20 minutes, up to 150 mg.
• Determine if CT has evidence of hemorrhage. Alternatively, following the first bolus of labetalol,
• If patient has severe head or neck pain, or is som- an intravenous infusion of 2 to 8 mg/min labetalol
nolent or stuporous, be sure there is no evidence may be initiated and continued until the desired
of subarachnoid hemorrhage. blood pressure is reached.
• If there is a significant abnormal lucency suggestive • Monitor blood pressure every 15 minutes during
of infarction, reconsider the patient’s history, since the antihypertensive therapy. Observe for hypoten-
the stroke may have occurred earlier. sion.
• Review required test results — Hematocrit, Plate- • If, in the clinical judgment of the treating physi-
16
Acute Stroke Treatment
cian, an intracranial hemorrhage is suspected, the
The search for a thrombolytic agent that can be
administration of rt-PA should be discontinued and
used beyond the 3 hours of acute ischemic stroke
an emergency CT scan or other diagnostic imaging
is being addressed by the ongoing DIAS-3 study or
method sensitive for the presence of intracranial
Desmoteplase In Acute Stroke Study. This double blind
hemorrhage should be obtained.
randomized trial will determine whether desmoteplase
is effective and safe in the treatment of patients with
Management of Intracranial Hemorrhage
acute ischaemic stroke when given within 3-9 hours
• Suspect the occurrence of intracranial hemorrhage
from onset of stroke symptoms. Patients should have
following the start of rt-PA infusion if there is any
an NIHSS Score of 4-24 and a documented vessel
acute neurological deterioration, new headache,
occlusion or high-grade stenosis on MRI or CTA in
acute hypertension, or nausea and vomiting.
proximal cerebral arteries. The Philippines is partici-
• If hemorrhage is suspected then do the following:
patory in this trial.
♦ Discontinue rt-PA infusion unless other causes
of neurological deterioration are apparent.
♦ Immediate CT scan or other diagnostic imaging
BLOOD PRESSURE MANAGEMENT AFTER ACUTE
method sensitive for the presence of hemor-
STROKE
rhage.
♦ Draw blood for PT, aPTT, platelet count, fibrino-
A. BP management in Acute Ischemic Stroke
gen, and type and cross (may wait to do actual
type and cross).
1. Use the following definitions:
♦ Prepare for administration of 6 to 8 units of
cryoprecipitate containing factor VIII.
Cerebral Perfusion Pressure (CPP) = MAP-ICP
♦ Prepare for administration of 6 to 8 units of
MAP = 2 (diastolic) + systolic
platelets.
3
• If intracranial hemorrhage is present:
Normal CPP = 70-100 mmHG
♦ Obtain fibrinogen results.
Normal ICP = 5-10 mmHG
♦ Consider administering cryoprecipitate or plate-
lets if needed.
2. Check if patient is in any condition that may increase
♦ Consider alerting and consulting a hematologist
BP such as pain, stress, bladder distention or
or neurosurgeon.
constipation, which should be addressed accord-
♦ Consider decision regarding further medical
ingly.
and/or surgical therapy.
♦ Consider second CT to assess progression of
3. Allow “permissive hypertension” during the first
intracranial hemorrhage.
week to ensure adequate CPP but ascertain cardiac
♦ A plan for access to emergent neurosurgical
and renal protection.
consultation is highly recommended.
This Protocol is Based on Research Supported by the National Institute a. Treat if SBP>220 or DBP>120 or MAP>130
of Neurological Disorders and Stroke (NINDS) (NOI-NS-02382, N01-NS-
02374, NO1-NS-02377, NO1-NS-02381, NO1-NS-02379, NOi-NS-02373, b. Defer emergency BP therapy if MAP is within
NO1-NS-02378, NOl-NS-02376, NOl-NS-02380).
110-130 or SBP=185-220 mmHg or DBP=l05-
120 mmHg, unless in the presence of:
Expansion of IV rt-PA Treatment Time Window up ♦ Acute MI
to 4.5 Hours ♦ Congestive heart failure
♦ Aortic dissection
Eligibility for IV treatment follows the same criteria as ♦ Acute pulmonary edema
treatment within the first 3 hours with the following addi ♦ Acute renal failure
tional exclusion criteria: ♦ Hypertensive encephalopathy
• Patients older than 80 years old
• Patients on oral anticoagulants, regardless of INR Rationale for Permissive Hypertension:
level • In acute ischemic stroke, autoregulation is
• Patients with NIHSS >25 paralyzed in the affected tissues with CBF
• Patients with stroke and diabetes passively following MAP. Rapid BP lowering
can lead to further ↓ perfusion in the penum-
Ancillary care for patients receiving IV rt-PA treatment bra.
at 3 - 4.5 hours after acute ischemic stroke is similar to • HPN is typically present in acute stroke,
that listed above. with spontaneous decline within the first 5-7
Bibiography
days.
• ↑ ICP during the acute phase of large infarcts
1. Adams H, del Zoppo G, Alberts M et aL Guidelines for the early reduces the net CPP.
management of patients with ischemic stroke. 2007 Guidelines update, • Several reports have documented neurologi-
a scientific statement from the Stroke Council of the American Heart
Association. Stroke 2007;38:1655- 1711. cal deterioration & poor outcome from rapid
2. Del Zoppo, G, Saver J,Juach E and Adams, H on behalf of the American and aggressive pharmacologic lowering of
Heart Association Stroke Council. Expansion of the Time Window for BP.
Treatment of Acute Ischemic Stroke with Tissue Plasminogen Activator, a
science advisory from the American Heart Association / American Stroke
Association. Stroke 2009; 40:2945—2948.
4. Use the following locally available intravenous anti-
hypertensives in acute stroke to achieve target MAP
= 110-130 mmHg:
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Acute Stroke Treatment
Drug Dose Onset of Duration Availability/ Stability Adverse Action
Action of Action Dilution Reactions
1-15 mg/hour 5-10 mins 1-4 hours (10 mg/10 mL 1 to 4 hours Tachycardia, Inhibits calcium
amp); 10 mg headache, ion from
in 90 mL flushing entering slow
NSS/D5W dizziness, channel,
Nicardipine
somnolence, producing
nausea coronary,
vascular,
smooth
muscle relax-
ation &
vasodilation
IV push 10-20 10-20 mins 3-8 hours 25 mg/mL 4 days Tachycardia, Direct vasodila-
Hydralazine
5 mg lV push 2-5 mins 2-4 hours 5 mg/mL in 72 hours Orthostatic Alpha- & beta
over 2 mins 40 mL vial; hypotension, blocker. Beta-
repeat with 250 mg in drowsiness, adrenergic
incremental 250 mL dizziness, blocking activity
dose of 10, 20, NSS/D5W lightheaded- is 7x > than
Lobetalol
0.25-0.5 mg/ 2-10 mins 10-30 mins 100 mg/ 48 hours Hypotension, Short-acting
kg IV push 10 mL vial; bradycardia, beta-adrenergic
1-2 mins 2500 mg in AV block, blocking agent.
followed by 250 mL agitation, At low doses,
infusion of 0.05 D5W/NSS confusion, has little effect
mg/kg/min wheezing/ on beta 2
broncho- receptors
Esmolol
18
Acute Stroke Treatment
5. Treat patients who are potential candidates for rt-PA MANAGEMENT OF INCREASED INTRACRANIAL
therapy who have persistent elevations In SBP >185 PRESSURE
mmHg or DBP >110 mmHg with small doses of IV
antihypertensive agents. Maintain BP just below these A. Signs and symptoms of increased ICP
limits. 1. Deteriorating level of sensorium
2. Cushing's triad
B. Blood pressure management in Acute Hyperten- i. Hypertension
sive ICH ii. Bradycardia
iii. Irregular respiration
Treat if SBP >180 mmHg or MAP >130 mmHg. 3. Anisocoria
Maintain MAP = 110 or SBP = 160 mmHg
B. Management options for increased ICP
• Absence of ischemic penumbra allows for more General:
aggressive BP management 1. Control agitation and pain with short-acting medica-
• Sustained hypertension may promote early hema tions, such as NSAIDS and opioids.
toma expansion and worse, edema 2. Treat fever aggressively. Avoid hyperthermia.
• Hypotension may result in cerebral hypoperfusion 3. Control seizures if present. May treat with phenytoin
especially in the setting of increased intracranial with a loading dose of 18-20 mg/kg IV then main-
pressure (ICP) tained at 3-5 mg/kg or Levetiracetam 500 mg/IV q 12.
• Two recent phase II clinical trials on BP lowering Status epilepticus should be managed accordingly.
namely ATACH and INTERACT has shown that 4. Strict glucose control between 110-180 mg/dL.
intensive BP lowering to SBP = 140 in acute ICH is 5. Maintain normal fluid and electrolyte balance.
feasible and is probably safe. Phase III clinical stud- a. Avoid excessive free water or any hypotonic
ies are ongoing to determine its clinical efficacy. fluids such as D5W. Potential sources of free
Bibliography
water including hypotonic tube feedings, medi-
cations mixed in D5W, nasogastric tube flushes
1. Adams H, Adams R, del Zoppo G, Goldstein L. Guidelines for the early
with water should be minimized.
management of patients with ischemic stroke. 2005 Guidelines update, b. Maintain normal volume status (i.e., 3-3.5 liters
a scientific statement from the Stroke Council of the American Heart per day in a 60 kg patient).
Association. Stroke 2005;36:916-923. c. Encourage hyperosmolar state with hypertonic
2. Broderick JP, Adams HP, Barsan W, et al. Guidelines for the management saline and/or induce free water clearance with
of spontaneous intracerebral hemorrhage: a statement for healthcare mannitol or diuretics.
professionals from a special writing group of the Stroke Council of the 6. Use stool softeners to prevent straining.
American Heart Association. Stroke 1999;30:905-915.
3. Fogelhoim R, Avikainen S and Murros K. Prognostic value and Specific:
determinants of first day mean arterial pressure in spontaneous 1. Elevate the head at 30 to 45 degrees to assist
supratentorial intracerebral hemorrhage. Stroke 1997;28:1396-1400. venous drainage.
4. Guyton A and HaII J. Guyton and Hall’s Textbook of Medical Physiology, 2. Do CSF drainage in the setting of hydrocephalus.
11th ed. USA: WB Saunders; 2005. 3. Administer osmotic therapy:
5. Kidwell CS, Saver JL, Mattiello J, et al. Diffusion perfusion MR evaluation • Give Mannitol 20%. Typical doses range from
of perihematomal injury in hyperacute intracebral hemorrhage. Neurology 0.5-1.5 g/kg every 3-6 hours. Doses up to 1.5
2001;57:161 1-1617. g/kg are appropriate when treating a deteriora
6. Powers WJ, Zazulia AR, Videen TO, et al. Autoregulation of cerebral ting patient because of mass effect.
blood flow surrounding acute (6-22hours) intracerebral hemorrhage. • Hypertonic Saline is an option. It has the advan-
Neurology 2001;57:18-24. tage of maintaining an effective serum gradient
7. Qureshi A, Wilson D, Hanley D, Traystman R. No evidence for an or rise in osmolality for sustained periods with
ischemic penumbra in massive experimental intracerebral hemorrhage. lower incidence of intracranial hypertension.
Neurology I 999;52:266-272. • Always maintain serum osmolality at 300-320
8. Schellinger P, Fiebach J, Hoffman K, et al. Stroke MRI in intracerebral mOsmol/kg
hemorrhage: is there a perihemorrhagic penumbra? Stroke 2003;34:1647- Serum osmolality = 2 (Na) + glucose/18 + BUN/2.8
1680. 4. Hyperventilate only in impending herniation by
9. The Brain Matters Stroke Initiative. Acute Stroke Management Workshop adjusting tidal volume to achieve target PCO2
Syllabus. Basic Principles of Modern Management for Acute Stroke. levels 30-35 mm Hg. Hyperventilation is recom-
mended only for a short term as its effect on CBF
and ICP is short lived ( ≅ 6 hours). Prophylactic
hyperventilation without regard to the level of ICP
and the clinical state should not be done.
5. Carefully intubate patients with respiratory failure
defined as SpO2 of less than 90% by pulse oximeter
and PaO2 <60 mmHg, and/or PaCO2 >55 mmHg
by arterial blood gas analysis.
6. Consider surgical evacuation or decompressive
hemicraniectomy if indicated.
7. ICP catheter insertion is useful for the diagnosis,
monitoring and therapeutic lowering of increased
ICP. It is recommended in patients with a GCS ≤8,
those with significant IVH or hydrocephalus. CPP
should be maintained at 60-70 mmHg.
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Acute Stroke Treatment
C. Sedatives and Narcotics available locally
20
Acute Stroke Treatment
Items Scale Definition Items Scale Definition
3 = Bilateral hemianopia (blind, any dysphasia, or is mute/anarthric
including cortical blindness) 9 = intubated or other physical
4. Facial palsy 0 = Normal symmetrical movement barrier; explain
1 = Minor paralysis (flattened na- 11. Extinction & 0 = No abnormality
solabial fold, asymmetry on smiling) Inattention 1 = Visual, tactile, auditory, spatial
5. Motor (Arm) or personal inattention or extinction
5a. Leftarm to bilateral simultaneous stimula-
5b. Right arm 0 = No drift; limb holds 90 (or 45) tion in one of the sensory modalities
degrees for full 10 seconds 2 = Profound hemi-attention or hemi-
1 = Drifts; limb holds 90 (or 45) inattention to more than one modal-
degrees but drifts down before ity. Does not recognize own hand or
full 10 seconds; does not hit bed orients to only one side of space.
or other support
2 = Some effort against gravity, *Total score = 42
limb cannot get up to or maintain Fig. 1: Aphasia
(if cued) 90 (or 45) degrees; drifts
down to bed, but has some effort
against gravity Ask the patient to describe what is happening on the
3 = No effort against gravity, limb falls picture and name items.
4 = No movement
9 = Amputation or joint fusion; explain
6. Motor (Leg)
6a. Right leg 0 = No drift; leg holds 30-degree
6b. Left leg position for full 5 seconds
1 = Drifts; leg falls by the end of the 5-
second period but does not hit bed
2 = Some effort against gravity,
leg falls to bed by 5 seconds but
has some effort against gravity
3 = No effort against gravity, leg
falls to bed immediately
4 = No movement Fig. 2: Dysarthria
9 = Amputation or joint fission; explain
7. Limb ataxia 0 = absent Ask the patient to read or repeat words from the list.
1 = Present in one limb
2 = Present in two limbs MAMA
9 = Amputation or joint fusion; explain TIP-TOP
8. Sensory 0 = Normal; no sensory loss FIFTY-FIFTY
1 = Mild to moderate sensory loss; THANKS
patient feels pinprick is less sharp HUCKLEBERRY
or dull on the affected side; or BASEBALL PLAYER
there is a loss of superficial pain
with pinprick, but patient is aware III. Modified Rankin Scale
he/she is being touched
2 = Severe or total sensory loss; Score
patient is not aware of being
touched in the face, arm or leg No symptoms at all 0
9. Best Language 0 = No aphasia No significant disability despite 1
(Fig. 1) 1 = Mild to moderate aphasia; some symptoms; able to carry out all usual
obvious loss of fluency or facility duties and activities
of comprehension, without signifi- Slight disability; unable to carry out all 2
cant limitation on ideas expressed previous activities but able to look after
or form of expression. Reduction own affairs without assistance
of speech and/or comprehension,
however, makes conversation Moderate disability; requiring some 3
on provided material difficult. help but able to walk without assistance
2 = Severe aphasia; all communi- Moderately severe disability; unable to 4
cation is through fragmentary ex- walk without assistance and unable to attend
pression; great need for inference, to own bodily needs without assistance
questioning and guessing by the
listener. Range of information that Severe disability; bedridden, incontinent and 5
can be exchanged is limited; listener requiring constant nursing care and attention
carries the burden of communication Death 6
3 = Mute, global aphasia; no usable
speech or auditory comprehension Bibliography
1. Brott T, Adams H, Olinger CP, et al. Measurements of acute cerebral
10. Dysarthia 0 = Normal infarction: a clinical examination scale. Stroke 1989;20:864-870.
(Fig. 2) 1 = Mild to moderate; patient slurs at 2. Goldstein LB, Bartels C. Davis JN. Interrater reliability of the NIH Stroke
least some words and at worst, can Scale. Arch Neurol 1989;46:660-662,
3. Rankin J. Cerebral vascular accidents in patients over the age of 60.
be understood with some difficulty Scot Med J 1957;2:200- 215.
2 = Severe; patient’s speech is so 4. Van Swieten JC, Koudstaal JP, Visser MC, et al. Interobserver agreement
slurred as to be unintelligible in the for the assessment of handicap in stroke patients. Stroke 1988;19:604-607.
5. The Brain Matters Stroke Initiative. Acute Stroke Management Workshop
absence of or out of proportion to Syllabus. Basic Principles of Modern Management for Acute Stroke.
Anticoagulants Citilin
Nicholin
Heparin Sodium Somazine
Heparin Leo
Zynohep Hypnotic /Sedative
Antiplatelets Benzodiazepines
Aspirin Diazepam
Aspen Trankil
Aspilets Valium
Aspilets-EC Midazolam
Bayer Aspirin 100 mg Dormicum
Bayprin EC Sedoz
Cor-30
Drugmaker's Biotech General Anesthetics
Aspirin
Rhea Aspirin Parenteral
Tromcor
Aspirin/Dipyridamole Propofol
Aggrenox Diprivan
Cilostazol Fresofol 1%
Ciletin IV-Pro
Clazol
Dancitaz Analgesic/Antipyretics & Muscle
Pletaal Relaxants
Trombocil
Clopidogrel NSAIDS
Clopimet Ketorolac
Declot Acular
Klopide Ketanov
Plavix Ketodol
Plogrel Ketomed
Winthrop Clopidogrel Kortezor
Vivelon Remopain
Clopidogrel bisulfate Toradol
Cardogrel Xevolac
Clopida
Clopido Opiates & Antagonist
Clotiz Fentanyl
Deplatt Durogesic D Trans
Noklot Sublimaze
Norplat Morphine
Thromvix Hizon Morphine Sulfate
Clopidogrel hydrogen sulfate MST Continus
Clopivaz Tramadol
Dipyridamole Dolmal
Drugmaker's Biotech Dolotral
Dipyridamole Gesidol
Persantin Milador
Ticlopidine HCl Milador Inj
Clotidone Radol
Relidol
Calcium Antagonist Siverol
TDL
Nicardipine HCl Tolma
Cardepine Tradonal
Tramal
Vasodilators Tramid
Tramundin
Hydralazine HCl Vistra
Apresoline Vitral
Tramadol/Paracetamol
CNS Stimulants/Neurotonics Algesia
Cetra
Citicholine Dolcet
Brainact
Cholinerv
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