ACUTE ISCHEMIC STROKE (1994) PHILIPPINE NEUROLOGICAL ASSOCIATION Philippine Neurological Association Room 1006, 10/F, Rear Tower Cathedral Heights Bldg. St. Luke's Medical Center E. Rodriguez Sr. Avenue, Quezon City Tel No. 723-0101 local 5006 Officers, 1998 President Vice President Secretary Treasurer Board of Directors Immediate Past President Ramon S. Javier, M.D., FPNA Philip A. Ramiro, M.D., FPNA Alejandro Baroque II, M.D., FPNA Artemio Roxas, Jr. M.D., FPNA Emmanuel G. Eduardo, M.D., FPNA Raymond L. Espinosa, M.D., FPNA Servando T. Liban, M.D., FPNA Ester S. Bitanga, M.D., FPNA Stroke Council Dr. Artemio S. Roxas - Chairman ACUTE ISCHEMIC STROKE CPM 2ND EDITION Practice Guidelines on Management of Acute Ishemic Stroke Emergent Evaluation: agreement to recommend supplemental oxygen to hypoxic patients. 3. Avoid using drugs that can lower the blood pressure rapidly. For patients with markedly elevated BP, (>130 mm Hg mean BP* or >220 mm Hg systolic BP), cautious use of antihypertensive agents is recommended. Most patients with acute ischemic stroke do not need parenteral antihypertensive drugs. Oral antihypertensive are preferred Objectives: 1. Confirm that the cause is stroke and not other brain lesion. 2. Give clues about the most likely etiology. 3. Provide information about possible reversibility of the pathology. 4. Predict likelihood of immediate complications. 5. Start appropriate treatment Recommended Diagnostic Tests: 1. CT scan on the brain without contrast (when available) 2. ECG 3. Chest X-Ray 4. Hematologic studies CBC Platelet count Prothrombin Time Partial Thromboplastin Time/or Clotting Time, if not available Sedimentation Rate* • MABP = Systolic + (Diastolic) 3 If patient in the pediatric age group, the following tests are recommended: 5. (Serum electrolytes) Na+, K+ 6. Blood glucose (RBS) 7. BUN, Creatinine 8. Arterial blood gas level (if hypoxia is suspected) 9. Renal and hepatic chemical analyses 10. Lumbar puncture (if subarachnoid hemorrhage is suspected and CT is negative, in children, this should always be done in the absence of increase ICP-to rule out CNS infection) 11. Toxicology screen* (if highly suspected) 12. PPD* 13. Rheumatologic screen* 14. Cranial ultrasound* (in infants where CT Scan could not be done) *Additional test recommended for acute ischemic stroke in children. Emergent Supportive Care ecommendations: R 1. Stroke patients who have depressed levels of consciousness should have airway support and ventilatory assistance. 2. Not all patients with Acute Ischemic Stroke require supplemental oxygen. There is general 400 4. Control of either hyperglycemia or hypoglycemia after stroke is recommended. General Early Supportive Care ecommendations: R 1. Early mobilization and measures to prevent subacute complications of stroke (aspiration, malnutrition, pneumonia, deep vein thrombosis, pulmonary embolism, decubitus ulcers, contractures and joint abnormalities are strongly recommended). 2. Prophylactic administration of heparin or low molecular weight heparin or heparanoids to prevent deep vein thrombosis, is recommended for immobilized patients. For patients who cannot receive antithrombotic agents, intermittent external compression stockings are recommended. References 1. Anthony Riela and Steven Roach, Etiology of Stroke in Children. JOURNAL OF CHILD NEUROLOGY, Vol. 8 (July 1993). 2. Guidelines for the Management of Patients with Acute Ischemic Stroke. STROKE, Vol 24, No. 9 (Sept. 1994), 3. Emergency Cardia Care Committee and Subcommittees, AH, IV, Special Resuscitation Situations, JAMA 1992; 268224250 4. Britton M, et al, Hazards of therapy for excessive hypertension in acute stroke Acta Med. Scan 1980; 207:253-257