1. Monitoring: What, when and how long? George Ntaios University of Thessaly, Larissa, Greece

2. Disclosures Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. Honoraria: Medtronic; Quintiles; Boehringer-Ingelheim. Speaker fees: Sanofi; Boehringer-Ingelheim; Galenica; Bayer. Support for educational events: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer- Ingelheim; Galenica; Elpen; Bristol Myers Squibb. Participation in trials: – NAVIGATE-ESUS / National coordinator (Greece) – PRECIOUS / National coordinator (Greece). – ENOS / National coordinator (Greece). – BIOSIGNAL / Principal Investigator (Larissa). – EBBINGHAUS / Principal Investigator (Larissa). – FOURIER / Principal investigator (Larissa). – PREVISE / Principal investigator (Larissa). – GLORIA-AF / Sub-investigator (Larissa).

3. Stroke is an earthquake San Francisco Bay Area, California, USA. August 24, 2014 10:20 AM

4. Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG

5. Monitor for diagnostic reasons

6. Continuous ECG monitoring vs. Holter Rizos. Stroke 2012; 43:2689-94

7. Continuous monitoring vs. Holter

8. Sanna. N Engl J Med 2014;370:2478-86 CRYSTAL-AF

9. CRYSTAL-AF: the more you look, the more you find Sanna. N Engl J Med 2014;370:2478-86

10. EMBRACE Gladstone. N Engl J Med 2014;370:2467-77

11. EMBRACE : the more you look, the more you find Gladstone. N Engl J Med 2014;370:2467-77

12. Monitor ECG – for how long?

13. Gladstone. Stroke 2015; 46:936-41 Atrial extrasystoles predict AF

14. Gladstone. Stroke 2015; 46:936-41 Atrial extrasystoles predict AF

15. Gladstone. Stroke 2015; 46:936-41 Atrial extrasystoles predict AF

16. Monitor ECG in lacunar strokes ? Sacco. Neurology 2006; 66:1335-8

18. Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli

19. Monitor for diagnostic reasons

20. Microemboli monitoring

22. Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure

23. Monitor Blood Pressure Jorgensen. Cerebrovasc Dis 2002;13:204-9

24. Monitor Blood Pressure Vemmos. Journ Intern Med 2004; 255: 257–265

25. Monitor Blood Pressure Sandset. Lancet 2011; 377:741-50

26. Monitor Blood Pressure Sandset. Lancet 2011; 377:741-50

27. Monitor Blood Pressure Sandset. Lancet 2011; 377:741-50

28. Monitor Blood Pressure ENOS. Lancet 2015; 385:617-28

29. Monitor Blood Pressure ENOS. Lancet 2015; 385:617-28

30. ESO Guidelines Cautious BP lowering is recommended in patients with extremely high BPs (>220/120mmHg) (Class IV, GCP) It is recommended that BP of >185/110mmHg lowered before thrombolysis (Class IV, GCP) ESO Guidelines. CVD 2008

31. Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose

32. Monitor glycemia Quinn. Cerebrovasc Dis 2009;27:148–155

33. Monitor glycemia Previously diagnosed DM Newly diagnosed DM Stress hyperglycemia Fasting Glu ≥ 126 Random Glu ≥ 200 HbA 1c ≥ 6.5% Fasting Glu ≥ 126 Random Glu ≥ 200 HbA 1c < 6.5%

34. Monitor glycemia Ntaios, Michel. Stroke 2010; 41:2366-70

35. Monitor glycemia Gray. Lancet Neurol 2007; 6: 397–406

36. Monitor glycemia Gray. Lancet Neurol 2007; 6: 397–406

37. Insulin treatment – functional outcome Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013

38. Insulin treatment - mortality Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013

39. Insulin treatment - hypoglycemia Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013

40. Monitor glycemia https://clinicaltrials.gov/ct2/show/NCT01369069

41. AHA guidelines Jausch. Stroke 2013 it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL and to closely monitor to prevent hypoglycemia in patients with acute ischemic stroke (Class IIa; Level of Evidence C).

42. Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia

43. Monitor for dysphagia Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Videofluoroscopy

44. Monitor for dysphagia

45. ESO guidelines ESO Guidelines. CVD 2008 Swallowing assessment is recommended but there are insufficient data to recommend a specific approach for treatment (Class III, GCP)

46. Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia Temperature

47. Monitor temperature Kakaletsis/Ntaios/Michel. Larissa 2015

48. Monitor temperature

49. Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia Temperature Oxygen

50. ESO guidelines ESO Guidelines. CVD 2008 Intermittent monitoring of oxygen saturation is recommended for 72 h in patients with significant persisting neurological deficits (Class IV, GCP) It is recommended that oxygen should be administered if the oxygen saturation falls <95% (Class IV, GCP)

51. Monitor 0 2 Roffe. Nice 2014

52. Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia Temperature Oxygen Lab tests (CRP, WBC…) Clinically

53. Monitor clinically -Physical examination -Neurological status -NIHSS -yawning -vomit -headache -GCS

54. Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia Temperature Oxygen Lab tests (CRP, WBC…) Clinically Repeat imaging

55. Stroke unit works Langhorne, Cochrane 2009; CD000197

57. One size does not fit all

58. Take-home messages

59. Free ESO Membership SPECIAL DEAL ! ESOC delegates who are not yet member of the ESO and have paid their conference registration fee can receive free ESO membership for the year 2015. JOIN NOW ! Application forms available at the ESO booth in the exhibition.