1. General Care After Stroke, Including Stroke Units and Prevention and Treatment of Complications of Stroke

2. Reasons for Admission Serious illness Potentially life-threatening disease Risk for medical or neurological complications Neurological deterioration Observation, evaluation and treatment

3. Organization of Stroke Care Acute Stroke Units –Concentrate admissions to a specialized facility with skilled care and monitoring. –Shorten hospitalizations and reduce death and disability. –Reduce complications and promote rehabilitation.

4. Organization of Stroke Care Stroke Teams –Coordinated teams of health care professionals to coordinate efficient and effective care for stroke patients. –Stroke Teams play a part in the hyperacute, the acute and the rehabilitation phases of stroke care. –Involve the multidisciplinary team.

5. Stroke Centers Primary Stroke Centers –Use the cardiac/trauma model of delivering care. –Major elements: patient care and support services. –Define institutions where appropriate care can be given.

6. Goals of Treatment After Admission Continue care started in emergency department. Observe for and prevent or control neurological and medical complications. Start rehabilitation and discharge planning. Evaluate for cause of stroke and start therapies to prevent recurrent stroke.

7. Neurological Complications Progression of thrombosis Recurrent embolism Brain edema Hydrocephalus Increased intracranial pressure Hemorrhagic transformation Seizures

8. Medical Complications Myocardial infarctionPneumonia Congestive heart failureAirway obstruction Cardiac arrhythmiasHypertension Deep vein thrombosisBladder infections Pulmonary embolusDepression Gastrointestinal bleedingElectrolyte disturbance

9. Initially treated with bed rest; mobilization begins as soon as the patient’s condition is stable Pulse oximetry first 24-48 hours Cardiac monitoring first 24 hours After Admission

10. Frequent assessments of vital signs and neurological status by nursing staff. Protection of airway, especially if depressed consciousness or signs of brain stem dysfunction. Supplemental oxygen if patient is hypoxic. Assessment for cause of hypoxia.

11. Heart Disease and Stroke Heart disease often is the cause of stroke. Most patients with stroke have heart disease. Stroke, especially intracranial hemorrhage, can cause myocardial ischemia or cardiac arrhythmias. Many persons will have cardiac arrhythmias or electrocardiographic abnormalities after stroke.

12. Sinus bradycardiaSinoatrial arrhythmia Ventricular tachycardiaAtrial fibrillation Ventricular fibrillationPVC Idioventricular rhythmsPSVT Torsades de pointesAV block Heart Disease and Stroke

13. ST-T segment elevation/depression Pathological Q waves Negative T waves Abnormal U waves QT prolongation ECG Changes and Stroke

14. Arterial hypertension is common among persons with stroke: –risk factor for stroke –consequence of stroke Usually declines spontaneously Secondary to pain, vomiting, stress, anxiety Secondary to increased intracranial pressure Hypertension in Stroke

15. Treatment of Arterial Hypertension Oral agents preferred Continue or re-institute antihypertensive medications Goal of lowering pressure by 15% during first 24 hours If parenteral medications are used, prefer short-acting drugs

16. Treat fever and search for the cause of fever; suspect pulmonary or urinary tract infections Maintain hydration with intravenous fluids Treat hyperglycemia and hypoglycemia Assess swallowing before starting oral feedings If necessary, consider enteral feedings Initial Management of Acute Stroke

17. Early mobilization –positive for morale –expedites rehabilitation –lessens risk of pulmonary, skin, musculoskeletal complications Watch for hypotension or neurological worsening Protect against falls Mobilization After Stroke

18. Prevention of DVT and Pulmonary Embolism Mobilization Heparin LMW heparins/heparinoids Oral anticoagulants Aspirin Alternating pressure stockings

19. Brain Edema and Increased Intracranial Pressure Peaks within one week of stroke Earlier with hemorrhagic stroke A leading cause of death Seen with large multi-lobar strokes Can be secondary to hydrocephalus or mass effect of a hematoma

20. Common cause of neurological worsening –progression of stroke –secondary brain ischemia –herniation syndromes Hallmark is depression of consciousness Vital signs unstable and arterial hypertension Brain Edema and Increased Intracranial Pressure

21. Management of Brain Edema and Increased Intracranial Pressure Restrict fluids moderately Avoid hypo-osmolar fluids Control fever, hypoxia, hypercarbia Elevate head of bed by 30% Monitor intracranial pressure

22. Trial of Dexamethasone for Supratentorial Intracerebral Hemorrhage Dexamethasone Placebo n=46 n=47 Good Recovery 8 5 Poor Survivor 17 21 Dead 21 21 Infectious Complications 13 6 Pougvarin, et al. New England Journal of Medicine 1987;316:1229-1233..

23. Hyperventilation to a pCO 2 of approximately 28-30 mm Hg Corticosteroids are not recommended Mannitol, 0.25-1 g/kg intravenously given every 6 h maximum osmolarity 310 Furosemide 40 mg intravenously Intracranial Pressure

24. Drainage of CSF fluid Evacuation of hematoma Resection of infarcted tissue Hemicraniectomy Surgical Management of Brain Edema and ICP

25. Evaluation for Cause of Stroke Magnetic resonance imaging of brain Magnetic resonance angiography Spiral CT imaging Carotid duplex Transcranial Doppler Transthoracic echocardiography Transesophageal echocardiography

26. Prevention of Recurrent Stroke Cardioembolic Stroke Oral anticoagulants –prosthetic valves: INR 2.5-3.5 –other causes: INR 2.0-3.0 Stroke despite adequate anticoagulation –add aspirin –add dipyridamole Contraindication for anticoagulation –Aspirin

27. Prevention of Recurrent Stroke Carotid endarterectomy if ipsilateral high-grade stenosis, acceptable risk, and skilled surgeon Antiplatelet aggregating drugs –Aspirin –Ticlopidine –Aspirin and dipyridamole

28. Rehabilitation Critical part of care after stroke Begin as soon as patient is stable and while the patient is still in an acute care bed Tailor to individual patient’s needs Progress in a step-wise progression Maximize patient’s independence

29. Decisions About Rehabilitation Influence Discharge Planning In-patient rehabilitation unit –attached to acute hospital –free-standing hospital Outpatient care Home care Skilled nursing facility

30. Discharge Planning Considerations Cognitive and functional status Family and caregivers’ support Financial resources Patient and family education Follow-up medical care, rehabilitation Identify safe place of residence Community support or resources