MANAGEMENT OF ACUTE STROKE (ISCHEMIC STROKE) Dr Truong Dinh Tri Resident, general internal medicine DEFINITION OF STROKE A NEUROLOGICAL DEFICIT OF  Sudden onset  With focal rather than global dysfunction  In which, after adequate investigations, symptoms are presumed to be of non-traumatic vascular origin  and last for >24 hours ISCHEMIC STROKE PATHOPHYSIOLOGY The First Few Hours “TIME IS BRAIN: SAVE THE PENUMBRA” Penumbra Core Penumbra is zone of reversible ischemia around core of irreversible infarction —salvageable in first few hours after ischemic stroke onset Penumbra damaged by: • Hypoperfusion • Hyperglycemia • Fever • Seizure Clot in Artery The typical patient loses 1.9 million neurons each minute in which stroke is untreated Stroke Risk Factors Non-modifiable       AGE Gender -male Race – Blacks > Asians or Hispanics> Whites Family Hx Coagulation Disorders Cardiac Disease Stroke Risk Factors Modifiable        Hypertension Diabetes mellitus Hypercholesterolemia Elevated LDL or Low HDL Elevated homocystein Smoking Drug abuse Alcohol Abuse  Oral Contraceptives  Pregnancy  Migraine Headaches  Obesity  Sleep apnea  Carotid stenosis A combination of these risk factors will increase risk of stroke!  Stroke management issues Stabilization of ABCs IV Fluids: Avoid D5W and excessive fluid administration + IV isotonic sodium chloride solution at 50 mL/h unless otherwise indicated Blood glucose: + hypoglycemia: treat with D50 + hyperglycemia: treat with insulin +achieve serum glucose concentrations: 140-180 mg/dl (7,8-10) Swallowing assessment: Dysphagia Nulla per os (NPO) Temperature: Avoid hyperthermia, use oral or rectal acetaminophen and cooling blankets as needed Stroke management issues Patient Positioning  Cerebral perfusion pressure is maximized when patients are maintained in a supine position  Lying flat may serve to increase ICP and thus is not recommended in cases of subarachnoid or other intracranial hemorrhage  Because prolonged immobilization may lead to its own complications, including deep venous thrombosis, pressure ulcer aspiration, and pneumonia, patients should not be kept flat for longer than 24 hours