stroke management

1. Current Stroke
Management Guideline

2. Anticoagulant
 The usefulness of anticoagulant in severe ICA stenosis or nonocclusiveextracranial
intraluminal thrombus is not established.
 Usefulness of thrombin inhibitors or oral Factor Xa inhibitors are not established.
 Urgent anticoagulation with the goal of preventing early recurrent stroke, halting
neurological worsening or improving outcome is not recommended in AIS.

3. Other emergency treatment
 Pharmacological or nonpharmacological treatments with commonly accepted
neuro-protective actions are not recommended.
 Hemodilution by volume expansion, administration of vasodilatory agents and
device to augment cerebral blood flow are not recommended.
 The usefulness of urgent carotid endarterectomy or angioplasty in patients with
critical carotid stenosis or stroke in evolution is not recommended.

4. General supportive care
 The benefit of flat head positioning early after hospitalization is uncertain
 Supplemental oxygen is not recommended in non hypoxic patient.
( O2 Sat 94%)
 Hyperbaric oxygen therapy is not recommended except when AIS caused byair
embolism.
 Benefit of treatment with induced hypothermia is uncertain.(2b,B-R)

5. General supportive care
 Dysphagia screening before patient start taking orally is effective to identify
patients at increased risk of aspiration.
 For patient with dysphagia it is reasonable to use nasogastric tube for early phase
of stroke( first 7 days).
 Percutaneous gastrostomy tube should be placed in patients with anticipated
persistent dysphagia. (>2-3 weeks)
 Routine use of prophylactic antibiotics has not been shown beneficial.

6. General supportive care
 In immobile AIS patients without contraindication Intermittentpneumatic
compression device is recommended to prevent DVT.
 Benefit of prophylactic dose of heparin (UFH or LMWH) is not well established
to prevent DVT.
 Blood glucose level should be maintained in range of 140-180 mg/dl and close
monitoring to prevent hypo or hyperglycemia.
 Hypotension and hypovolemia should be corrected to maintain systemic
perfusion level.

7. BP management
 Early treatment of hypertension is indicated when required by comorbid conditions.
 BP >=220/120 mmhg:- benefit of initiating or reinitiating treatment of hypertension
in first 48 to 72 hrs is uncertain. It might be reasonable to lower it by 15% during
first 2- 4 hours.
 BP should be maintained <180/105 mmhg in patient whor received IV alteplaseor
undergo mechanical thrombectomy for first 24 hours.

8. Treatment of acute complications
 Brain swelling:-
 Use of osmotic therapy for patients with clinical deterioration is reasonable.
 Use of brief moderate hyperventilation ( PCO2– 30-34mm Hg) is reasonable as a
bridge to more definitive therapy in acute neurological decline.
 Hypothermia or barbiturate coma is not recommended.
 Corticosteroids should not be administered.

9. Treatment of acute complications
 Surgical treatment supratentorial infarction:-
 Optimal trigger for decompressive craniectomy is unkown however decrease in
level of consciousness is reasonable to use as selection criteria.
 Patient with unilateral MCA infarction deteriorate neurologically within 48hours
despite medical therapy should receive craniectomy with dural expansion.
Ventriculostomy is recommended for the treatment of obstructive hydrocephalus in
cerebellar infarction.

10. Treatment of acute complications
 Seizures:-
 Recurrent seizures after stroke should be treated in similar manner as with other
neurological conditions.
 Antiseizures drug should be selected on basis of specific patient characteristics.
 Prophylactic use of antiseizure drug is not recommended.

11. In hospital--- secondary stroke
prevention
 Brain imaging:-
 Use of MRI is reasonable in following patients:-
 Patient with carotid stenosis who are eligible for carotid revascularization in
whom NCCT or neurological examination dose not permit actual
localization.
Vascular imaging:-
 Nondisabling stroke in carotid territory:- vascular imaging including
extracranial
vessel should be done in 24 hours.

12. In hospital--- secondary stroke prevention
 Cardiac monitoring should be performed for the at least 24 hours after AIS.
 Usefulness of routine Echocardiography is uncertain and used in selected
patients.
 It is reasonable to screen all patients for DM.

13. Antithrombotic agent
 For noncardioembolic AIS use of antiplatelet agent is recommendedover
anticoagulants.
 Patients who have AIS while taking aspirin, increasing dose of aspirin or
switching to alternative antiplatelet agent or warfarin for additional benefit is not
recommended.
 Starting of oral anticoagulation between 4 to 14 days after AIS withAF is
reasonable.

14. Antithrombotic agent
 AIS with extracraniial arterial dissection :- antiplatelet or anticoagulant for 3-6
mths is reasonable.
 AIS with hemorrhagic transformation :- intiation or continuation of antiplatelet
or anticoagulant may be considered.
 For minor nondisabling stroke carotid revascularization should be
performed between 2-7 days of event.

15. Hyperlipidemia
 Measurment of fasting or nonfasting plasma lipid profile is effective in estimating
atherosclerotic cardiovascular risk and documenting baseline LDL level.
Measurement of lipid profile should be done at 4 to 12 weeks after statin
initiation or dose adjustment and 3 to 12 months thereafter.

16. Hyperlipidemia
 Statin therapy can be continued or initiated during acute period.
 Women in child bearing age on statin therapy should explain to stop it 1-2
months prior to pregnancy attempted.
 Patients with advance kidney disease on dialysis may be continued with
statin therapy but should not be initiated.

17. Thank You