Management of Stroke

Prof. (Dr.) Maliha Hakim

Professor & Head
Neurology Dept.
Shaheed Suhrawardy
Medical College, Dhaka
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Aims of stroke management

Minimizing the volume of irreversibly
damaged area
Preventing complications

Reducing the risk of recurrent stroke

Investigation
Aims of investigation
To confirm nature of the lesion
To exclude differential diagnosis
Risk factors assess

Investigation

CBC, ESR

Blood Urea

Urine R/E

S.Creatinine

Blood sugar
Fasting lipid profile

S.Electrolytes
Clotting /Thrombophilia
screen
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Investigation
ECG

MRI of brain

Echo cardiogram

Duplex ultrasound of carotids

CXR
Magnetic resonance
angiography (MRA)
CT scan of brain
CT angiography (CTA)
CSF study
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Indication for an immediate CT

scan
Patient on anticoagulants or with abnormal
coagulation
Plan to give thrombolysis or immediate
anticoagulants
Deteriorating conscious level or rapidly
progressing
deficits
Suspected cerebellar haematoma to exclude
hydrocephalus
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Investigation

Investigation

Investigation

General Management
Airway
Breathing
Circulation
Hydration
Nutrition

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Blood pressure
BP should not reduced in first week (Causes
decrease cerebral perfusion & increase
infarction)
Reduced if BP >185/110, heart failure, renal
failure, hypertensive encephalopathy, aortic
dissection or plan for thrombolysis

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General Management
Blood glucose
Hyperglycemia increase infarct volume,
therefore blood glucose 11.1 mmol/L should
treated with insulin
Temperature
Raised brain temperature may increase infarct
volume

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General Management
Pressure sore
Treat infection, maintain nutrition, provide a
pressure
reliving mattress and turn immobile
patients regularly
Incontinence
Ensure that patient is not constipated or in
urinary retention
Treatment of raised ICP if any
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Specific treatment
For ischaemic stroke
Thromblysis
I/V thrombolysis with recombinant tissue
plasminogen activator(rt-PA)
Revascularization with intra-arterial thromolysis,
mechanical dissolution or removal of thrombus.
Antiplatelate- Asprin,Clopidogrel or Dipyridamole
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Specific treatment
Lipid lowering agents Statin

If atrial fibrilation
Anticoagulant(Warfarin)
and
treatment of underlying
causes
Carotid endarterectomy and angioplasty
Patients with a carotid territory ischemic
stroke or TIA will have a >70% stenosis
of the
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same side

Specific treatment
For haemorrhagic stroke
Stop anticoagulant if any
Administration of recombinant factor VII
Ref. for Neurosurgical consultation
GCS 8-12
Feature of raised ICP
Large volume haematoma
Superficial haematoma
Haematoma in posterior fossa
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Management of SAH
General management-same
Special management
Prevention of rebleeding prior to surgical
treatment by antifibrinolytic agents
Prevention of vasospasm by:
Ca channel blocker-Nimodipine
Adequate hydration-3L/day
Avoid antihypertensive therapy
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Management of SAH
Headache and neckache if severe- mild
sedation,analgesic & glucocorticoids.
Rx of raised ICP if any
Prior to definite Rx for ruptured aneurysmmaintain
adequate cerebral perfusion pressure

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Management of SAH
Surgical Rx
-Within 3 days if patient conscious
- After 2 weeks if patient unconscious
For aneurysm
Clipping of aneurysm neck
Balloon embolisation
Platinum/Titanium coil embolisation

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Management of SAH
For AVM
Embolisation
Steriotactic radiotherapy

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Complications of SAH
Intracranial
Re - bleeding
Cerebral ischaemia/infarction
Hydrocephalus
Seizure
Extra cranial
Myocardial infarction
Cardiac arrhythmias
Pulmonary oedema
Gastric haemorrhage(stress ulcer)
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Secondary stoke prevention

Lifestyle modification
Smoking cessation
Lower Salt intake
Lower fat intake
Lower alcohol intake
Increase exercise
Lose excess weight

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Secondary stoke prevention

Drugs for ischemic stroke/TIA
Antipaletet: Aspirin,Clopidogrel,Dipyridamole
Carotid endarterectomy and
angioplasty:Patients with a carotid territory
ischemic stroke or TIA will have a >70%
stenosis of the same side.
Risk factor modification
Blood pressure- Target BP <120/80
Drugs:ACEI/ARB
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Secondary stoke prevention

Control of Diabetes
Control of dyslipidaemia
Rehabilitation and physiotherapy

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Complications of Acute Stroke

Immediate

Aspriation
Infection
Respiratory infection
Urinenary infection
Electrolyte imblance
Deep vein thrombosis
Pulmonary embolism
Constipation
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Complications of Acute Stroke

Intermediate
Pressure sore
Frozen shoulder
Nutritional imblance
Late
Epileptic seizure
Osteoporosis
Joint contracture
Depression & anxiety
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THANK YOU

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