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If the neurologic deficit progresses over the following minutes or hours, administering heparin may limit or arrest further deterioration Since the signs of progressing stroke may be simulated by an intracerebral hematoma, the latter must be excluded by immediate CT scanning or angiography before the patient is heparinized Intravenous thrombolytic therapy with recombinant tissue plasminogen activator (09 mg/kg to a maximum of 90 mg, with 10% given as a bolus over 1 minute and the remainder over 1 hour) is effective in reducing the neurologic deficit in selected patients without CT evidence of intracranial hemorrhage when administered within 3 hours after onset of ischemic stroke, but later administration has not been proved effective or safe Recent hemorrhage, increased risk of hemorrhage (eg, treatment with anticoagulants), arterial puncture at a noncompressible site, and systolic pressure above 185 mm Hg or diastolic pressure above 110 mm Hg are among the contraindications to this treatment Another approach involves the mechanical removal of an embolus or clot from an occluded cerebral artery; several intra-arterial mechanical thrombolytic devices are undergoing trials for this purpose Early management of a completed stroke otherwise consists of attention to general supportive measures During the acute stage, there may be marked brain swelling and edema, with symptoms and signs of increasing intracranial pressure, an increasing neurologic deficit, or herniation syndrome Prednisone (up to 100 mg/d) or dexamethasone (16 mg/d) has been used in an attempt to reduce vasogenic cerebral edema, but the evidence that corticosteroids are of any benefit is conflicting Dehydrating hyperosmolar agents have also been prescribed in efforts to reduce brain swelling, but there is little evidence of any lasting benefit Likewise, clinical benefit from treatment with vasodilators such as papaverine is minimal Neither hypercapnia nor hypocapnia has been shown to have any benefit Barbiturates are known to decrease neuronal metabolism and energy requirements and have been reported to improve functional recovery in experimental stroke models; their use in humans, however, is experimental Attempts to lower the blood pressure of hypertensive patients during the acute phase (ie, within 2 weeks) of a stroke should generally be avoided, as there is loss of cerebral autoregulation and lowering the blood pressure may further compromise ischemic areas However, if the systolic pressure exceeds 200 mm Hg, it can be lowered with continuous monitoring to 170 200 mm Hg and then, after 2 weeks, it can be reduced further to less than 140/90 mm Hg Anticoagulant drugs should be started when there is a cardiac source of embolization Treatment is with intravenous heparin while warfarin is introduced The target is an INR of 20 30 for the prothrombin time If the CT scan shows no evidence of hemorrhage and the cerebrospinal fluid is clear, anticoagulant treatment may be started without delay Some physicians prefer to wait for 2 or 3 days before initiating anticoagulant treatment; the CT scan is then repeated and anticoagulant therapy is initiated if it again shows no evidence of hemorrhagic transformation.

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Physical therapy has an important role in the management of patients with impaired motor function Passive movements at an early stage will help prevent contractures As cooperation increases and some recovery begins, active movements will improve strength and coordination In all cases, early mobilization and active rehabilitation are important Occupational therapy may improve morale and motor skills, while speech therapy may be beneficial in patients with expressive dysphasia or dysarthria When there is a severe and persisting motor deficit, a device such as a leg brace, toe spring, frame, or cane may help the patient move about, and the provision of other aids to daily living may improve the quality of life

<Window x:Class="Exercise_19_2.Window1" xmlns="http://schemas.microsoft.com/winfx/2006/xaml/presentation" xmlns:x="http://schemas.microsoft.com/winfx/2006/xaml" Title="Window1" Height="300" Width="300"> <Grid> <Button Height="23" Margin="55,44,0,0" Name="button1" VerticalAlignment="Top" HorizontalAlignment="Left" Width="75" Content="Button"> <Button.Triggers> <EventTrigger RoutedEvent="Button.Loaded"> <BeginStoryboard> <Storyboard> <DoubleAnimation Storyboard.TargetName="button1" Storyboard.TargetProperty="Height" To="200" Duration="0:0:5"

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The prognosis for survival after cerebral infarction is better than after cerebral or subarachnoid hemorrhage The only proved effective therapy for acute stroke requires initiation within 3 hours after stroke onset, and the prognosis therefore depends on the time that elapses before arrival at the hospital Patients receiving such treatment with tissue plasminogen activator are at least 30% more likely to have minimal or no disability at 3 months than those not treated by this means Loss of consciousness after a cerebral infarct implies a poorer prognosis than otherwise The extent of the infarct governs the potential for rehabilitation Patients who have had a cerebral infarct are at risk for additional strokes and for myocardial infarcts Statin therapy to lower serum lipid levels may reduce this risk Antiplatelet therapy reduces the recurrence rate by 30% among patients without a cardiac cause for the stroke who are not candidates for carotid endarterectomy Nevertheless, the cumulative risk of recurrence of noncardioembolic stroke is still 3 7% annually A 2-year comparison did not show benefit of warfarin (INR 14 28) over aspirin (325 mg daily), and higher doses of warfarin should be avoided as they lead to an increased incidence of major bleeding Patients with massive strokes from which meaningful recovery is unlikely should receive palliative care (see 5)

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Amarenco P et al; Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators High-dose atorvastatin after stroke or transient ischemic attack N Engl J Med 2006 Aug 10;355(6):549 59 [PMID: 16899775] Di Carlo A et al; European BIOMED Study of Stroke Care Group Risk factors and outcome of subtypes of ischemic stroke Data from a multicenter multinational hospital-based registry The European Community Stroke Project J Neurol Sci 2006 May 15;244(1 2):143 50 [PMID: 16530226] Edgell R et al Acute endovascular stroke therapy Curr Neurol Neurosci Rep 2006 Nov;6(6):531 8 [PMID: 17074290] Hart RG et al Lessons from the Stroke Prevention in Atrial Fibrillation trials Ann Intern Med 2003 May 20;138(10): 831 8 [PMID: 12755555] Subramaniam S et al Massive cerebral infarction Neurologist 2005 May;11(3):150 60 [PMID: 15860137]

Spontaneous intracerebral hemorrhage in patients with no angiographic evidence of an associated vascular anomaly (eg, aneurysm or angioma) is usually due to hypertension The

A complete blood count, platelet count, bleeding time, prothrombin and partial thromboplastin times, and liver and renal function tests may reveal a predisposing cause for the hemorrhage Lumbar puncture is contraindicated because it may precipitate a herniation syndrome in patients with a large hematoma, and CT scanning is superior in detecting intracerebral hemorrhage

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Display PDF within web browser using MVC3 - CodeProject
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