Supportive Therapy
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
- Early rehabilitation interventions during hospital stay should be considered for eligible patients
- 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