Definition

Stroke (means Lakava in hindi) is a medical emergency and is characterized by the sudden onset of neurologic deficit of cerebrovascular origin.

Associated with hypertension, diabetes mellitus, tobacco use, atrial fibrillation, atherosclerosis, etc.

Table of content

Stroke classification:-

Ischemic stroke	Hemorrhagic stroke
Thrombotic step wise progression of symptoms	Intra cerebral hemorrhage Headache, vomiting, impaired consciousness
embolic maximum deficit at the time of onset	SAH thunderclap headache, impaired consciousness

classification

Clinical Features :

In addition to usual history taking the following points should also be asked.

Time of onset :

This is very important if thrombolytic therapy is to be considered. If the patient is presenting within 4.5 hrs(Golden period) of stroke onset, then thrombolysis with recombinant tissue plasminogen activator may be done.

History of Systemic Hypertension/Dibetes/Dyslipidemia.

History of Arrhytymias, valvular heart disease, prosthetic.

Vitals:

Look for rhythm abnormalities (AF)
Look for bradycardia (Cushing’s reflex)
Blood pressure
Relevant Neurological Examination
Assess sensorium
Check pupillary reflexes
Neck stiffness
If the sensorium is normal, assess the Tone and power
Deep Tendon Reflexes
Plantar reflex

Investigations:

RBS
Plain CT Brain
Serum Electrolytes
ECG
Blood Routine
LFT
RFT
Serum Cholesterol
PT-INR and APTT if planning for Thrombolysis

Treatment:

(A) If CT report is pending:

Ryles Tube Feeding for stroke patients with dysphagia or dysarthria or facial deviation.
CBD
Inj. Pantoprazole 40mg IV BD.
Inj. Mannitol 20℅ 100ml IV (over 20 min) Q8H (if sensorium is altered)
Tab Atorvastatin 10mg 0-0-1.

(B) If CT report shows Acute Infarct:

In a case of acute ischemic stroke, if the patient reaches us within 4.5 hours of onset of stroke, then thrombolysis with rTPA may be considered.

If the patient is seen out of this window period then management is as follows:

Order (1), (2), (3), (4) and (5) same as above. Also add (6) T. Ecopspirin 150mg od.

(C) If CT shows Intra Cranial Hemorrhage:

Order (1), (2), (3),(4) and (5) same as above

(6) Inj. Phenytoin 100mg IV Q8H.

(7) Syp Lactulose 30ml tds.

(8) neurosurgery consultation

Note:

Antiepileptics are required only in case of a Lobar Hemorrhage. Prophylactic anti epileptics are not advised. Also, phenytoin is not the ideal anti-epileptic in stroke due to its drug interaction. So Levitiracetam is advisable ( Inj. Levetiracetam 500mg IV Q8H).

(D) If CT shows sub Arachnoid Hemorrhage:

Oredr (1), (2), (3) and (4) same as above.

5) T. Nimodipine 30mg 2-2-2-2-2.

6) Syp. Lactulose 30ml tds.

7) Neurosurgery consultation.

Management of Hypertension in acute stroke:

Ischemic stroke:

Perfusion pressure in areas of brain distal to the arterial occlusion may be low Cerebral perfusion depends on mean systemic arterial pressure. Thus a degree of Hypertension may be necessary to maintain adequate perfusion pressure. Therefor aggressive lowering of BP is not advised in acute ischemic stroke.

But in case of hypertensive crisis with end-organ involvement or Congestive heart failure or systolic BP >220 or Diastolic BP >120. Anti-hypertensives should be added. Target BP should be <180/115 mm Hg and more than 140/85.

Hemorrhagic stroke:

Gradual reduction of BP is advised in hemorrhagic stroke to a mean arterial pressure of 160 mmHg.

Physiotherapy in post stroke patients:

Must be started as soon as the patient’s condition is stable.
For a patient with grade 0 power, passive movements exercises in a full range of movement is advised.
For hemiparesis, both active and passive movements must be encouraged.
Position change at least 2hourly to prevent bedsore.

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