encephalopathy, retinal hemorrhage, cardiac ischemia, congestive heart failure or evidence of progressive renal dysfunction, should also be treated. Agents such as labetalol, esmolol and enalaprilat, which are short-acting, easily titrat-able and have a predictable response, are preferred . Invasive arterial monitoring is necessary in patients treated with vasopressors or potent vasodilators.
Close monitoring of fluid status, electrolytes and blood sugar is necessary in the ischemic stroke patient. Normovolemia and euglycemia is the goal, since hyperglycemia is associated with increased morbidity and mortality after stroke . Maintenance of normo- or hypothermia provides brain protection, since hyperthermia can worsen outcome in cerebral ischemia . Fever after a stroke is a common occurrence. Acetaminophen and cooling blankets help in reducing acute increases in temperature. An infectious source for the fever should always be sought and treated with appropriate anti-microbial agents. Fever in the chronic phase of stroke is usually the result of aspiration pneumonia or urinary tract infection .
Cytotoxic and vasogenic edema can be seen after an ischemic stroke. Death during the first week after an ischemic stroke is usually the result of brain edema and elevated intracranial pressure. Cerebral edema usually peaks at between 3 and 5 days after a stroke and it warrants medical intervention in 10-20% of patients. Clinical signs of neurological deterioration secondary to brain edema and incipient herniation include a decrease in the level of consciousness, pupillary asymmetry, irregular breathing and a positive Babinski sign contralateral to the hemiparesis. Patients on mechanical ventilation may be hyperventilated to a PCO2 of between 33 and 35 mmHg. Osmotic diuretics such as mannitol, which help to decrease the intracranial pressure, can be administered every 4-6 hours, with careful attention to volume status, serum electrolytes and serum osmolarity. In the case of refractory intracranial hypertension, CSF drainage via a ventriculostomy or surgical decompression via a hemicraniectomy with duraplasty might be indicated.
Seizures can occur during the acute stroke period in 4-43% of cases. They usually occur within 24 hours of a stroke and tend to be partial in nature. Recurrent seizures occur in approximately 73% of cases, usually within the first year. Seizure control can usually be achieved with antiepileptic monotherapy in the majority of cases.
Nutrition is important in both the acute and chronic phases of the ischemic stroke patient. Patients with ischemic stroke have increased caloric requirements. Nutritional support should be started as soon as possible after stroke and, preferentially, via the enteral route. This can be usually accomplished by placing either a nasogastric or feeding tube or, if long-term nutritional support is needed, either because of swallowing difficulties or increased aspiration risk, via a percutaneous gastrostomy tube.
The services of rehabilitation physicians, physical, occupational and speech therapists, as well as those from social workers and counseling professionals, should be implemented as soon as the patient is stabilized. Early mobilization of the stroke patient is desirable to prevent complications such as pneumonia, atelectasis, DVT, decubitus ulcers and PE, all of which are associated with increased morbidity and mortality.
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