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Management of Patients with Acute Ischemic Stroke

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Ischemic StrokeStroke is the third leading causes of death in the United States and the leading cause of disability in adults. When the brain cannot store oxygen or glucose, the brain becomes deprived of the proper nutrients that are essential for its proper functioning. The blood supply to the brain can be altered through several different processes in stroke. These include embolism, thrombosis, hemorrhage, and compression or spasm of the vessels. Ischemic stroke to embolism or thrombus formation accounts for approximately 85% of all strokes. Edema occurs in the area of ischemic or infarcted tissue and contributes to further neuronal cell death.

Stroke is a medical emergency and is treated with the same urgency as acute as myocardial infarction. The goals of treatment are to restore circulation to the brain when possible, stop the ongoing ischemic process and prevent secondary complications.

Evolution of Conditions that Mimic Acute Ischemic Stoke

Other conditions may mimic an acute ischemic stroke and must be ruled out. Hypoglycemia may cause stroke-like symptoms and is easily detected by using a bedside monitor to the check blood glucose. Other conditions that may mimic acute ischemic stroke include toxic or metabolic disorders, migraines, brain tumors and seizures.

Thrombolytic therapy

Thrombolytic therapy is administered in an attempt to restore perfusion to the affected area. IV administration of recombinant tissue plasminogen activator (rtPA) is considered in all patients who meet the inclusion/exclusion criteria and can be treated within 3 to 4.5 hours from the onset of symptoms based on the scientific advisory of the American Heart Association. The recommended dose for rtPA is 0.9 mg/kg, with 10% of the total dose given as a bolus over 1 to 2 minutes followed by the remainder as an infusion over 1 hour. The maximum dose recommended of rtPA is 90 mg. The constant monitoring of the patient who received rtPA is imperative as there is an increased risk of intracerebral hemorrhage following rtPA administration.

Endovascular Treatment

Endovascular Treatment options for acute ischemic stroke include intra-arterial thrombolysis and mechanical clot destruction. Intra-arterial thrombolysis allows medication to be given directly to the clot or thrombus thus smaller doses can be used. This treatment is best for patients who can be treated within 6 hours of the onset of symptoms.

Blood Pressure Measurement

Careful blood pressure management is essential after acute ischemic stroke because a marked or sudden decrease in BP can significantly reduce the cerebral perfusion. For patients who are not eligible for thrombolytic therapy, blood pressure is treated emergently unless the systolic blood pressure exceeds 220 mmHg or diastolic of 100 mmHg.

Management of increased Intracranial Pressure

Cerebral edema occurs in the area of the infarct which leads to increased ICP. Hemicraniectomy may be used to alleviate increased ICP in patients with large infarcts particularly in the distribution of the middle cerebral artery.

Glucose Management

Although hyperglycemia has not been specifically identified as a cause of worse outcomes after a stroke, there is a significant correlation between stroke and glucose. Hyperglycemia is associated with an increased risk of intracranial hemorrhage following rtPA administration. Hypoglycemia is deleterious and must be avoided as it contributes to the risk of stroke.

Preventing and Treating Secondary Complications

ischemic stroke

Abnormal blood flow in deep vein thrombosis that can contribute to blood clot in ischemic stroke

Patients are at significant risk for decreased airway management and aspiration following a stroke. Decreased level of consciousness, facial weakness, and cranial never deficits contribute to it. Intubation may be necessary during the acute phase. Some patients recover enough function to be extubated but others may need a tracheostomy. A feeding tube may also be indicated. Deep Vein Thrombosis (DVT) is a common complication in stroke patients and may lead to pulmonary embolism. Strategies to decrease the risk include elastic compression stockings, pneumatic compression devices, use of anticoagulants and early progression in activity.

Preventing recurrent stroke

The use of antiplatelet and anticoagulant medications varies depending on the size of the infarct, presumed etiology, and whether or not the patient thrombolytic therapy. Patients are placed on aspirin. However, if a stroke is very large, then coagulation is typically not used in the acute phase of treatment because it increases the risk of hemorrhagic conversion.

A stroke is a medical emergency. Take the person immediately to a hospital or call 911 at the first signs of the symptoms of stroke.