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PostPosted: 30 Dec 2013 18:55 
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New Stroke Management Guidelines: A Quick and Easy Guide
Bret S. Stetka, MD, Helmi L. Lutsep, MD
Anticoagulation. Antiplatelet Agents Anticoagulation .

The Basics:

Urgent anticoagulation not recommended in acute ischemic stroke Urgent anticoagulation not recommended for noncerebrovascular conditions in the setting of strokeAnticoagulation with 24 hours of IV rtPA not recommended. Efficacy of thrombin inhibitors not well established in acute strokeThe Bottom Line: Trials have not yet provided indications for anticoagulation in acute stroke. Urgent anticoagulation is not recommended in acute ischemic stroke, nor is it for noncerebrovascular conditions in the setting of moderate-to-severe strokes due to an increased risk for intracerebral hemorrhage. Anticoagulation within 24 hours of IV rtPA administration is also not recommended.

New: The usefulness of argatroban and other thrombin inhibitors in acute ischemic stroke is not well established at the time of guideline publication, nor is the usefulness of anticoagulating patients with severe stenosis of an internal carotid artery ipsilateral to an ischemic stroke.Antiplatelet Agents

The Basics:
Aspirin within 24-48 hoursOther antiplatelet agents not recommended

The Bottom Line: Aspirin remains the only antiplatelet agent for which data support use in acute stroke, although trials with other agents are in progress.Oral aspirin is recommended for most patients within 24-48 hours of initial symptoms; however, it is not a suitable substitute for other acute stroke interventions, including rtPA.

Revised: Clopidogrel's usefulness is not well established, and the use of IV antiplatelet drugs that inhibit the glycoprotein IIb/IIIa receptor is not recommended. Adjunctive aspirin, or other antiplatelet therapies, within 24 hours of IV fibrinolysis are also not recommended.

New: The efficacy of glycoprotein IIb/IIIa inhibitors tirofiban and eptifibatide is not well-established.

PS This is a long article, I have just focussed on the anticoagulation aspect of treatment.

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PostPosted: 01 Jan 2014 13:47 
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Hello Raghu,
This is a timely message. During the long span of our practice in general medicine we have seen a number of therapeutic adventures in the case of stroke. Finally when it comes to the result of our interventions I think we have not had much as far as patients’ outcome is concerned. When we are not able to do much, we should ensure that what we do should not cause any harm to the patients. Some years ago I burnt my fingers when I was treating a CT proved brain infarction. After a few days of starting aspirin I saw his condition was deteriorating. A repeat CT scan brain showed haemorrhage over the previous infarct lesion.
In the same way the enthusiastic and radical treatment of hypertension also fraught with danger. The development of hypertension in a previously normotensive person is a healthy natural reaction. In normal persons the blood circulations in each hemisphere of the brain is strictly confined to the same side, without getting mixed with the other side. But when ischemia develops on one side the blood flow is maintained from across the midline. This is accomplished by increasing the systemic blood pressure. With our overenthusiasm to treat this high blood pressure we actually create a steal phenomenon on the affected side further jeopardising the ischemic state. So judicial use of anti-hypertensive therapy is what is required.
Another point to be born in mind while managing the stroke is the care we must take in treating diabetes mellitus. In the case of stroke the hypoglycaemia is more dangerous than hyperglycaemia. Even during our student days one of our teachers used to tell us that it was better to err on hyperglycaemic side. The younger generation nowadays bent of strict blood sugar control. While in the hospital it is usual to give multiple injections of insulin. Even though patients are averse to frequent blood checking, the next dose of insulin should be given only after checking the blood sugar, at least by glucometer. Most dangerous hypoglycaemia develops usually in the wee hours of mornings when the patient is in sleep and by-standers are also dozing and the hospital staff are in a lax state.

UA Mohammed


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