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Stroke fast track and complications Khwanrat Wangphonphatthanasiri,MD.

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1 Stroke fast track and complications Khwanrat Wangphonphatthanasiri,MD

2 When cerebral artery occlude


4 In the first few hours of vascular insult there is only a penumbral pattern (low CBF and high CBV due to maximally functioning autoregulation mechanism and collateral circulation). This is viable tissue at risk that could be saved, but it may not yet show diffusion restriction. Subsequently, the autoregulation mechanism starts to fail and the infarction core spreads, gradually reaching its final extent, which is the entire penumbra (low CBF region). The mean lesion-to-contralateral region CBV ratio of 0.19 (range, 0.03–0.36) may suggest a viability threshold.


6 DWI and ADC map demonstrate an area of diffusion restriction in the right MCA territory consistent with acute infarction. CBF and MTT map (PWI) demonstrate the infarct penumbra which is larger than the core, indicating the presence of salvageable tissue. CBV map (PWI) demonstrates infarct core which is slightly smaller than the area of diffusion restriction.


8 Patient imaged pre-tPA treatment at 1.5 hours, with large left MCA occlusion (MRA), and a penumbral pattern with a large PWI lesion and small DWI lesion. Subacute studies post- tPA (day 5) show recanalisation, reperfusion and minimal expansion of the infarct core on DWI.

9 Ischemic stroke in middle cerebral artery territory. (A) Low flow area with irreversible damage on final magnetic resonance image (MRI) predicted by low oxygen consumption and decreased oxygen extraction fraction (OEF). Penumbra tissue outside the final infarct is characterized by preserved oxygen consumption and increased OEF. (B) Reperfusion is not effective if tissue is already damaged. (C) Effective reperfusion to viable (penumbra) tissue.

10 Intravenous Thrombolytic Therapy National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study ( NINDS rt-PA Stroke Study) European Cooperative Acute Stroke Study ( ECASS I, ECASS II,) Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS trial)

11 Administration of rtPA (Protocol Guidelines) I. Inclusion criteria Age 18 years or older Signs of a measurable neurologic deficit from an ischemic stroke on examination Time of onset < 3 hours

12 Exclusions to Thrombolytics Stroke or head trauma in 3 mo Major surgery within 14 days Any history of intracranial hemorrhage SBP > 185 mm Hg DBP > 110 mm Hg Rapidly improving or minor symptoms Symptoms suggestive of subarachnoid hemorrhage Glucose 400 mg/dl GI hemorrhage within 21 days Urinary tract hemorrhage within 21 days Arterial puncture at non- compressible site past 7 days Seizures at the onset of stroke Patients taking oral anticoagulants Heparin within 48 hours and elevated PTT PT >15 / INR >1. 7 Platelet count <100,000

13 rtPA Treatment Based on CT Findings CT Findings None Subtle < 1/3 MCA Subtle > 1/3 MCA Hypodensity < 1/3 MCA Hypodensity > 1/3 MCA Recommendations >>Treat >>Probably treat >>Don’t treat


15 NINDS rtPA Stroke Study 31 to 50% had a complete or near-complete recovery at three months, as compared with 20 to 38 %of the patients given placebo Motarity rate was similar at one year Symptomatic brain hemorrhage, which occurred in 6.4 percent of the patients given t- PA, as compared with 0.6 percent of those given placebo ( 36 hrs) N Engl J Med 1995;333:

16 Factors Associated with Increased Risk of ICH Treatment initiated > 3 hours Increased thrombolytic dose Elevated blood pressure NIHSS > 20 * Acute hypodensity or mass effect

17 Modified Rankin Scale scores at 3 and 12 months in patients treated in Cologne compared with patients from the NINDS rtPA Stroke Trial placebo and treatment groups (3 and 12 months) and with the ECASS I and ECASS II 3 h rtPA cohorts (3 months).

18 Stroke is a "Brain Attack" Stroke is an emergency! Time is brain

19 Onset Emergency Room Stroke Fast Track; Treatment Stroke Unit vs General neurological ward or General ward Home, Home care, … By ?

20 Time framesNINDS times (min) Time to first physician Time to CT Time to Lab Time to CT result Time to Lab result Time to Treatment (rtPA cases) Time to Monitor bed (rtPA cases) N/A 45 N/A Consensus time-frames criteria for effective hospital stroke response system by National Institute of Neurological Disorders & Stroke Rapid Identification and Treatment of Acute Stroke. Arlington, VA. National Institute of Neurological Disorders and Stroke; 1997

21 GUIDELINE OF ACUTE ISCHEMIC STROKE TREATMENT BY INTRAVENOUS THROMBOLYTIC SUSPECTED ISCHEMIC STROKE ONSET WITHIN 3 hrs ER NURSE ASSESSM ENT 1.Sudden of either weakness, numbness, paralysis of the face, arm or leg, especially on one side of the body. 2. Confusion, trouble speaking or understanding 3. Loss of vision in one or both eyes 4. Trouble walking, dizziness, loss of coordination of balance, especially if combined with other signs Notify Neurologist CHECK V/S, N/S and basic life support, stool occult blood,blood examination Coagulogram, Electrolyte,CBC, BS, BUN,Cr, (Blood Clot 1 tube) Notify CT Contract SU Non contrast CT NON HEMORRHAGE HEMORRH AGE Consult neuro- Surgeon SU; Neurologist & Nurses 1. Thrombolytic check lists 2. Consent form resident / Staff neurology 3. Notify neurosurgeon before start intravenous Thrombolytic




25 Step by step for rtPA Step 1 – Screening at ER by Nurse Step 2 – Clinical; Lab Screening by doctor Step 3 – IV Thrombolysis Step 4 – Post Thrombolysis care (24 hrs; > 24 hrs)

26 Step 1 – Screening at ER by Nurse พยาบาลต้องซักถามอาการที่ สงสัยว่าเป็นโรคหลอดเลือดสมอง แขนขา ชา อ่อนแรง ข้างใด ปากเบี้ยว พูดไม่ชัด พูดไม่ได้ เดินเซ ตามองเห็นภาพซ้อนหรือมืดมัว ปวดศีรษะรุนแรงทันที ระยะเวลาที่เป็นต้องไม่เกิน 3 ช. ม พยาบาลต้องแจ้งแพทย์เพื่อ ยืนยันการเข้า Stroke fast track 1. Sudden of either weakness, numbness, paralysis of the face, arm or leg, especially on one side of the body. 2. Confusion, trouble speaking or understanding 3. Loss of vision in one or both eyes 4. Trouble walking, dizziness, loss of coordination of balance, especially if combined with other signs

27 Step 2 – Clinical; Lab Screening by doctor พยาบาล Notify แพทย์ เมื่อแพทย์ ได้รับแจ้งต้องไป ดูผู้ป่วยทันทีเพื่อประเมินอาการและระยะเวลาที่เกิด อาการ Blood for Coagulogram, E’lyte,CBC, BS, BUN, Cr, (Blood Clot 1 tube), Stool occult blood CT Brain, EKG แพทย์ ประเมิน Exclusion & Inclusion Criteria for IV Thrombolysis

28 THROMBOLYSIS CHECK LIST Name……………………Age HN…………..AN………….. Date:……………Attending staff………….. Time: Symptom Onset …………rtPA given:………..NIHSS……… INCLUSION criteria (must all be YES) Age ≥ 18 years  Yes  No Time of onset well established to be < 3 hours  Yes  No Clinical diagnosis of ischemic stroke causing a measurable neurological deficit  Yes  No CT without hemorrhage or significant edema  Yes  No

29 EXCLUSION criteria (must all be No) SBP>185 or DBP>110  Yes  No Symptoms rapidly improving or minor symptoms (NIHSS = 0-6)  Yes  No Coma or severe obtundation (or NIHSS>25)  Yes  No Seizure at onset  Yes  No Symptoms of SAH (diffuse headache, stiffness of neck)  Yes  No Prior stroke or head trauma within 3 months  Yes  No Major surgery within 14 days  Yes  No Prior intracranial hemorrhage  Yes  No GI hemorrhage or urinary tract hemorrhage within 21 days  Yes  No Arterial puncture at a noncompressible site or LP within 7 days  Yes  No Recent Myocardial infarction  Yes  No Patients receiving heparin within 48hrs and with an elevated PTT  Yes  N PT >15 or INR > 1.7  Yes  No Platelet count < 100,000  Yes  No Plasma glucose 400  Yes  No Hematocrit < 25%  Yes  No Pregnant (Note: menstruation is NOT a contraindication)  Yes  No Hypodense > 1/3 MCA territory Stroke from other causes

30 rt-PA (rt-PA 50mg Total 2 Set) Stroke Lysis Box Box Step 3 – IV rtPA (Recombinant Tissue Plasminogen Activator)


32  Weight (kg) : __× 0.9 mg = __ mg  Give 10% bolus over 1 minute __ mg (ml)  Give remaining 90 % constant infusion over 60 minutes __ mg (ml) Total maximum dose 90 mg. M.D. Physician Signature ………………… Dosage calculation and How to infuse

33 Checklist prior to rt-PA Time of stroke onset: < 180 min  done Check Head CT – completed  done Check Lab – completed  done Physician order set completed  done Contraindication checklist completed  done Patient and Family Consent completed  done Notify neurosurgeon Signature of Incharge nurse……………………… Date…/…………./…………. Time ………………… A checklist prior to rt-PA has to be made, including time of stroke onset lesser than 3 hrs, a complete check of head CT, Lab and Physician Order set, not to mention the completeness of contraindication checklist and concent.


35 Step 4 – Post Thrombolysis care (in 24 hrs) Complication form rtPA การประเมินที่สำคัญ 1. ก่อนและขณะให้ยา BP ต้อง < 185/110 mmHg อาการและอาการแสดงที่สงสัยว่ามี ICH 2. อาการและอาการแสดงที่สงสัยว่ามี ICH อาการทางระบบประสาทที่เลวลงอย่างฉับพลัน อาการทางระบบประสาทที่เลวลงอย่างฉับพลัน ปวดศีรษะ ปวดศีรษะ BP> 185/ 110 mmHg อย่างฉับพลั น BP> 185/ 110 mmHg อย่างฉับพลั น N/V N/V

36 ผู้ป่วยควรได้รับการดูแลรักษาทั่วไป เช่น o ได้รับยาต้านการแข็งตัวของเกล็ดเลือด o การดูแลทั่วไป การทำกายภาพบำบัด o การประเมินอาการทางระบบประสาท o การป้องกันภาวะแทรกซ้อนเป็นระยะ o การสอนให้ความรู้ปัจจัยเสี่ยงและการป้องกัน o การกลับเป็นซ้ำ Step 4 – Post Thrombolysis care (> 24 hrs)

37 MONITORING AND THROMBOLYTIC TREATMENT DATE ORDER FOR ONE DAYDATEORDER FOR CONTINUATIONWARD - Prior on rt – PA Check NIHSS,V/S,N/S and basic life support, stool occult blood, blood examination Coagulogram, Electrolyte,CBC, FBS, BUN,Cr (Blood Clot 1 tube) - CT brain non contrast - On rt – PA …. mg IV bolus in 1 minute Then rt – PA … mg IV drip in 60 minute -Check vital sign, neurological sign &NIHSS after infusion q 15 mins. for 2 hrs. then q 30 mins. for 6 hrs. then q 60 mins. until 24 hrs.- If SBP >185 or <110 mm Hg DBP >110 or < 60 mm Hg if BP out of ranges please notify doctor - NPO except medications for 24 hrs. -IV fluid as appropriate - Bed rest - Record l /O - Medication consider 1. H2 receptor blocker / Proton Pump Inhibitor 2. Antihypertensive drugs If BP >185 /110 mm Hg (Page 10 GUIDELINE OF ACUTE ISCHEMIC STROKE TREATMENT BY INTRAVENOUS THROMBOLYTIC NAME LAST - NAME AGE H.N ALLERG Y DIAGN OSIS

38 DATE ONE DAYDATECONTINUATIONWARD If Hemorrhage is suspected - Stop infusion of the Thrombolytic drug - Repeat CBC, platelet, INR, PTT, PT - CT brain stat - Prepare FFP or platelet count, Cryo-precipitate. - Notify Neurologist Neurosurgeon and Team for discussion. NAME LAST - NAME AGE H.N ALLERGY DIAGNOS IS MONITOR AND THROMBOLYTIC TREATMENT

39 ศักยภาพของโรงพยาบาลที่สามารถ ดำเนินการรักษาโรคหลอดเลือดสมอง ตีบด้วยการให้ยาละลายลิ่มเลือดทาง หลอดเลือดำ สถานบริการต้องสามารถให้บริการ 24 ชั่วโมง ในหัวข้อดังต่อไปนี้ ประสาทแพทย์ หรือแพทย์เวชศาสตร์ฉุกเฉิน / อา ยุรแพทย์ ที่ได้รับประกาศนียบัตรฝึกอบรมใน การให้สารละลายลิ่มเลือด ประสาทศัลยแพทย์ CT brain มีห้องปฏิบัติการที่สามารถตรวจ BS, CBC, Coagulogram, E’lyte, BUN, Cr สามารถหาเลือดและส่วนประกอบของเลือดได้ เช่น FFP, CP, PC และ PRC มี ICU หรือ stroke unit ที่สามารถให้การดูแล ผู้ป่วยในระหว่างหรือภายหลังการให้ยาได้ มีการสำรองยา rt-PA ไว้ในบริเวณที่ให้การ รักษา


41 Complications of stroke Neurological deterioration in acute stroke ; - decrease of level of consciousness - motor deficit progression

42 General medical complications

43 Prospectively collected data; suggest direct effect of ischemic stroke account for most deaths within first week after stroke mortality resulting from medical complications predominate there after

44 Neurological deterioration in acute stroke 1.Recurrent stroke - The International Stroke Trial (IST) show recurrence rate (first 14 days) 2.8 % in those tx with aspirin 3.9% in those not receive aspirin - ASA ( mg) begin within 24 hrs after stroke is recommended to lower risk of early ischemic stroke recurrence(IST,CAST) Lancet 1997;349: Lancet 1997;349:

45 risk factors/predictors for stroke progression risk factors/predictors for stroke progression Age Hx of DM Elevated SBP on admission Prior antiplatelets Hyperthermia Hyperglycemia High Hct Early positive CT brain


47 2.Hemorrhagic transformation symptomatic (headache,worsening of focal deficit,decreased level of consciousness) asymptomatic

48 - prospective study; assess 65 pts. with acute supratentorial infarct - serial CT in 4 weeks 43%(28/65) found hemorrhagic transformation 5% (3/65) or 10% of pts.hemorrhagic transformation have neurological deterioration correlation between size of infarct and present of hemorrhagic transformation Stroke 1986;17:

49 Rate of hemorrhagic transformation (total and symptomatic) according to time to treatment

50 In case suspected ICH associated with thrombolysis; tx hold drug infusion emergency CT blood component check &prepare cryo ppt,PRC,Platelet neurosurgical option for selected case

51 3.Cerebral edema - related to large infarct & tend to have delayed clincial deterioration most serious rising ICP – brain herniation -As ICP rises CPP&CBF are reduced local increase in tissue pressure interfere local microcirculation -; worsening ischemia & 2’ cerebral damage - maximal edema occurs between day cause mainly by cytotoxic brain edema

52 2 hr after onset 24 hrs later with clinical deterioration CT brain show subfalcial herniation, massive ACA+ MCA infarction with brain swelling and hemorrhagic conversion

53 treatment of elevated ICP in stroke 1. elevate head of bed 15-30’; both ICP & CPP are lowest while head elevate by 30’

54 2. hyperventilation act almost immediately to lower ICP by leading to vasoconstriction 2’ to alkalosis of CSF hyperventilation pCO2 below 30 mmHg can induced ischemia via vasoconstriction J Neurosurgery 1991;75:

55 3.pharmacological treatment 3.1 manitol ; almost immediate decrease In whole blood viscosity leadind to vasoconstriction and decrease ICP(non infarcted brain) - maximal duration of effect on ICP range min (mean 88 min) - dose g/kg over 20 min repeat q 6 hr monitor fluid input/output,serum osmolarity typical maximum daily dose 2g/kg Circulation 1994;90: J Neurosurgery 1981;55: J Neurosurgery 1983;59: Acta Neurochir 1977;36: Neurology 2001;57:

56 4.Surgical intervention- specific condition hemicreniectomy in case massive MCA infarction craniotomy or suboccipital craniectomy in case large cerebellar infarct & depressed level of consciousness secondary to BS compression

57 Right middle cerebral artery infarction

58 cranial vault is closed, fixed bony box, its volume is constant. This volume is described by Monro-Kellie doctrine, v.intracranial (constant) = v.brain + v.CSF + v.blood + v.mass

59 4.Seizure and epilepsy - seizure & post ictal state lead to depressed level of consciousness & worsening focal neurological deficit - incidence of seizure after stroke ~ 8.6% early onset (2 wks) occur 3.8% ; predictor of recurrent seizure 55% of pts.late onset seizure developed epilepsy - status epilepticus – uncommon(9%) - AED recommended for seizure in acute stroke setting long term AED individualized Arch Neurol 2000;57: Neurology 1996;46:

60 5. Unknown causes of deterioration in small &large vessel infarct early deterioration (within 7 days onset ) occurs in ~ 25% of pts. Stroke 2000;31: excluded of consciousness change,progressive motor deficit --- cause mostly by lacunar infarct esp.DM Stroke 2002;33:

61 - mechanism – not well understood - hypothesis 1.thrombos propagation 2. microemboli or low perfusion from large vessel 3. excitotoxicity ; elevated serum glutamate & depressed serum GABA found associated with motor deterioration in first 48 hrs Neurology 1996;47: Stroke 2001;32:

62 4. inflammatory contribute; inflammatory marker ex.IL6,TNF alfa elevate in case early deterioration 5.hypoperfusion, lower blood pressure Stroke 2002;33:

63 6. Systemic conditions -systemic process affect neurological status in stroke pts. by furthering cerebral ischemia or leading to neuronal dysfunction - transient worsening or recurrence of original symptom - ex. Fever ; potential mechanism – release of excitatory amino acid & hydroxyl radicals sedative medications J Neurochem1995;65: Neuroscience 1998;83:

64 General medical complications

65 A recent prospective study 95% patients had at least 1 medical complication 32% patients had at least 1 serious complication( immediately life treatening,prolonged hospitalization or death) Stroke 1998;29:

66 Common complications after acute stroke -Falls 25% -UTI 24% -Chest infection 22% -Pressure sore 21% -Depression 16% -Shoulder pain 9% -DVT 2% -Pulmonary embolism 1% Data derived from Langhome P,Stott DJ,Robertson L,et al.Medical complications after stroke; a multicenter study.Stroke2000;31 ; Data from a prospective multicentered study with patients followed up to 30 months.Of those patients,89 percent had ischemic strokes and 11 percent had primary intracerebral hemorrhage

67 Serious medical complications after stroke -All pneumonia 5% -Aspiration pneumonia alone 3% -CHF 3% -Gastrointestinal bleeding 3% -Cardiac arrest 2% -Angina/MI/cardiac ischemia 1% -DVT 1% -Pulmonary embolism 1% -Hypoxia 1% -Urinary tract infection 1% From Johnston KC,Li JY,Lyden PD,et al.medical and neurological complications of ischemic stroke; experience from the RANTTAS trial. RANTTAS investigators. Stroke 1998;29;

68 1)Systemic thrombotic complications 1.1Deep venous thrombosis(DVT) / pulmonary embolism leg paresis is predisposed to developing DVT, (75% paretic side) degree of paresis related graded risk of DVT peak incidence at 2-7 days risk of death from untreated prox DVT in stroke patients = 15% Arch Neurol1992;49: Stroke 2001;32:

69 Sign and symptom of DVT leg swelling and pain positive Homan’s sign Screening by duplex ultrasound


71 DVT(cont.) Pulmonary embolism ; % of early deaths after stroke in 2-4 weeks severe hypoxia Treatment by anticoagulant weighted against risk of bleeding esp. in case large stroke Stroke 2001;32:

72 2)Pulmonary complications 2.1Aspiration study by videofluoroscopy to assessment swallowing in post stroke patients 50% found abnormality bedside predictors ; aspiration to thin liquid shown spontaneous cough during test swallowing absent of gag reflex ( healthy elderly subjects,bilaterally absent gag reflex found 43%) Stroke1999;30: J Commun Disord2001;34:55-72 Lancet1995;345:

73 Independent predictor of dysphagia Initial presentation male gender age >70 yrs disabling stroke impair pharyngeal response,incomplete oral clearance Palatal weakness or asymmetry Dysphagia2001;16:

74 study ; at 6 month 87% return to their pre stroke diet 50% found evidence of swallowing abnormality on clinical assessment Stroke 1999;30:

75 Prevention of aspiration in patient dysphagia Initial nil per os (NPO) for those who may be risk of aspiration ex.drowsiness at onset Retain NG tube in case of dysphagia,choking,aspirate

76 2.2 Pneumonia ; Most common cause of fever in stroke patients in first 48 hours most common medical complication 2-4 weeks after supratentorial ischemic infarct 66% of cases cause by aspiration Aspirated of colonizes oropharyngeal material Stroke 1998;29: Stroke 1984;15:

77 Common site of lungs involvement; - posterior segment of upper lobe or apical segment of lower lobe if aspiration occurs while recumbent - posterior segment of upper lobe or apical segment of lower lobe if aspiration occurs while recumbent - basal segment of lower lobe if aspiration occurs while upright or semi upright - basal segment of lower lobe if aspiration occurs while upright or semi upright

78 Common organism ; CAP S.pneumonia,Strap.aureus, H. influenzae,Enterobacteriaceae HAP ; gram negative organism (include Pseudomonas) HAP ; gram negative organism (include Pseudomonas) anaerobic in case putrid sputum,severe peridental dz,alcoholism anaerobic in case putrid sputum,severe peridental dz,alcoholism

79 mechanical ventilation required - high morbidity &mortality - Wijdicks and Scott series; 24 pts. found 3 major reasons for stroke pts. to require mechanical vent. 1. pulmonary edema (10) – neurogenic PE ? 2. brain swelling (8) 3. seizure (6) 17/24 died Mayo Clin Proc 1997;72:

80 3. Cardiac complications 3.1 arrhythmia through effects of ANS via combination of humurally mediated & directed effect -- EKG change more common in setting of stroke Prog Cardiovasc Dis1993;36:

81 one study ; follow 3 times EKG within the first 1 week ischemic stroke pts who did not have any hx of pre existing heart dz found that only 23 % had normal tracing Angiology 1990;41:

82 series using control matched for age,previous hx of heart dz, factors known to be associate with increase risk of arrhythmia ; presence of heart dz did not appear to confer an increased risk of arrhythmias Association between stroke and arrhythmia Stroke1982;13:

83 Cardiac arrhythmia after stroke QTc prolonged 28% (37) Tall U waves 9% (25 ) ST change 25% T wave changes 34% Sinus tachycardia 15% (22) LVH 4% Q wave 9%(22) AF 0%(13) VPCs 0%(13) Sinus bradycardia 11% 1’AV block 2% ST elevate,RBBB,LBBB NR(3,7,0) Arrhythmia detected in stroke patients without a known history of cardiac disease as documented by Ramani et al.

84 -occurrence of lethal arrythmia may be more common than anticipated -A series ; 6/30 had asystole,complete atrioventricular block, ventricular tachycardia -Sudden cardiac death occur 1% of supratentorial ischemic infarct within first 30 days (+/- comorbid cardiac dz) JAMA1981;246: Stroke 1984;15:

85 Complete AV block Ventricular tachycardia

86 3.2 elevated cardiac enzyme -creatine kinase (CK),CKMB,myoglobulin, found elevated above normal threshold values over 3 days then decrease

87 -Troponin T,more sensitive & specific marker of myocytolysis, remained within normal range useful value to differentiate myocardial dysfunction associated with MI & other stroke related cause Stroke 2002;33:

88 3.3 Myocardial infarction -co incidence stroke & MI – common - only 1% have been considered to have serious cardiac ischemia Stroke 1998;29:

89 -treatment option; limit in setting of acute ischemic stroke ex. Thrombolysis,combined antiplt,ACEI,beta blocker angioplasty may be option for coronary revascularization in acute stroke setting

90 4. genitourinary complication 4.1 urological complications - urinary incontinence ; common after stroke % of stroke pts.on admission 25-28% on discharge s troke1998;29:

91 most common finding is detrusor hypereflexia cause by loss inhibitory input from higher centre leading to urinary urgency,frequency,urge incontinence detrusor hyporeflexia or areflexia lead to overflow incontinence,more common in hemorrhage (10% pt ischemic stroke in 72 hrs) J Uro 1996;156:

92 other contributions to urinary retention; - anticholinergic drugs - diabetic cystopathy - bladder outlet obstruction Prevalence of incontinence post stroke decreases with time 20% at 3 month 8% at 1 yrs 3 % at 2 yrs Stroke 2001;32:

93 Urinary incontinence –poor prognosis sign after stroke Treatment ; detrusor hypereflexia : scheduled voiding,fluid restriction,anticholinergic drugs avoid foley catheter placement to lower risk of nosocomial infection

94 4.2 urinary tract infection - 11% of stroke pts. followed 3 months(only 1% serious med complication) - foley catheter placement & duration related to risk of UTI - most common organism : Escherichia coli Circulation1994;90: Stroke1998;29:

95 catheter related UTI may asymptomatic and lack of present peripheral WBC related-catheter UTI found WBC in urine >10 /HF only 37 % urine culture important in Dx catheter related UTI Arch Intern Med2000;160:

96 4.3 Sexual dysfunction -related to; fear of stroke recurrence physical disability medication effect sensory deficit

97 2 months of stroke,40% of pts. express moderate or complete dissatisfaction with their sex lives male; libido,ejaculatory dysfunction,impotence female; decline vaginal lubrication> orgasm failure in case of decline libido should exclude depression or hormonal deficiency J Urol2001;165:

98 5.Gastrointestinal complication 5.1 GI bleeding 3% serious medical complication GI prophylaxis recommended for intensive care unit patients with a central nervous system process but not as routine therapy for all stroke pateints NPO patients – reasonable Stroke 1998;29: Am J gastroenterol 1995;90:

99 6. Miscellaneous complications 6.1 falls -hip fracture 2-4 times more common in stroke patients (secondary from fall)

100 -hospitalized stroke pts. have skeletal unloading secondary to bed rest & disused of paretic limb; predisposing to bone resorption

101 6.2 skin breakdown - pressure sore ; 20% of stroke pts. - prevention ;early mobilization, frequent turning, use specialized alternating pressure mattress close surveilance

102 6.3 depression post stroke depression incidence = % risk factor for post stroke depression; 1. female gender 2. higher disability scores 3. Prior hx of depression Curr Opin Neurol 2002;15:85-89

103 depression at 3 months correlated with poor outcome at 1 year Match for initial functional,outcome Pts whose depression remit have better outcome at 3 and 6 months - treatment; SSRI Stroke 1998;29: Stroke 2001;32:

104 Rehabilitation Early initiation of rehabilitation services may increase the potential for improved functional outcome Early rehabilitation is key for recovery Early mobilization also prevents: –Deep venous thromboses and pulmonary emboli –Decubitus ulcers –Contractures –Malnutrition –Pneumonias –UTI

105 Nutritionists Social Workers Case Managers Occupational Therapists Nurses Medical Doctors Physiotherapists Neurologist Phamacologist Patient Nerosurgeon Multidisciplinary in Stroke ญาติ

106 Thank you for your attention

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