STROKE Definition The traditional definition of stroke, devised by the World Health Organization in the 1970s, is a "neurological deficit

of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours". This definition was supposed to reflect the reversibility of tissue damage and was devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. The 24-hour limit divides stroke from transient ischemic attack, which is a related syndrome of stroke symptoms that resolve completely within 24 hours. With the availability of treatments that, when given early, can reduce stroke severity, many now prefer alternative concepts, such as brain attack and acute ischemic cerebrovascular syndrome (modeled after heart attack and acute coronary syndrome respectively), that reflect the urgency of stroke symptoms and the need to act swiftly. Types Strokes can be classified into two major categories: ischemic and hemorrhagic. Ischemic strokes are those that are caused by interruption of the blood supply, while hemorrhagic strokes are the ones which result from rupture of a blood vessel or an abnormal vascular structure. About 87% of strokes are caused by ischemia, and the remainder by hemorrhage. Some hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"). It is unknown how many hemorrhages actually start as ischemic stroke. Initial Management The goal for the acute management of patients with stroke is to stabilize the patient and to complete initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of patient arrival. Critical decisions focus on the need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic intervention. Table 1. NINDS* and ACLS** Recommended Stroke Evaluation Time Benchmarks for Potential Thrombolysis Candidate Time Interval Time Target Door to doctor 10 min Access to neurologic expertise 15 min Door to CT scan completion 25 min Door to CT scan interpretation 45 min Door to treatment 60 min Admission to stroke unit or ICU 3h *National Institute of Neurologic Disorders and Stroke **Advanced Cardiac Life Support guidelines

Hypoglycemia and hyperglycemia need to be identified and treated early in the evaluation. Not only can both produce symptoms that mimic ischemic stroke, but they can also aggravate ongoing neuronal ischemia. Administration of glucose in hypoglycemia produces profound and prompt improvement, while insulin should be started for patients with stroke and hyperglycemia. Ongoing studies will help to determine the optimal level of glycemic control. Hyperthermia is infrequently associated with stroke but can increase morbidity. Administration of acetaminophen, by mouth or per rectum, is indicated in the presence of fever (temperature >100.4 F [38 C]).

Supplemental oxygen is recommended when the patient has a documented oxygen requirement. To date, there is conflicting evidence whether supernormal oxygenation improves outcome. Optimal blood pressure targets remain to be determined. Many patients are hypertensive on arrival. American Stroke Association guidelines have reinforced the need for caution in lowering blood pressures acutely. In the small proportion of patients with stroke who are relatively hypotensive, pharmacologically increasing blood pressure may improve flow through critical stenoses. Serial monitoring and interventions when necessary early in the clinical course and eventual stroke rehabilitation and physical and occupational therapy are the ideals of management. In patients with transient ischemic attacks (TIAs), failure to recognize the potential for near- term stroke, failure to perform a timely assessment for stroke risk factors, and failure to initiate primary and secondary stroke prevention exposes the patient to undue risk of stroke and exposes clinicians to potential litigation. TIAs confer a 10% risk of stroke within 30 days, and one half of the strokes occurring after a TIA, occurred within 48 hours. Table 2. General Management of Patients With Acute Stroke Treat hypoglycemia with D50

Blood glucose

Treat

hyperglycemia

with

insulin

if

serum

glucose

>200

mg/dL

Blood pressure

See recommendations for thrombolysis candidates and noncandidates (Table 3) Cardiac monitor Continuous monitoring for ischemic changes or atrial fibrillation Intravenous fluids Avoid D5W and excessive fluid administration

IV isotonic sodium chloride solution at 50 mL/h unless otherwise indicated Oral intake Oxygen Temperature NPO initially; aspiration risk is great, avoid oral intake until swallowing assessed Supplement if indicated (Sa02 < 94%) Avoid hyperthermia; use oral or rectal acetaminophen and cooling blankets as needed

REFERENCES: http://emedicine.medscape.com/article/1159752-overview http://en.wikipedia.org/wiki/Stroke