Dr PS Deb MD, DMGNRC Guwahati

Primary PreventionPrimary Prevention

Primary prevention Primary prevention

Do regular exercise (at least 3x30min/week) Do regular exercise (at least 3x30min/week) Don’t smokeDon’t smoke Don’t take AlcoholDon’t take Alcohol Do take a diet low in salt and saturated fat, high in Do take a diet low in salt and saturated fat, high in

fruit and vegetables and rich in fibre. fruit and vegetables and rich in fibre. Do keep body weight to < 22 BMIDo keep body weight to < 22 BMI Don’t take Antioxidant vitamin supplements (Vit Don’t take Antioxidant vitamin supplements (Vit

E and A) E and A) Do practice Relaxation exercise.Do practice Relaxation exercise.

Blood Pressure ManagementBlood Pressure Management

Do maintain BP < 140 mm Hg systolic and < 90 Do maintain BP < 140 mm Hg systolic and < 90 mm Hg diastolic.mm Hg diastolic.

Do maintain BP in patients with diabetes or Do maintain BP in patients with diabetes or chronic kidney disease < 130 mm Hg systolic and chronic kidney disease < 130 mm Hg systolic and < 80 mm Hg diastolic.< 80 mm Hg diastolic.

Diabetes managementDiabetes management

Do control blood sugar : HbA1C ≤7.0% in order Do control blood sugar : HbA1C ≤7.0% in order to reduce the risk of microvascular and to reduce the risk of microvascular and macrovascular complications. macrovascular complications.

Lipid managementLipid management

Do Statin treatment to reduce LDL-cholesterol Do Statin treatment to reduce LDL-cholesterol <150 mg/dl <150 mg/dl

Do more rigorous control of lipids in Diabetic Do more rigorous control of lipids in Diabetic adults at high risk of a vascular event to achieve adults at high risk of a vascular event to achieve an LDL-C <=100mg/dl.an LDL-C <=100mg/dl.

Hormone Replacement TherapyHormone Replacement Therapy

Don’t use Hormone replacement therapy in post Don’t use Hormone replacement therapy in post menopausal women, it increases stroke by 44%.menopausal women, it increases stroke by 44%.

Antithrombotic Therapy Antithrombotic Therapy

Do use low dose Aspirin in women over 45 years Do use low dose Aspirin in women over 45 years to reduces the risk of ischemic stroke and man to reduces the risk of ischemic stroke and man from MI.from MI.

Atrial fibrillation (AF)Atrial fibrillation (AF)

Do use Aspirin to reduces stroke in patients with Do use Aspirin to reduces stroke in patients with non-valvular AFnon-valvular AF

Do use Warfarin (INR 2.0-3.0) in valvular heart Do use Warfarin (INR 2.0-3.0) in valvular heart diseases.diseases.

Don’t use aspirin in valvular heart diseaseDon’t use aspirin in valvular heart disease.. Don’t use Combination of aspirin and Don’t use Combination of aspirin and

clopidogrel, it is less effective than warfarin and clopidogrel, it is less effective than warfarin and has a similar bleeding ratehas a similar bleeding rate..

Asymptomatic carotid artery stenosisAsymptomatic carotid artery stenosis

Do use Aspirin in asymptomatic carotid artery Do use Aspirin in asymptomatic carotid artery disease with stenosis less than 80%.disease with stenosis less than 80%.

Do refer patients with a more than 80% stenosis Do refer patients with a more than 80% stenosis for carotid artery Surgery (or Angioplsaty).for carotid artery Surgery (or Angioplsaty).

Stroke Acute CareStroke Acute Care

Clinical DiagnosisClinical Diagnosis

Do detail quick history and examination to Do detail quick history and examination to diagnose stroke.diagnose stroke.

Neuro-imagingNeuro-imaging

Do CT scan for every patient of suspected stroke Do CT scan for every patient of suspected stroke with significant neurological deficit or depressed with significant neurological deficit or depressed level of consciousness and headache or seizure to level of consciousness and headache or seizure to detectdetect– Ischaemia as early as 2 h after stroke onsetIschaemia as early as 2 h after stroke onset– Cerebral haemorrhage immediatelyCerebral haemorrhage immediately– Other neurological diseasesOther neurological diseases

Do MRI if planning for thrombolysisDo MRI if planning for thrombolysis

Laboratory testsLaboratory tests

Do RBC, WBC, platelet countDo RBC, WBC, platelet count Do Basic clotting parametersDo Basic clotting parameters Do ElectrolytesDo Electrolytes Do Renal and hepatic chemistryDo Renal and hepatic chemistry Do Blood GlucoseDo Blood Glucose Do CRP, sedimentation rateDo CRP, sedimentation rate

MonitoringMonitoring

Do Continuous monitoring ofDo Continuous monitoring of– Heart rateHeart rate– Breathing rateBreathing rate

– OO22 saturation saturation

Do Discontinuous monitoring of Do Discontinuous monitoring of – Blood pressureBlood pressure– Blood glucoseBlood glucose– Vigilance (GCS), pupilsVigilance (GCS), pupils– Neurological statusNeurological status

Pulmonary function Pulmonary function

Don’t use oxygen routinely.Don’t use oxygen routinely. Do use oxygen if their ODo use oxygen if their O22 saturation drops below saturation drops below

95% by administration of > 2 l O95% by administration of > 2 l O22 . .

Body temperatureBody temperature

Do search for infection if Do search for infection if pyrexia >37.5°C. pyrexia >37.5°C. Do treat pyrexia (>37.5°C) with paracetamol and Do treat pyrexia (>37.5°C) with paracetamol and

fanning.fanning. Don’t use Antibiotic prophylaxis in Don’t use Antibiotic prophylaxis in

immunocompetent patients. immunocompetent patients.

Fluid balanceFluid balance

Do regular monitoring of fluid balance and Do regular monitoring of fluid balance and electrolytes with severe stroke with swallowing electrolytes with severe stroke with swallowing problems.problems.

Do use Normal saline (0.9%) for fluid replacement Do use Normal saline (0.9%) for fluid replacement during the first 24 hours after stroke.during the first 24 hours after stroke.

Don’t use Dextrose saline or Dextrose.Don’t use Dextrose saline or Dextrose.

Dysphagia and feedingDysphagia and feeding

Don’t use dietary supplements routinely.Don’t use dietary supplements routinely. Do use oDo use oral dietary supplements only for non-ral dietary supplements only for non-

dysphagic stroke patients who are malnourished.dysphagic stroke patients who are malnourished. Do nasogastric (NG) feeding (within 48 hours) Do nasogastric (NG) feeding (within 48 hours)

with impaired swallowingwith impaired swallowing Don’t do percutaneous enteral gastrostomy (PEG) Don’t do percutaneous enteral gastrostomy (PEG)

feeding in the first 2 weeks.feeding in the first 2 weeks.

Seizure and Antiepileptic drugsSeizure and Antiepileptic drugs

Don’t use prophylactic anticonvulsant medication Don’t use prophylactic anticonvulsant medication routinelyroutinely

Do use anticonvulsant Do use anticonvulsant – Clinical seizure Clinical seizure – Subclinical seizure with EEG changes Subclinical seizure with EEG changes – Altered consciousness not explained by other Altered consciousness not explained by other

causes.causes.

Raised ICTRaised ICT

Don’t use mannitol routinely when consciousness Don’t use mannitol routinely when consciousness is retainedis retained..

Do head end elevation up to 30°Do head end elevation up to 30° Do pain relief and sedationDo pain relief and sedation Do use mannitol when there is loss of Do use mannitol when there is loss of

consciousness. consciousness. Do ventilatory support Do ventilatory support Do decompressive surgery for large supratentorial Do decompressive surgery for large supratentorial

surface or cerebellar hematoma. surface or cerebellar hematoma.

Ischemic infarctionIschemic infarction

Electrocardiogram (ECG)Electrocardiogram (ECG)

Do ECG for every case of suspected stroke to Do ECG for every case of suspected stroke to detect arrhythmias and CADdetect arrhythmias and CAD

Do Holter monitoring for detection of atrial Do Holter monitoring for detection of atrial fibrillation (AF). Routine monitoring is not fibrillation (AF). Routine monitoring is not enough.enough.

Echocardiography (TTE / TOE)Echocardiography (TTE / TOE)

Do Echocardiography to detect potential causes Do Echocardiography to detect potential causes of strokeof stroke,, – CADCAD– Valvular heart diseaseValvular heart disease– Aortic disease, and Aortic disease, and – ASD, PFO with suspected paradoxical ASD, PFO with suspected paradoxical

embolismembolism Do Transoesophageal echocardiography (TOE) if Do Transoesophageal echocardiography (TOE) if

available.available.

Blood pressure Blood pressure

Don’t reduce blood pressure < 220/120mmHg)Don’t reduce blood pressure < 220/120mmHg) Do Cautious blood pressure lowering when Do Cautious blood pressure lowering when

– BP >220/120 mmHgBP >220/120 mmHg– Severe cardiac failureSevere cardiac failure– Aortic dissection Aortic dissection – Hyper-tensive encephalopathyHyper-tensive encephalopathy

Don’t reduce blood pressure abruptlyDon’t reduce blood pressure abruptly Do improve BP in dehydration with volume Do improve BP in dehydration with volume

expanders.expanders.

Glucose metabolismGlucose metabolism

Do Do monitor serum glucose levelsmonitor serum glucose levels Do treat serum glucose levels >180mg/dl Do treat serum glucose levels >180mg/dl

(>10mmol/l) with insulin.(>10mmol/l) with insulin. Do treat severe hypoglycaemia (<50 mg/dl) with Do treat severe hypoglycaemia (<50 mg/dl) with

intravenous dextrose or infusion of 10–20% intravenous dextrose or infusion of 10–20% glucose.glucose.

Don’t use glucose as maintanance IV fluid.Don’t use glucose as maintanance IV fluid.

Antiplatelet therapyAntiplatelet therapy

Do use Aspirin Do use Aspirin (160–325 mg loading dose) (160–325 mg loading dose) within 48 hours after ischaemic stroke.within 48 hours after ischaemic stroke.

Don’t use other antiplatelet agents (single or Don’t use other antiplatelet agents (single or combined).combined).

AnticoagulantsAnticoagulants

Don’t use anticoagulants routinely. Don’t use Anticoagulants in patients with Don’t use Anticoagulants in patients with

progressing stroke.progressing stroke. Do use anticoagulation for patients with atrial Do use anticoagulation for patients with atrial

fibrillation with warfarin early after minor stroke fibrillation with warfarin early after minor stroke or TIA.or TIA.

Do use LMWH when there is high risk of venous Do use LMWH when there is high risk of venous thromboembolic diseasethromboembolic disease..

Lipid managementLipid management

Don’t use statin within 48 hours of strokeDon’t use statin within 48 hours of stroke Do continue statin those who were already Do continue statin those who were already

receiving before onset of strokereceiving before onset of stroke

NeuroprotectionNeuroprotection

Don’t use neuroprotective drugs Don’t use neuroprotective drugs

Spontaneous Intracerebral Spontaneous Intracerebral HemorrhageHemorrhage

Blood pressure controlBlood pressure control

Do control systolic BP of 150 to 220 mm Hg by Do control systolic BP of 150 to 220 mm Hg by acute lowering of systolic BP to 140 mm Hg. acute lowering of systolic BP to 140 mm Hg.

Prevention of ComplicationPrevention of Complication

Do Early mobilizationDo Early mobilization Do prevent and treat Aspiration PneumoniaDo prevent and treat Aspiration Pneumonia Do prevent Urinary tract infectionDo prevent Urinary tract infection Don’t use prophylactic antibioticsDon’t use prophylactic antibiotics Do prevent and treat Bed soreDo prevent and treat Bed sore Do prevent DVT by stocking, LMW heparinDo prevent DVT by stocking, LMW heparin Do prevent FallDo prevent Fall Do treat AgitationDo treat Agitation Do treat DepressionDo treat Depression Do Shoulder careDo Shoulder care

THANK YOUTHANK YOU