Ischemic stroke

The concept of ischemic stroke , cerebral infarction ), refers to diseases that affect the nervous system suddenly and violently. Cerebral infarction is defined as a neurological deficiency that lasts more than 24 hours and is caused by insufficient blood flow to part of the brain. The result is a stroke, that is, an irreversible injury to the brain.

Evolving stroke (progressive stroke) : a growing cerebral infarction manifested by neurological deficits that worsen in 24 to 48 hours.

Complete stroke (established stroke) : cerebral infarction manifested by neurological deficits involving an established injury.

Typically, strokes are secondary to arteriosclerotic or hypertensive stenosis , thrombosis, or embolism .

Summary

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  • 1 Diagnosis
  • 2 Forecast
  • 3 Treatment
  • 4 Rehabilitation
  • 5 See also
  • 6 Bibliography

Diagnosis

Ischemic stroke is usually diagnosed clinically, especially in patients over 50 years of age with hypertension, diabetes mellitus or signs of arteriosclerosis, or in subjects with embolic disease. The thrill or carotid murmurs in the neck may indicate a stenosis or the formation of a plaque; neurological symptoms and signs may suggest which artery is affected, although the correlation is not entirely accurate.

Forecast

During the first days of an ischemic stroke, neither the progression nor its prognosis can be predicted. Approximately 20% of patients die in the hospital; the mortality rate increases with age. The extent of neurological recovery depends on the age of the patient, her general baseline condition, and the location and size of the infarction. Altered level of consciousness, cognitive decline, aphasia and signs of TE involvement imply a worse prognosis. Full recovery is rare, but the earlier it starts the better the prognosis. About 50% of patients with moderate or severe hemiplegia and most of those with mild deficits have started functional recovery at discharge and can generally take care of their basic needs, have sensory clarity and walk, although the use of an affected member is limited. Any deficit lasting more than 6 months is likely to be permanent, even if the patient continues to improve slowly. Cerebral infarction recurs relatively frequently, and each recurrence is likely to add new disabilities.

Treatment

Immediate measures for a comatose patient include maintenance of the airway, adequate oxygen therapy, IV serums to maintain fluid and nutritional supply, control of bladder and intestinal function, and measures to prevent pressure ulcers. Corticosteroids are not indicated in the treatment of ischemic stroke.

Heart failure, arrhythmias, severe hypertension, intercurrent respiratory infections, and temperatures> 37.8 ° C should be treated. Spasmolytic drugs are preferable for the treatment of malignant hypertension. Barbiturates and other sedatives are contraindicated. Passive exercises, particularly of the paretic limbs, and respiratory physiotherapy should be started early if possible.

Recombinant tissue plasminogen activator (tPA) can improve neurological prognosis in selected patients (see exclusion criteria in Table 174-3) with acute stroke if administered within the first 3 hours after symptom onset. The recombinant tPA dose is 0.9 mg / kg iv (maximum dose: 90 mg); 10% of the total dose is administered by rapid iv route and the rest by continuous iv infusion for 60 min. The use of tPA in acute stroke should only be entrusted to doctors experienced in its management. Vital signs should be monitored for 24 hours after treatment and any bleeding complications should be vigorously managed. Anticoagulants and antiplatelets should not be used within 24 hours of treatment with tPA.

Heparin anticoagulation can stabilize symptoms in patients with evolving strokes who are not candidates for tPA treatment. However, it is being studied whether anticoagulants should be administered before determining the etiology of the stroke.

Patients with small non-hemorrhagic heart attacks of cardioembolic origin should be treated initially with heparin and then switch to warfarin, which will be continued for at least 6 months and indefinitely if the rhythm disturbance or valve disorder persists. Continuous heparin infusion should increase the partial thromboplastin time (TTP) to 1.5 to 2.0 times the control value, until the prothrombin time (TP) reaches an INR of 2.0 to 3.0. Anticoagulation should be delayed 5 to 7 days in patients with extensive non-hemorrhagic infarcts of cardioembolic origin, and up to 2 to 4 weeks in patients with hemorrhagic infarcts of cardioembolic origin. Heparin (20,000 U in 500 ml of 5% glucose serum) should be administered by continuous iv route using an infusion pump; iv injection is not recommended Quick to start or maintain heparin treatment in stroke. Patients with hypercoagulability syndromes should receive heparin and warfarin early. In patients with a high titer of anticardiolipin antibodies or a positive lupus anticoagulant, heparin is administered until warfarin increases the INR to 3.0. The antiplatelet agents are still being studied as the best prophylactic treatment for atherothrombotic stroke.

The vascular surgery is not indicated as emergency treatment and should only be resorted to after a full stroke hemiplegic if viable tissue remains hemispherical risk of further injury and loss functional. The indications for prophylactic thromboendarterectomy are the same as for endarterectomy in TIAs (see above).

Rehabilitation

Repeated assessment of the patient’s condition by the physician, physical therapist, and nursing staff will be the guide to rehabilitation. Very elaborate programs are not necessary and the value of speech rehabilitation is unproven, especially in the early recovery phase. Factors that favorably influence rehabilitation are poor age, mild motor and sensory deficits, intact mental function, and a pleasant home environment. Early treatment, continuous stimulation and training are essential for the real needs of daily life.

The patient, family and friends must understand what their disability implies and that improvement is possible, but only with time, patience and perseverance. Mood changes can be secondary to heart attack and also to the patient’s frustration with her condition, and should be expected; Those who care for the sick person must respond in a comprehensive and reassuring manner. Sedatives or antidepressants can help after the patient has been clinically stabilized. Physical and occupational therapy should encourage the use of the affected limbs and enable the patient to eat, dress, clean, and other basic needs. Sometimes certain devices are needed (eg hearing aids, walkers); Handrails and bars (eg in the sink and bathtub) and ramps can be useful at home.

Some patients are so severely affected that rehabilitation is probably useless; In these cases, basic long-term care is more appropriate. They must receive appropriate assistance to eliminate suffering

 

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