ischemic%20stroke
ISCHEMIC STROKE
Ischemic stroke occurs when a blood vessel supplying the brain is obstructed.
Consider stroke in any patient presenting with sudden focal neurological deficit or any alteration in level of consciousness.
Rapid evaluation is essential for sure of time-sensitive treatments.
Determine if patient's symptoms are due to stroke and exclude stroke mimics (eg migraine, hypertensive encephalopathy, hypoglycemia, seizures or post-ictal paresis); identify other conditions requiring immediate intervention and determine the potential causes of stroke.

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
  • 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 is reasonable treatment 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 7.8-10 mmol/L (140-180 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
    • 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 nasogastric tube 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 occupational 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
    • 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
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