General Management Goals

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Rapid diagnosis of stroke and initiation of treatment are important to maximize recovery and to prevent recurrence of stroke (see Chapter.45 ). Patients with an acute stroke should be admitted to the hospital for emergency evaluation and treatment, preferably in a stroke unit or intensive care unit where close medical and nursing observation is available. A multidisciplinary approach with referral to specialists with expertise in stroke is beneficial. Care should focus not only on the treatment of the stroke, but also on the prevention of complications.

Patients should be thoroughly investigated in an attempt to determine the likely etiology of the stroke. Appropriate therapy should be instituted to reduce the likelihood of a recurrent stroke. Choices for therapy that are available include antiplatelet therapies such as aspirin or ticlopidine, anticoagulation with heparin acutely followed by warfarin (usually reserved for a cardiac etiology of stroke), thrombolytic agents such as tissue plasminogen activator (in appropriate situations), and carotid endarterectomy (in appropriate situations). In the patient with an intracranial hemorrhage, hemostatic defects should be sought and corrected, if present. Offending drugs such as warfarin, heparin, and thrombolytic therapy should be stopped and, in appropriate situations when there is an antidote, reversed immediately. Neurosurgical consultation and intervention may be indicated in patients with large cerebellar infarctions; large, nondominant hemispheric ischemic infarctions with deterioration and herniation; and in selected patients with accessible, large lobar hemorrhages, when there is a progressive course. Patients with cerebellar hemorrhages should have a neurosurgical consultation. Further guidelines for specific therapy are detailed in Part III (see Chapter 45 ).

Frequent neurological checks are vital to early recognition of neurologic changes associated with herniation, recurrent or progressive stroke, recurrent hemorrhage or vasospasm in the patient with subarachnoid hemorrhage, and seizures. Cerebral edema with resultant herniation is the leading cause of death in the first week after an ischemic or hemorrhagic stroke.y Cerebral edema caused by ischemia overlaps both cytotoxic and vasogenic forms. Vasogenic edema is the type of edema seen most frequently after a subarachnoid hemorrhage.

In patients with stroke, the blood pressure should be monitored frequently or even continuously for the first 48 to 72 hours. It is not unusual for the blood pressure to be transiently elevated after a stroke. Within a few days, the blood pressure may return to prestroke levels. Whether transient elevations should be treated is controversial.^] , '77] It is important not to overtreat the blood pressure and cause hypotension. The most important objective is to maintain adequate cerebral blood flow in the presence of impaired autoregulation.

Cardiac monitoring is recommended for the first 24 to 48 hours after stroke due to the high frequency of cardiac dysfunction associated with stroke. In approximately 3 percent of cases, concomitant cerebral and myocardial ischemia can occur. A variety of cardiac arrhythmias can occur after ischemic or hemorrhagic stroke and subarachnoid hemorrhage (SAH), including tall P waves, longer or shorter PR and QT intervals, ST segment elevation or depression, peaked or inverted T waves, U waves, sinus bradycardia, wandering atrial pacemaker, paroxysmal atrial pacemaker, nodal bradycardia, AV block, premature atrial or ventricular contractions, atrial fibrillation and flutter, and AV dissociation. These abnormalities have generally been attributed to increased circulating levels of catecholamines. If ischemic ECG changes occur, serial creatine kinase and lactate dehydrogenase isoenzymes are indicated. Ventricular wall motion abnormalities have been demonstrated by echocardiography in patients with aneurysmal SAH. Patients with SAH often have microscopic changes consistent with subendocardial necrosis at post mortem.

Prevention of pulmonary complications is necessary in the bedridden patient or in the patient with impaired oropharyngeal function. Management of the airway and maintenance of adequate oxygenation and ventilation should be accomplished immediately. Ventilatory assistance is indicated if there are signs of respiratory depression, a Glasgow Coma scale of less than 8, or raised intracranial pressure and herniation. Pneumonia is the most common cause of non-neurological death in the first 2 to 4 weeks after a stroke.y The mortality rate from pneumonia is as high as 15 to 25 percent. It is important to place a temporary enteral feeding tube if there is evidence of oropharyngeal dysfunction to avoid aspiration. Good pulmonary toilet is needed, including chest physical therapy, frequent turning, and volumetrics.

Lower extremity deep venous thrombosis (DVT) in the hemiparetic limb is a common occurrence if DVT prophylaxis is not initiated. If there are no contraindications, low-dose subcutaneous heparin in used at a dosage of 5000 units twice daily. If heparin is contraindicated, as in the patient with intracranial hemorrhage, intermittent pneumatic compression stockings are recommended.

The patient's nutritional status and fluid requirements

should be assessed. Patients with a large ischemic stroke may need fluid restriction during the first few days. In patients with intracranial hemorrhage, one should try to maintain euvolemia. In patients with SAH, strict fluid restrictions should be avoided due to the possible risk of increasing cerebral ischemia in patients developing vasospasm. The patient's swallowing function should be assessed before intake of fluid or food is initiated. Patients who have significant oropharyngeal dysfunction will require parenteral or tube feeding.

Indwelling catheters should be placed only if absolutely necessary and should be removed at the earliest possible time to avoid urosepsis. The chronic use of an indwelling catheter should be limited to patients with incontinence or urinary retention that is refractory to other treatments.

The development of pressure sores occurs in approximately 15 percent of patients after a stroke. y Steps to avoid this complication include frequent inspection of the skin, routine skin cleansing, frequent turning, use of special mattresses and protective dressings, maintaining adequate nutritional status, and trying to improve the patient's mobility as soon as possible after stroke.

One of the most common causes of injury to the patient with a stroke is falling. Assessments of the risk for falling should be made at regular intervals during the acute hospitalization. Measures should be instituted to minimize the risk of falls. Rehabilitation plays an important role in recovery in patients who are good candidates for intensive therapies.

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