Treatment of Ischaemic Stroke The American Heart Association American Stroke Association Guidelines Stroke. 2007;38:

Acute Evaluation During initial evaluation, the single most important point in the patient's history is the time of symptom onset. Patients with acute stroke symptoms should receive testing for blood glucose, coagulation times, and complete blood count with platelets, along with 12-lead electrocardiogram and serum cardiac enzymes. However, chest radiography may be withheld if there are no signs of pulmonary or cardiac disease. The evaluation of the patient should be concluded within 60 minutes of arrival in the emergency department

Imaging  CT remains the most common imaging modality for the evaluation of acute stroke, and, besides hemorrhage, there is no CT finding that is specific enough to preclude treatment with recombinant tPA (rtPA). MRI also is acceptable in the evaluation of acute stroke.

Blood Pressure  Patients' blood pressure may decline spontaneously in the first 24 hours after stroke. Patients who are candidates for rtPA should have their systolic blood pressure lowered to at least 185 mm Hg and their diastolic blood pressure lowered to at least 110 mm Hg. Consensus opinions state that patients with persistent elevations in systolic blood pressure higher than 220 mm Hg or diastolic blood pressure higher than 120 mm Hg should receive antihypertension therapy.  Hyperglycemia in the range of 140 to 185 mg/dL in the stroke patient should prompt consideration of insulin therapy.

Thrombolysis rtPA is the treatment of choice for thrombolysis in acute stroke. rtPA is the treatment of choice for patients who present within 3(4.5) hours of the onset of stroke symptoms. Treatment with streptokinase is not recommended, and reteplase, urokinase, and other thrombolytic agents should not be used outside of the setting of a clinical trial. Intra-arterial thrombolysis may be used for patients with occlusions of the middle cerebral artery who can be treated within 6 hours of symptom onset.

IV tPA 0.9mg/Kg max 90mg infused over 60 min 10% dose administered as initial IV bolus over 1 min Following tPA no aspirin, heparin, or warfarin for 24 hours

Subacute Treatment Avoidance of Hypovolemia Avoidance of Hyponatraemia Treatment of Hyperthermia Decompressive surgery in massive hemispheric or cerebellar infarction

Treatment of Acute Neurological Complications Patients with major infarctions affecting the cerebral hemisphere or cerebellum are at high risk for complicating brain edema and increased intracranial pressure. Measures to lessen the risk of edema and close monitoring of the patient for signs of neurological worsening during the first days after stroke are recommended (Class I, Level of Evidence B).

Treatment of Acute Neurological Complications Patients with acute hydrocephalus secondary to an ischemic stroke most commonly affecting the cerebellum can be treated with placement of a ventricular drain (Class I, Level of Evidence B).

Treatment of Acute Neurological Complications Decompressive surgical evacuation of a space-occupying cerebellar infarction is a potentially life-saving measure, and clinical recovery may be very good (Class I, Level of Evidence B). Although data from clinical trials are not available, it is recommended for patients with major cerebellar infarction.

Treatment of Acute Neurological Complications Recurrent seizures after stroke should be treated in a manner similar to other acute neurological conditions (Class I, Level of Evidence B).

Treatment of Acute Neurological Complications. Although aggressive medical measures, including osmotherapy, have been recommended for treatment of deteriorating patients with malignant brain edema after large cerebral infarction, these measures are unproven (Class IIa, Level of Evidence C). Hyperventilation is a short-lived intervention. Medical measures may delay decompressive surgery.

Treatment of Acute Neurological Complications Decompressive surgery for malignant edema of the cerebral hemisphere may be life- saving, but the impact of morbidity is unknown. Both the age of the patient and the side of the infarction (dominant versus nondominant hemisphere) may affect decisions about surgery. Although the surgery may be recommended for treatment of seriously affected patients, the physician should advise the patient’s family about the potential outcomes, including survival with severe disability (Class IIa, Level of Evidence B).

Treatment of Acute Neurological Complications No specific recommendation is made for treatment of patients with asymptomatic hemorrhagic transformation after ischemic stroke (Class IIb, Level of Evidence C).

Treatment of Acute Neurological Complications. Because of lack of evidence of efficacy and the potential to increase the risk of infectious complications, corticosteroids (in conventional or large doses) are not recommended for treatment of cerebral edema and increased intracranial pressure complicating ischemic stroke (Class III, Level of Evidence A).

Treatment of Acute Neurological Complications Prophylactic administration of anticonvulsants to patients with stroke but who have not had seizures is not recommended (Class III, Level of Evidence C).

Cerebral Venous Thrombosis CT with contrast – Empty delta sign(filling defects in in the superior sagittal sinus torcula (30%) Parenchymal abnormalities suggestive of deranged venous drainage (60%) Contrast enhancement of falx & tentorium from venous hypertension