General Care

• Vital signs and neurological status should be monitored frequently during 1st 24-72 hours
• Bed rest followed by mobilization as soon as patient’s condition is stable
  • Close observation is necessary during transition from sitting to standing; patient may experience a worsening in neurological status upon movement to the upright position
  • Early mobilization reduces risk of major complications (eg pneumonia, deep venous thrombosis, etc)
• During the 1st 24 hours, passive- and full-range motion exercises may be started for paralyzed limbs
• Frequent turning, alternating pressure mattresses and close observation of skin will decrease chance of pressure sores
• Fall precautions should be taken during mobilization

Oxygenation

• Administration of supplementary O₂ to hypoxemic stroke patients is recommended
  • Not recommended in hospitalized nonhypoxic patients with acute ischemic stroke
• Target oxygen saturation level: >94%
• Provide ventilatory support if upper airway is threatened or sensorium is impaired
• Available data at present do not support routine use of hyperbaric oxygen in the management of acute ischemic stroke patients
• Brief moderate hyperventilation (pCO₂ target 30-34 mmHg) for patients with acute severe neurological decline from brain swelling may be considered as aid to more definitive management

Glucose Control

• Goal is to achieve normoglycemia
• Persistent hyperglycemia post stroke is associated with poor outcome; treat hyperglycemia to achieve blood glucose levels in the range of 6.0-10 mmol/L (108-180 mg/dL)
• Insulin may be considered for patients with acute ischemic stroke when the serum glucose level is >180 mg/dL; close glucose monitoring is recommended to avoid hypoglycemia
• Hypoglycemia (blood glucose <3.3 mmol/L or <60 mg/dL) should be treated in patients with acute ischemic stroke

Body Temperature

• Fever in the setting of acute ischemic stroke is associated with poor neurological outcome
• The source of any fever following stroke must be identified; fever should be treated with antipyretic agents and cooling blankets if available
• Maintain normothermia

Volume Expansion

• Hemodilution by volume expansion is not recommended for treatment of patients with acute ischemic stroke

Drug-Induced Hypertension

• Usefulness among ischemic stroke patients is not well established

Nutrition and Hydration

• Malnutrition and dehydration may slow down recovery
• Enteral nutrition should be initiated within 7 days of admission after an acute stroke
• IV fluids should be administered initially in patients with acute stroke to maintain a balanced fluid status
  
  • Avoid dextrose-containing solution
  • Acute ischemic stroke patients are predominantly either euvolemic or hypovolemic at presentation
  • If euvolemic at presentation, start maintenance fluids (estimated at 30 mL/kg body weight)
  • If hypovolemic at presentation, rapid fluid replacement is reasonable using isotonic solutions (0.9% saline solution), with extra precaution in patients vulnerable to volume overload (eg patients with heart or renal failure)
• Assess for the presence of dysphagia
  • A water swallowing test is warranted prior to allowing patients to eat and drink 
  • Start nasogastric tube (NGT) feedings early within 48-72 hours in patients with signs of dysphagia, altered sensorium, or in those unable to consume sufficient quantities of food or fluids orally
• In patients who cannot take solid food or liquids orally, it is reasonable to use NGT over endoscopic gastrostomy tube until 2-3 weeks after stroke onset
• In conscious patients with varying degrees of dysphagia:
  
  • Oral feeding may progress to thickened liquids or semisolids upon careful assessment and recommendations by the rehab physician and/or speech therapist
  • Gradually introduce mechanically soft, blended diet and eventually regular diet

Rehabilitation

• All persons with stroke should be assessed for their rehabilitation needs
  • Prevention of complications: Swallowing problems, skin breakdown, deep venous thrombosis, bowel and bladder dysfunction, malnutrition, pain, contractures
  • Assessment of impairments: Communication and motor impairments, cognitive deficits, visual and spatial deficiency (eye movements, visual field, perceptual deficits), psychological deficits, sensory deficits
• Once patient is stable, an individualized rehabilitation program should be started to prevent long-term complications
  • Early rehabilitation interventions during hospital stay should be considered for eligible patients
    • Based on some evidences from trials, Cerebrolysin may be given in addition to rehabilitation in the first 7 days after moderate to severe acute ischemic stroke
  • Studies showed that very early mobilization (<24 hours) may affect the outcome and thus should be avoided
• Rehabilitation process should include:
  • Prevention and management of comorbid illnesses
  • Training for maximum independence
  • Helping patient and family with psychological coping and adaptation
  • Promote community integration
• Improve quality of life if disabilities are present
  • Prevention of recurrent stroke or other vascular events
• A tailored home exercise program is recommended after completion of stroke rehabilitation program