General Care After Stroke, Including

Stroke Units and Prevention and Treatment of

Complications of Stroke

Reasons for Admission

• Serious illness• Potentially life-threatening disease• Risk for medical or neurological

complications• Neurological deterioration• Observation, evaluation and treatment

Organization of Stroke Care

• Acute Stroke Units– Concentrate admissions to a specialized

facility with skilled care and monitoring.– Shorten hospitalizations and reduce death

and disability.– Reduce complications and promote

rehabilitation.

Organization of Stroke Care

• Stroke Teams– Coordinated teams of health care

professionals to coordinate efficient and effective care for stroke patients.

– Stroke Teams play a part in the hyperacute, the acute and the rehabilitation phases of stroke care.

– Involve the multidisciplinary team.

Stroke Centers

• Primary Stroke Centers – Use the cardiac/trauma model of delivering

care.– Major elements: patient care and support

services.– Define institutions where appropriate care

can be given.

Goals of Treatment After Admission

• Continue care started in emergency department.

• Observe for and prevent or control neurological and medical complications.

• Start rehabilitation and discharge planning.• Evaluate for cause of stroke and start

therapies to prevent recurrent stroke.

Neurological Complications

• Progression of thrombosis• Recurrent embolism• Brain edema• Hydrocephalus• Increased intracranial pressure• Hemorrhagic transformation• Seizures

Medical Complications

Myocardial infarction PneumoniaCongestive heart failure Airway

obstructionCardiac arrhythmias HypertensionDeep vein thrombosis Bladder infectionsPulmonary embolus DepressionGastrointestinal bleeding Electrolyte

disturbance

• Initially treated with bed rest; mobilization begins as soon as the patient’s condition is stable

• Pulse oximetry first 24-48 hours

• Cardiac monitoring first 24 hours

After Admission

After Admission

• Frequent assessments of vital signs and neurological status by nursing staff.

• Protection of airway, especially if depressed consciousness or signs of brain stem dysfunction.

• Supplemental oxygen if patient is hypoxic.

• Assessment for cause of hypoxia.

Heart Disease and Stroke

• Heart disease often is the cause of stroke.• Most patients with stroke have heart

disease.• Stroke, especially intracranial hemorrhage,

can cause myocardial ischemia or cardiac arrhythmias.

• Many persons will have cardiac arrhythmias or electrocardiographic abnormalities after stroke.

Sinus bradycardia Sinoatrial arrhythmia

Ventricular tachycardia Atrial fibrillation

Ventricular fibrillation PVC Idioventricular rhythms PSVTTorsades de pointes AV block

Heart Disease and Stroke

• ST-T segment elevation/depression• Pathological Q waves• Negative T waves• Abnormal U waves• QT prolongation

ECG Changes and Stroke

• Arterial hypertension is common among persons with stroke:– risk factor for stroke– consequence of stroke

• Usually declines spontaneously• Secondary to pain, vomiting, stress,

anxiety• Secondary to increased intracranial

pressure

Hypertension in Stroke

Treatment of Arterial Hypertension

• Oral agents preferred• Continue or re-institute

antihypertensive medications• Goal of lowering pressure by 15%

during first 24 hours

• If parenteral medications are used, prefer short-acting drugs

• Treat fever and search for the cause of fever; suspect pulmonary or urinary tract infections

• Maintain hydration with intravenous fluids

• Treat hyperglycemia and hypoglycemia• Assess swallowing before starting oral

feedings• If necessary, consider enteral feedings

Initial Management of Acute Stroke

• Early mobilization– positive for morale– expedites rehabilitation– lessens risk of pulmonary, skin,

musculoskeletal complications• Watch for hypotension or neurological

worsening• Protect against falls

Mobilization After Stroke

Prevention of DVT and Pulmonary Embolism

• Mobilization• Heparin• LMW heparins/heparinoids• Oral anticoagulants• Aspirin• Alternating pressure stockings

Brain Edema and Increased Intracranial Pressure

• Peaks within one week of stroke• Earlier with hemorrhagic stroke• A leading cause of death• Seen with large multi-lobar strokes• Can be secondary to hydrocephalus

or mass effect of a hematoma

• Common cause of neurological worsening– progression of stroke– secondary brain ischemia– herniation syndromes

• Hallmark is depression of consciousness• Vital signs unstable and arterial

hypertension

Brain Edema and Increased Intracranial Pressure

Management of Brain Edema and Increased Intracranial Pressure

• Restrict fluids moderately• Avoid hypo-osmolar fluids• Control fever, hypoxia, hypercarbia• Elevate head of bed by 30%• Monitor intracranial pressure

Trial of Dexamethasone for Supratentorial Intracerebral Hemorrhage

Dexamethasone Placebo n=46 n=47

Good Recovery 8 5Poor Survivor 17 21Dead 21 21Infectious Complications 13 6

Pougvarin, et al. New England Journal of Medicine 1987;316:1229-1233..

• Hyperventilation to a pCO2 of approximately 28-30 mm Hg

• Corticosteroids are not recommended• Mannitol, 0.25-1 g/kg intravenously

given every 6 h maximum osmolarity 310

• Furosemide 40 mg intravenously

Intracranial Pressure

• Drainage of CSF fluid• Evacuation of hematoma• Resection of infarcted tissue• Hemicraniectomy

Surgical Management of Brain Edema and ICP

Evaluation for Cause of Stroke

• Magnetic resonance imaging of brain• Magnetic resonance angiography• Spiral CT imaging• Carotid duplex• Transcranial Doppler• Transthoracic echocardiography• Transesophageal echocardiography

Prevention of Recurrent Stroke Cardioembolic Stroke

• Oral anticoagulants– prosthetic valves: INR 2.5-3.5– other causes: INR 2.0-3.0

• Stroke despite adequate anticoagulation– add aspirin– add dipyridamole

• Contraindication for anticoagulation– Aspirin

Prevention of Recurrent Stroke

• Carotid endarterectomy if ipsilateral high-grade stenosis, acceptable risk, and skilled surgeon

• Antiplatelet aggregating drugs– Aspirin– Ticlopidine– Aspirin and dipyridamole

Rehabilitation

• Critical part of care after stroke• Begin as soon as patient is stable and

while the patient is still in an acute care bed

• Tailor to individual patient’s needs • Progress in a step-wise progression• Maximize patient’s independence

Decisions About Rehabilitation Influence Discharge Planning

• In-patient rehabilitation unit – attached to acute hospital– free-standing hospital

• Outpatient care• Home care• Skilled nursing facility

Discharge Planning Considerations

• Cognitive and functional status• Family and caregivers’ support• Financial resources• Patient and family education• Follow-up medical care,

rehabilitation• Identify safe place of residence• Community support or resources