Medical Surgical and Pharmalogic Management Poststroke

Cards (34)

  • Goal for the acute management of patients with stroke
    1. Stabilize the patient
    2. Complete initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of patient arrival
    3. Make critical decisions on need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic intervention
  • Medical management of completed stroke
    • Reestablishing circulation and oxygenation
    • Providing interventions to stop progression of the lesion to limit deficits by improving cerebral perfusion
    • Maintaining acceptable blood pressure
    • Maintaining adequate cardiac output
    • Restoring and maintaining fluid and electrolyte balance
    • Maintaining blood glucose levels within the normal range
    • Managing seizures and infections
    • Controlling edema, intracranial pressure, and preventing brain herniation
    • Maintaining bowel and bladder function
    • Maintaining skin integrity and joint range of motion
  • Neurosurgical interventions
    • Repair superficial ruptured aneurysm or arteriovenous malformations
    • Prevent rebleeding
    • Evacuate a clot
    • Resect superficial unruptured arteriovenous malformations
    • Craniotomy
    • Endovascular procedures
    • Mechanical thrombectomy
    • Carotid endarterectomy
  • Computed tomography (CT)
    Commonly used neuroimaging technique, allows identification of large arteries and veins and venous sinuses, but demonstrates poor sensitivity for detecting small infarcts and infarction in the posterior fossa
  • Magnetic resonance imaging (MRI)

    More sensitive in the diagnosis of acute strokes, allowing detection of cerebral ischemia as early as 30 minutes after vascular occlusion and infarction within 2 to 6 hours, able to detail the extent of infarction or hemorrhage and can detect smaller lesions than a CT scan
  • Magnetic resonance angiography
    Type of magnetic resonance image that uses special software to create an image of the arteries in the brain, used to identify vascular abnormalities such as stenosis and alterations in blood flow as a result of embolus or thrombosis
  • Doppler ultrasound imaging
    Noninvasive technique that sends sound waves into the body, echoes bounce off the moving blood and artery and are formed into an image, used to examine the posterior circulation of the brain or the vertebrobasilar system
  • National Institutes of Health Stroke Scale
    Valuable screening tool that focuses on initial and serial examination of impairments following acute stroke, includes 11 items and uses a variable ordinal scale
  • Doppler ultrasound imaging
    Noninvasive technique that sends sound waves into the body and forms an image from the echoes that bounce off the moving blood and artery
  • Transcranial Doppler
    Used to examine the posterior circulation of the brain or the vertebrobasilar system
  • Positron emission tomography scan

    Used to evaluate blood flow to the brain
  • Angiography
    Used to evaluate blood flow to the brain
  • National Institutes of Health Stroke Scale
    A valuable screening tool that focuses on initial and serial examination of impairments following acute stroke
  • Items on the National Institutes of Health Stroke Scale
    • Level of consciousness
    • Best gaze
    • Visual fields
    • Facial palsy
    • Limb ataxia
    • Sensory
    • Best language
    • Dysarthria
    • Extinction and inattention
    • Motor arm
    • Motor leg
  • The National Institutes of Health Stroke Scale has been used to discriminate between stroke subtypes and is recommended as the measure for stroke severity, from acute to chronic patients, in stroke recovery research trials
  • Biomarkers
    Can be used to help identify acute cerebral ischemia, including inflammatory mediators and markers of glial activation
  • Biomarker assays may play an increasing role in the diagnosis of acute stroke as more research becomes available
  • Biomarkers using neuroimaging techniques will serve as measures to predict structural and functional stroke recovery
  • Standardized blood analyses performed
    • Hematological studies
    • Serum electrolyte levels
    • Renal tests
    • Hepatic tests
  • Biomarker tests
    These tests are used to rule out metabolic abnormalities as well as blood, kidney, or liver conditions
  • Pharmacologic management for stroke
    Can be divided into stroke-specific treatment, stroke prevention, and medications for common associated conditions
  • Tissue plasminogen activator (tPA)
    A thrombolytic that converts plasminogen to plasmin, degrades fibrin present in clots, dissolves clots and reestablishes blood flow
  • Use of tPA for ischemic stroke

    • Indicated in patients presenting to the treating facility within 3 hours and 4.5 hours in certain, eligible patients after the onset of symptoms
    • Can reduce the severity of a stroke by decreasing the amount of damage to the brain that can occur during the stroke and is associated with better long-term functional outcomes and survival
  • Aspirin
    An antiplatelet therapy given to patients poststroke to prevent platelets from sticking together and is used long-term in a low dose to decrease risk of thrombosis and recurrent stroke
  • Anticoagulants (e.g. Coumadin)

    Used to reduce the risk of blood clots and prevent existing clots from getting bigger by thinning the blood
  • Antihypertensive agents and angiotensin II receptor antagonists
    Used to control hypertension and lower blood pressure, which has been shown to reduce the risk of stroke by 30 to 40%
  • Anticholesterol agents or statins
    Used to lower cholesterol for management of hypercholesterolemia and mixed dyslipidemias
  • Medications used for stroke management
    • Antispasmodics and antispastic medications
    • Anticonvulsants
    • GABA receptor antagonists (e.g. baclofen)
    • Neurotoxins or Botox injections
    • Antidepressants
  • Acute phase

    0 to 7 days poststroke, a period of inflammation and scarring occurs
  • Subacute phase
    7 days to 6 months poststroke, a period of endogenous plasticity that peaks in the early subacute phase and plateaus in the late subacute phase
  • Chronic phase
    More than 6 months poststroke
  • Better functional outcomes have been reported in patients poststroke who receive specialized care such as more likely to be alive, independent, and living at home one year after the stroke
  • A shorter onset-to-admission interval for inpatient rehabilitation poststroke, within the first 20 days, has been shown to significantly improve functional outcomes compared to longer intervals
  • Many of the interventions begun during inpatient rehabilitation are continued and progressed in order to sustain the gains made and improve functional performance during the chronic phase