SPREAD V Ed.

Acute stroke:
monitoring and complications
in the steady-state

 
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Collaborations
Authors
Introduction
Methodology
Epidemiology
Diagnostic work-up
Risk factors
Primary prevention
Acute stroke: pre-hospital
Acute stroke: diagnosis
Acute stroke: treatment
Acute stroke: steady-state
Secondary prevention
Surgical treatment
Organising rehabilitation
Rehabilitation
Post-stroke sequels
Juvenile-uncommon causes

Acute stroke:
monitoring and complications in the steady-state

R 11.1
Grade D		 During the first 48 h after stroke onset, monitoring of the vital functions and neurological status is recommended. This should continue in case of clinical instability.
R 11.2
Grade D		 During the first 48 h after stroke onset, on-line ECG monitoring is recommended, where feasible, in patients with: medical history of heart disease and/or arrhythmias, unstable blood pressure, clinical signs of heart failure, abnormal baseline ECG and infarcts involving the deep middle cerebral artery territories, especially insular cortex.
In case of clinical instability, the monitoring should proceed beyond 48 h.
R 11.3
Grade D		 Where the facilities for continuous monitoring are not available, repeated ECG controls are recommended during the first 24 hours.
In case of clinically evident heart failure, an early trans-thoracic echocardiography is recommended. 
R 11.4
Grade D		 In patients with moderate-to-severe stroke, oxygenation monitoring is recommended at least during the first 24 h from onset. In case of respiratory abnormalities this should continue as long as the respiratory pattern recovers.
R 11.5
Grade D		 Routine oxygen administration is not recommended in patients with acute stroke.
Oxygen administration is recommended in case of hypoxaemia (blood gas analysis or O2 saturation <92% at pulse oxymetry).
Blood gas analysis is recommended based on the patient's clinical conditions
R 11.6
Grade D		 For the emergency treatment of blood pressure in patients with acute ischaemic stroke the following algorithm is recommended: (from Stroke Coding Guides of the American Academy of Neurology, Table 1. Algorithm for emergency treatment of blood pressure in patients with ischemic stroke at http://www.stroke-site.org/guidelines/stroke_coding.html; July 2007, modified):
1. Blood pressure obtained by automatic sphygmomanometer should be correlated with a manual blood pressure cuff reading.
2. If diastolic blood pressure >140 mm Hg occurs on two readings 5 minutes apart, then start a continuous IV infusion of an antihypertensive agent such as sodium nitroprusside (0.5-1.0 mg/kg/min). Patients who fall into this category are not candidates for t-PA therapy even if other inclusion criteria are met.
3. If systolic blood pressure is >220 mm Hg or diastolic blood pressure is 121-140 mm Hg or mean arterial blood pressure is >130 mm Hg on two readings 20 minutes apart, then give an easily titratable antihypertensive medication such as labetalol at 10 mg IV over 1-2 minutes. The labetalol dose may be repeated or doubled every 10-20 minutes until a cumulative dose of 300 mg has been administered via this mini-bolus technique. After the initial dosing schedule, labetalol doses may be administered every 6-8 hours as needed. Labetalol is usually avoided in patients with asthma, cardiac failure, or severe cardiac conduction abnormalities. In these cases, urapidil (a bolus of 10- 50 mg or an infusion at 0,15-0,5 mg/min) can be used. Patients who require more than two doses of labetalol or other antihypertensive agents to decrease blood pressure to <185 mm Hg systolic or <110 mm Hg diastolic are generally not candidates for thrombolytic therapy even if other criteria are met.
4. If systolic blood pressure is 185-220 mm Hg or diastolic blood pressure is 105-120 mm Hg, emergency therapy should be deferred in the absence of left ventricular failure, aortic dissection, or acute myocardial ischemia. Patients who are potential candidates for t-PA therapy, but who have persistent elevations in systolic blood pressure of >185 mm Hg or diastolic pressure of >110 mm Hg may be treated with small doses of IV antihypertensive medication to maintain the blood pressure just below these limits. However, more than two doses of an antihypertensive agent to lower the blood pressure below these limits is a relative contraindication for thrombolytic therapy and should be discouraged.
5. The use of sub-lingual calcium antagonists should be discouraged owing to the risky fast action of this administration route.
6. In case of cerebral haemorrhage antihypertensive therapy should be given if systolic blood pressure is >180 mm Hg or mean blood pressure is >130 mm Hg (see also Recommendation 10.26).
7. If blood pressure is lowered by antihypertensive agents in the setting of acute stroke, serial neurological examinations should be performed to look for signs of deterioration such as increasing weakness or reduced level of consciousness.
8. In acute stroke patients with systolic blood pressure <185 mm Hg or diastolic blood pressure <105 mm Hg, antihypertensive therapy is usually not indicated.
9. Although there are no data to support a threshold for treatment of hypotension in stroke patients, we recommend treatment for signs of dehydration, blood pressure that is substantially below the expected level for a given patient (consider past history of hypertension, treated or untreated), or both. Therapeutic options should include IV fluids, treatment of congestive heart failure and bradycardia, and consideration of pressor agents such as dopamine.
R 11.7
Grade D		 In acute stroke patients, maintenance of a balanced fluid status is recommended. Intravenous fluid therapy should be administered according to the fluid balance.
R 11.8
Grade D		 Hypotonic solutions (NaCl 0,45% or glucose 5%) are not recommended in acute stroke patients due to the risk of brain oedema.
R 11.9
Grade D		 Glucose solutions are not recommended due to the detrimental effects of hyperglycaemia.
R 11.10
Grade D		 Isotonic saline solutions are recommended for intravenous fluid therapy of acute stroke patients.
S 11-1 Experimental and clinical evidence show that hyperthermia increases infarct size and negatively influences clinical and functional outcomes.
Hypothermia has been shown to be neuroprotective. About 50% of patients with acute stroke present with fever over the initial 48 h of onset.
R 11.13
Grade D		 Treatment of body temperature ≥37°C is recommended in acute stroke patients, preferably with paracetamol.
R 11.14
Grade D		 In case of fever, the timely search of a possible infection is recommended in order to start as early as possible an appropriate treatment
R 11.15
Grade D		 Prophylactic antibiotic treatment is not recommended in immunocompetent stroke patients.
S 11-2 Urinary tract infection is the most frequent infectious complication in acute stroke. Its risk is associated with the use of indwelling urine catheter. Administration of a protected semi-synthetic penicillin is the first-choice empirical therapy. In allergic patients a fluoroquinolone may be used, taking into account the risk of seizures. In severe cases an aminoglycoside may be associated or a carbapenem may be used as monotherapy. The treatment may be modified once urine culture data and relevant susceptibility tests become available. Multi-resistant pathogens (Gram-positive pathogens, mycetes) may be treated with one among the newly available molecules (derivatives of streptogramine, oxazolidinone, glycylglycine, echinocandine, triazole).
S 11-3 Pneumonia, including aspiration pneumonia, is the second most frequent infectious complication in acute stroke. Initial antibiotic therapy is chosen empirically and based, in the early-onset infection, on a protected aminopenicillin, a II or III generation cephalosporin, a carbapenem (ertapenem) or, in patients allergic to beta-lactams, a fluoroquinolone (all of these in combination with an anti-anaerobials). In late-onset infections, a monotherapy with meropenem or cefepime or a broad-spectrum semi-synthetic penicillin associated with an aminoglycoside should be used.  The administration of a glycopeptide or, better, of linezolid should be considered for infections possibly due to methicillin-resistant S. aureus. Treatment should be continued up to 7-10 days in the infections by methicillin-susceptible or traditional respiratory bacteria; up to 10-14 days in the infections due to methicillin-resistant S. aureus or aerobic gram negative bacteria; and as long as 14-21 days in case of severe multilobar pneumonia. The treatment may be modified once culture data and relevant susceptibility tests become available.
S 11-4 The main risk factor for bacteraemia are vascular catheters. Their adequate management is therefore required, including their removal in case of documented bacteraemia. The initial therapy is empirical with an association of an anti-Pseudomonas  beta-lactam  and an aminoglycoside (or a broad-range cephalosporin or a carbapenem used alone), together with a glycopeptide, with linezolid or with daptomycin. The treatment may be modified once blood culture data and relevant susceptibility tests become available.
S 11-5 Pressure sores are a severe complication of acute stroke, being associated with increased mortality and poor clinical and functional outcomes. The risk of pressure sores is higher in patient with obesity, diabetes mellitus, and malnutrition. Antibiotic treatment is appropriate only in presence of extensive cellulitis, signs and symptom of infection, or positive blood cultures and should have a very broad spectrum.
R 11.14
Grade D		 Prevention of pressure sores is recommended in acute stroke patients. It should be based on frequent turning (every 1-4 h) of immobilised patients, careful hygiene and use of air-filled or fluid-filled mattress systems.
S 11-6 Protein-energy malnutrition is frequent in patients with stroke. In these patients, the assessment of nutritional status is important to early recognise and correct malnutrition. Adequate nutrition is advisable to prevent medical complications, to decrease the length of hospital stay and to improve the quality of life.
S 11-7 The essential diagnostic protocol to evaluate the nutritional status and risk in the stroke patients include: a) the integrated nutritional indices to be performed at entry on the hospital or rehabilitation centre; b) the anthropometric measurement, the biochemical marked, the monitoring of food intake and of associated medical conditions, to be repeated during hospital stay at intervals that depend from the individual nutritional risk.
R 11.15 a
Grade D		 The assessment of nutritional status and proper nutritional interventions are recommended as essential part of the diagnostic and therapeutic work-up in patients with acute stroke in the acute as well as in the rehabilitation settings.
R 11.15 b
Grade D		 It is recommended that expert professionals (nutritionist physician, dietician) participate in the multidisciplinary team of a stroke unit.
R 11.15 c
Grade D		 It is recommended that the procedures to assess the nutritional risk are included among the standards for the accreditation of health structures.
R 11.15 d
Grade D		 On admission to hospital and to the rehabilitation structure, it is recommended to evaluate the nutritional risk using the Nutritional Risk Screening (NRS) or the Malnutrition Universal Screening Tool (MUST).
R 11.15 e
Grade D		 The nutritional risk assessment within 24-48 h from hospitalisation is recommended.
R 11.15 f
Grade D		 In patients able to stand up, measurement of body weight and of abdominal circumference, and calculation of body mass index (BMI) is recommended.
In patients unable to stand up, measurement of body weight,( by means of appropriate devices), arm circumference and triceps skinfold thickness is recommended.
R 11.15 g
Grade D		 Evaluation of dietary intake and clinical assessment are indicated in the protocol to assess the nutritional status. Albumin dosing and lymphocyte count are indicated as essential biochemical assessments.
S 11-8 Nutritional support in patients with acute stroke is aimed at preventing and treating protein-energy malnutrition as well as electrolytes or micronutrients imbalance.
S 11-9 Energy requirement is calculated with the factorial technique. Basal metabolism is measured or estimated then corrected for the level of physical activity or the disease factors, expressed as multiples of the basal metabolism. Values between 1.15 and 1.30 are usually appropriate.
S 11-10 The daily minimum protein requirement in stroke patients is approximately 1 g/kg of measured (if of normal weight) or desired (if overweight or underweight) body weight, up to 1,2~1,5 g/kg in case of hypercatabolism or when decubital ulcers are present.
Timing and way of nutrition depend on the patient's clinical conditions.
R 11.16 a
Grade B		 The routine use of food integrators is not recommended in stroke patients who can be fed by oral route since it does not improve prognosis; their use should be guided by the assessment of the nutritional status and it  is recommendedin case of protein-energy malnutrition.
R 11.16 b
Grade D		 In patients with acute stroke, the recommended nutritional approaches are the following:
bulletnon-dysphagic patients without malnutrition:
 nutrition per os, following the nutritional profile of the Guidelines for Healthy Feeding;
bulletnon-dysphagic patients with protein-energy malnutrition:
 nutrition per os with food integrators;
bulletdysphagic patients:
progressive modification of the diet according to degree of deglutition disorder or enteral nutrition, integrated if needed.
R 11.17 a
Grade B		 In patients with stroke, enteral nutrition is the first choice way of nutrition.
It is recommended to begin the enteral feeding treatment early and anyway not later than 5-7 days in patient in normal feeding conditions; not later than 24-72 hours in patients with malnutrition.
R 11.17 b
Grade D		 Parenteral nutrition is recommended only if the enteral approach is not feasible or is contra-indicated, or if an integration to enteral nutrition is needed.
R 11.17 c
Grade B		 In patients unable to swallow, it is indicated to wait one to two days before placing the naso-gastric tube, hydrating the patient by parenteral route.
S 11-11 Enteral nutrition by means of pump-assisted naso-gastric tube is considered more appropriate than parenteral nutrition for short-term nutrition of patients with acute stroke and severe dysphagia. Care should be exerted to avoid possible problems in the application of the naso-gastric tube, especially in the elderly.
S 11-12 In patients with delayed gastric emptying, aspiration pneumonia may be not prevented by nasogastric feeding, especially in case of severe brain infarct. In this case the risk of aspiration may be reduced by positioning the tube beyond the Treitz angle.
R 11.18
Grade B		 In patients with dysphagia due to stroke, the placement of PEG (percutaneous endoscopic gastrostomy) tube should be considered within 30 days if dysphagia is expected to persist more than 2 months
S 11-13 Patients with stroke frequently experience dysphagia, which may negatively influence clinical and functional outcomes, length of hospital stay and mortality rate.
Possible complications secondary to dysphagia are: malnutrition, aspiration pneumonia, dehydration and haemoconcentration with negative effect on cerebral perfusion and renal function.
R 11.19
Grade D		 In patients with acute stroke a systematic surveillance of swallowing is recommended to prevent complications due to dysphagia.
R 11.20
Grade D		 A standard clinical assessment of the risk of dysphagia, (using for example the Bedside Swallowing Assessment) is recommended in patients with acute stroke.
If available, more sensitive and specific instrumental techniques can be utilised in selected centres .
S 11-14 Experimental and clinical data show that, regardless of a previous diagnosis of diabetes, hyperglycaemia increases infarct size, morbidity and mortality rate after stroke.
Derangement of glucose metabolism in diabetic patients with stroke is a severe complication.
Hypoglycaemia has a detrimental effect on ischaemic brain lesion as well.
R 11.21
Grade D		 When serum glucose level is higher than 200 mg/dL, treatment with insulin is recommended.
R 11.22
Grade D		 Immediate correction of hypoglycaemia is recommended in acute stroke patients, by intravenous dextrose bolus, combined with thiamine 100 mg in case of malnutrition or alcohol abuse.
S 11-15 Stroke is frequently complicated by dysfunctioning micturition related to site and size of brain lesion. Urine incontinence in the early phase of acute stroke is an independent prognostic predictor of death and severe disability after stroke. Urine retention is associated with a high risk of urinary tract infections.
R 11.23
Grade D		 Insertion of indwelling urine catheter is recommended only in patients with severe urinary dysfunction.
R 11.24
Grade D		 In patients without signs/symptoms of urinary dysfunction, regular check of post-micturition residuals is recommended and intermittent catheterisation is advisable if they are present.
R 11.25
Grade D		 Urinary bladder catheterisation is not recommended unless necessary.
S 11-16 Stroke patients who are at risk of deep venous thrombosis (DVT) should be screened according to standardised criteria before being addressed to a targeted diagnostic work up.
R 11.26
Grade D		 When lower limbs DVT is suspected in a stroke patient, a venous Doppler ultrasonography study is recommended.
R 11.27
Grade D		 Systematic measurement of D-dimer for DVT diagnosis is not recommended.
R 11.28
Grade D		 Treatment of factors known to increase intracranial pressure, such as hypoxaemia, hypercarbia, fever and head positioning (elevation of up to 30°), is recommended
R 11.29
Grade D		 Treatment of brain oedema is recommended in case of rapid deterioration of consciousness and appearance of other clinical signs of cerebral herniation with or without radiological signs of space-occupying lesion.
R 11.30
Grade A		 Corticosteroids are not recommended as systematic treatment of stroke.
R 11.31 a
Grade D		 Intravenous administration of furosemide (40 mg)
bulletis recommended as an emergency treatment of rapid clinical deterioration in stroke complicated by severe brain oedema,
bulletis not recommended for long-term therapy.
R 11.31 b
 		 For prolonged (few days) treatment of severe brain oedema, osmotherapy is recommended with:
bulletglycerol     Grade D
bulletmannitol   ®GPP
R 11.31 c
Grade D		 Short-acting barbiturates are not recommended for long-term therapy of brain oedema due to stroke .
S 11-17 In large infarct lesions expanding due to oedema, if response to pharmacological therapy is poor, surgical decompression can be considered, especially in young patients with involvement of the non-dominant hemisphere and without relevant comorbidity.
S 11-18 EEG examination has poor diagnostic and prognostic value in relation to the stroke event itself. It is useful for differential diagnosis in the clinical suspect of an epileptic event mimicking stroke
R 11.32
Grade D		 Antiepileptic therapy is not recommended as prophylactic in patients with recent stroke who have no seizures.
R 11.33
Grade D		 Administration of antiepileptic drugs in patients with acute stroke:
bulletis not recommended after a first seizure
bulletis recommended in recurrent seizures,
avoiding the use of phenobarbital for its detrimental effect on functional recovery.
R 11.34
Grade D		 The standard anticonvulsant therapy of status epilecticus is the recommended treatment also for status epilecticus after stroke, carefully monitoring for possible detrimental side effects on stroke.
R 11.35
Grade A		 In patients with acute stroke, an early rehabilitative approach is recommended.
R 11.36
Grade D		 In stroke patients, limb mobilisation is recommended at least 3-4 times a day.
R 11.37
Grade D		 Encouraging and motivating patients with stroke to participate to daily activities is recommended.
R 11.38
Grade D		 Selection of drugs with no detrimental effect on functional recovery is recommended.
R 11.39
Grade D		 Promotion of early standing position, after trying sitting position within the third day, is recommended, if not contra-indicated.
R 11.40
Grade D		 Promotion of the participation of patient and relatives to care and rehabilitation processes is recommended.

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