Stroke Society of the Philippines: Guide for Stroke Treatment

Stroke Society of the Philippines
14/F 1403 Cathedral Heights Complex, St. Luke's Medical Center,

E. Rodriguez Sr. Ave., Quezon City
Telephone No: 722-5877/723-0103 loc. 5143
Email: ssp_secretariat@yahoo.com
Board of Trustees 2005-2006

President
1st Vice-President
2nd Vice-President
Secretary
Treasurer
P.R.O
Members
Immediate Past President
Abdias V. Aquino, M.D.

Ester S. Bitanga, M.D.
Jose C. Navarro, M.D.
Artemio A. Roxas Jr., M.D.
Betty D. Mancao, M.D.
Carlos L. Chua, M.D.
Alejandro C. Baroque, M.D.
Fatima R. Collado, M.D.
Ma. Epifania V. Collantes, M.D.
Danilo J. Lagamayo, M.D.
Manuel M. Mariano, M.D.
Dante D. Morales, M.D.
Peter P. Rivera, M.D.
Isabelita C. Rogado, R.N.
Ma. Cristina Z. San Jose, M.D.
Joven R. Cuanang, M.D.
Stroke: Think Globally, Act Locally

Principles:
1. Stroke is a "brain attack"

...needing emergency management, including specific treatments and secondary and

tertiary prevention.
2. Stroke is an emergency

...where virtually no allowances for worsening are tolerated
3. Stroke is treatable

...optimally, through proven, affordable, culturally-acceptable and ethical means
4. Stroke is preventable

...in implementable ways across all levels of society

8th-Acute Stroke Treatment-Cla.i1 1
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CPM 8TH EDITION
acute stroke treatment
Algorithm for Acute Stroke Treatment

Definition of Stroke
- Sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathol1
4
Stroke
Alert patients with any of the ff:
a. mild pure motor weakness of one

side of the body defined as can raise
arm above shoulder, clumsy hand, or
can ambulate without assistance
3
2
TIA and
mild stroke?
Transient Ischemic Attack

(TIA):
- deficits resolved within
24 hrs including transient
blindness in one eye
(transient monocular
blindness)
b. pure sensory deficit
c. slurred speech but intelligible

d. vertigo with incoordination, like gait
disturbance, unsteadiness, or clumsy
hand
e. visual field defects alone
f. combination of (a) and (b)
Moderate
stroke?
Awake patient with signifi

cant motor and/or sensory
and/or language and/or visual
deficit
or
Disoriented, drowsy, or stu
porous patient but with pur
poseful response to painful
stimuli
See
Fig. 2
See
Fig. 3
Severe
stroke
Comatose patient with

non-purposeful response,
decorticate, or decerebrate
posturing to painful stimuli
(Appendix I)
or
See
Fig. 4
Comatose patient with no res

ponse to painful stimuli
Figure 1

06/16/2014 3:28:59 PM
acute stroke treatment cpm 8TH eDITION
Algorithm for Transient Ischemic Attack (TIA)

and Mild Stroke
2
Management Priorities
Ascertain clinical diagnosis of stroke or TIA - history and physical exam very
important
1
TIA & mild
stroke
Exclude common stroke mimickers (Appendix IIA and IIB). Monitor and manage blood pressure, treat if SBP 220 or DBP 120 or MAP >130 (appendix
IIIA).
Precautions:
Avoid precipitous drop in BP >20% of baseline MAP
Do not use rapid-acting sublingual agents; when needed use oral or easily
titratable IV anti-hypertensive medications (Appendix IIIB)
Ensure appropriate hydration. If IV fluid is needed, use 0.9 NaCl.
3
Emergent Diagnostics
Complete blood count (CBC)

Blood sugar (CBG, HGT, or RBS)
Electrocardiogram (ECG)
PT/PTT (if EKG shows atrial fibrillation or possible cardioembolic
source)
Plain CT scan of brain as soon as possible
Computation of volume if hemorrhagic (Appendix VI)
Early Specific
Treatment
(Appendix IV)
CT scan
confirmed?
(Appendix
VIA)
N
See
Fig. 2A
CT scan not available

No specific emergent drug
treatment recommended
Neuroprotection (Appendix IVD)
Consult a neurologist, or
neurosurgeon
Early supportive rehabilitation
Figure 2

06/16/2014 3:28:59 PM
CPM 8TH EDITION
3
Aspirin 160-325 mg/day start as
early as possible and continue for
14 days (for secondary prevention,
see below under delayed management)
Figure 2
2
Ischemic?
Cardioembolic
(Appendix V)?
Early rehabilitation once stable

within 72 hrs.
1. Anticonvulsant only if seizures
2. Steroids not recommended
6
Y
N
TIA

Early rehabilitation once stable
within 72 hrs.
Early neurology and/or

neurosurgeon consult for all ICH
recommended
Monitor and Maintain BP: MAP
>110 mmHg. Avoid precipitous
drop in BP 20% of baseline MAP
Hemorrhagic
Non-

cardioembolic
(Thrombotic,
N
5
Anticoagulation with IV heparin or
subcutaneous low molecular weight

heparin (LMWH), or
Aspirin 160-325 mg/day (if heparin

& PTT, or LMWH not available)
Early rehabilitation within 72 hrs.
* If infective endocarditis is sus
pected, give antibiotics and do not
anticoagulate. Antifibrinolytic
agents no available data
Aspirin 160-325 mg/day

If crescendo TIA (multiple events within
hours, increasing severity and duration
of deficits), consider anticoagulation with
intravenous heparin.
3. Monitor and correct metabolic

parameters
4. Correct coagulation abnormalities
Place of Treatment (Appendix VII)
5. Follow recommendations of
surgical intervention (Appendix IVE)
1. Stroke onset within 48 hrs.

2. Patients requiring specific active interventions for any of the following:
a. BP control, monitoring, and stabilization
b. Cardiac stabilization, incl. atrial fibrillation, CHF, acute MI
c. Hydration
d. Anticoagulation, if bleed ruled out by CT scan
3. Rapidly worsening deficits
4. >4 TIA's in 2 weeks prior to consult
5. 1-4 TIA's in 2 weeks with high risk (multiple events within hours,
increasing severity and duration of deficits, cardiac arrhythmia,
carotid bruit)
Admit to Hospital (Stroke Unit)
Urgent Outpatient Work-up

1. Single TIA more than 2 weeks ago
2. 1-4 TIA's in 2 weeks but not high risk (no change in severity and
duration of deficit, cardiac arrhythmia, carotid bruit)
3. Transient monocular blindness alone
4. Stable mild strokes occuring >48 hrs not requiring specific active
intervention.
*Advise immediate re-consult if there is worsening of deficit
Figure 2A

06/16/2014 3:28:59 PM
1
Delayed Management
& Treatment
(Secondary Prevention)
(Appendix VIII)
3
Control of risk factors
Ischemic?
Thrombotic/
Lacunar?
Hemorrhagic
Cardioembolic
Carotid ultrasound
If this reveals >70% steno
sis, refer to neurologist
for decision-making regarding carotid endarte
rectomy
Antiplatelets (aspirin,
ticlopidine, clopidogrel,
dipyridamole, cilosta
zol)
Long-term blood pressure

monitoring and treatment
Consider CT angiogram if
age <45 years, normoten
sive, no clear cause of ICH
and candidate for surgery
Echocardiography and/or cardio

logy consult
If age <75 and PT/INR available,
anticoagulation with coumadin
(target INR 2-3)
If age >75, aspirin 80-325 mg/
day or coumadin with target INR
2-2.5 (if PT/INR available)
Figure 2B
06/16/2014 3:28:59 PM
CPM 8TH EDITION
Algorithm for Moderate Stroke

2
Neuro-vital signs: BP, PR, CR, RR, Temp, Pupils, Glasgow Coma
Scale (Appendix X)
Basic emergent supportive care (ABC of resuscitation)

Moderate
stroke
Monitor and manage blood pressure, treat if SBP 220 or DBP 120
or MAP >130 (Appendix IIIA).
Precautions:
Avoid precipitous drop in BP>20% of baseline MAP
Do not use rapid-acting sublingual agents; when needed use oral
or easily titratable IV anti-hypertensive medication (Appendix
IIIB)
Ascertain clinical diagnosis of stroke-history and physical exam
very important
Exclude common stroke mimickers (Appendix II)
Identify co-morbidities (cardiac disease, gastric ulcer, etc.)
Recognize and treat early signs and symptoms of increased ICP
(Appendix IX)
PT/PTT
Serum Na+ and K+
Plain CT scan of brain as soon as possible
Computation of volume if hemorrhagic
(Appendix VI)
Early Specific
Treatment
See
Fig. 3A
(Appendix IV)
Figure 3

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Figure 3
CT scan
confirmed?
(Appendix
VIA)
See Fig. 3B
CT scan not available

Use scoring system
(Appendix VIB)
Likely
ischemic?
No specific emergent
drug treatment recom
mended
Neuroprotection (Appen
dix IVD)
Refer to specialist
Early supportive rehabili
tation
N
6
Likely
hemorrhagic
Refer to neurologist neu

rosurgeon for further
diagnostic work-ups and/
or subsequent surgery
Neuroprotection (Appen
dix IVD)
Early supportive rehabili
tation
Figure 3A
06/16/2014 3:28:59 PM
CPM 8TH EDITION
Figure 3A
2
Ischemic?
Cardio-
embolic
(Appendix
Hemorrhagic
Medical/surgical
treatment
(Appendix IVE)
Non-
cardioembolic
Thrombotic/
Lacunar?
If within 3 hours of stroke

onset, consider rtPA treatment
and refer to specialist
Aspirin 160-325 mg/day start
as early as possible
Neuroprotection (Appendix
IVD)
Early supportive rehabilita
tion
If within 3 hours of stroke onset, consider rtPA

treatment and refer to specialist
Aspirin 160-325 mg/day start as early as possible
If source of embolism can be demonstrated,
consider early anticoagulation
Early supportive rehabilitation
* If infective endocarditis is suspected, give anti
biotics and do not anticoagulate
Place of Treatment (Appendix VII): Hospital - Intensive Care Unit or Stroke Unit
Figure 3B
Delayed Management and Treatment (Secondary Prevention) (Appendix VIII)
Mild stroke
Ischemic?

Antiplatelets (aspirin, ticlopidine,
clopidogrel, dipyridamole, cilostazol)
Carotid ultrasound
If this reveals >70% stenosis, refer
to neurologist for decision-making
regarding carotid endarterectomy.
Long-term blood pressure

Consider CT angiography, MRA, or angiography
in aneurysm or AVM sus
pects
Cardio-
embolic
Hemorrhagic
7
Thrombotic/
Lacunar?
Echocardiography and/or cardiology consult

If age <75 and PT/INR available, anticoagulation
with coumadin (target INR 2-3)
If age >75, aspirin 80-325 mg/ day or coumadin
with target INR 2-2.5 (if PT/INR available)
Figure 3C

06/16/2014 3:28:59 PM
Algorithm for Severe Stroke

2
1
Severe
stroke
Basic emergent supportive care (ABC of resuscitation)
Neuro-vital signs: BP, PR, CR, RR, Temp, Pupils, Glasgow Coma Scale (Appendix
X)
Recognize and treat early signs and symptoms of increased ICP (Appendix IX)
Monitor and manage blood pressure, treat if SBP 220 or DBP 120 or MAP>130
(Appendix IIIA).
Precautions:
Avoid precipitous drop in BP >20% of baseline MAP
Do not use rapid-acting sublingual agents; when needed use oral or easily titratable
IV anti-hypertensive medication (Appendix IIIB)
Ascertain clinical diagnosis of stroke-history and physical exam very important
Exclude common stroke mimickers (Appendix II)
Identify co-morbidities (cardiac disease, gastric ulcer, etc.)
PT/PTT
Serum Na+ and K+
Plain CT scan of brain
C omputation of volume if hemorrhagic (Appendix VI)
Early Specific
Treatment
(Appendix IV)
See Fig. 4A
Figure 4
10
06/16/2014 3:28:59 PM
CPM 8TH EDITION
Figure 4
CT Scan
confirmed?
See Figure
4B
CT Scan not available

Use scoring system
(Appendix VIB)
No specific emergent drug treat

ment recommended.
Refer to specialist
Figure 4A
Place of Treatment (Appendix VII): Intensive Care Unit

Delayed Management and Treatment (Secondary Prevention) (Appendix VIII)
1
Severe
stroke
Ischemic?
Thrombotic?
Long term blood pressure

Consider CT angiography,
MRA, or angiography in
aneurysm or AVM suspects

Antiplatelets (aspi
rin, ticlopidine, clopi
dogrel, dipyridamole,
or cilostazol)
Cardioembolic
Hemorrhagic
N
5
Echocardiography and/or
cardiology consult
If age <75 and PT/INR avai
lable, anticoagulation with
coumadin (target INR 2-3)
If age >75, aspirin 80-325
mg/day or coumadin with
target INR 2-2.5 (if PT/INR
available)
* Discuss prognosis with relatives of the patient in most compassionate manner

Figure 4C
11
06/16/2014 3:28:59 PM
Figure 4A
CT scan confirmed
(Appendix VIA)
Ischemic?
Non-cardioembolic
(Thrombotic)?
Hemorrhagic
May give aspirin 160-325 mg/

day
Neuroprotection (Appendix
IVD)
If cerebellar infarct, consult neu
rosurgeon as soon as possible
N
5
May give aspirin 160-325 mg/
Cardioembolic
(Appendix V)
day

If cerebellar infarct, consult neuro
surgeon as soon as possible
Supportive treatment:
1. Mannitol 20% 0.5 mg/kg BW q 6h for 2-5 days
2. Neuroprotection (Appendix IVD)
Neurosurgery consult if:
1. Patient not herniated, bleed located in putamen, subcortical area,
or cerebellum, and goal is reduction of mortality
2. Herniated patient but family is willing to accept consequences
of high mortality or irreversible coma and persistent vegetative
state
3. ICP monitoring contemplated and salvage surgery is considered
Figure 4B
12
06/16/2014 3:28:59 PM
CPM 8TH EDITION
Guidelines for Acute Stroke Treatment

See Algorithms for Acute Stroke Treatment, Transient
Ischemic Attack (TIA), and Mild Stroke, Moderate
Stroke and Severe Stroke.
Appendices for Acute Stroke Treatments

Appendix I
Abnormal motor posturing response to painful
stimuli (See Figure 5)
A. Localizes pain
B. Decorticate posturing
C. Decerebrate posturing
Other conditions to consider:

- Bell's palsy
- Migraine
- Toxins
Reference:
1. Libman RB, Wirkowski E, Alvir J, Rao H. Conditions that
mimic stroke in the emergency department. Arch Neurol
1995;52: 1119-1122.
Appendix III
Reference:
1. Plum F, Posner J. The Diagnosis of Stupor and Coma. 3rd
Ed. F.A. Davis Company, Philadelphia PA, c1982.
Appendix II
Differential Diagnosis of Stroke
A. The presence of any of the following should alert
the physician to consider conditions other than
stroke:

-
-
-
-
-
-
-
Gradual progressive course and insidious onset

Pure hemifacial weakness including forehead
Trauma
Fever prior to onset of symptoms
Recurrent seizures
Weakness with atrophy
Recurrent headaches
B. Conditions that mimic stroke in the emergency department (according to decreasing

frequency):

1. Seizures
2. Systemic infection
3. Brain tumor
4. Toxic-metabolic
5. Positional vertigo
6. Cardiac
7. Syncope
8. Trauma
9. Subdural hematoma
10. Herpes encephalitis
11. Transient global amnesia
12. Dementia
13. Demyelinating disease
14. Cervical spine fracture
15. Myasthenia gravis
16. Parkinsonism
17. Hypertensive encephalopathy

18. Conversion disorder
Blood Pressure Management

A. If SBP is 185-220 mmHg or DBP is 105-120 mmHg,
emergency therapy for blood pressure control should
be deferred unless there is left ventricular failure,
aortic dissection, or acute myocardial ischemia.
Patients who are potential candidates for rtPA
therapy but who have persistent elevations in SBP
>185 mmHg or DBP >110 mmHg may be treated
with small doses of IV anti-hypertensive medication
to maintain the BP just below these limits.
B. Mean Arterial Pressure (MAP):

MAP = Systolic BP + 2 (Diastolic BP)

3
C. Locally available intravenous antihypertensives

used in acute stroke. (See Table 1 on pp__)
References :
1. The Brain Matters Stroke Initiative. Acute Stroke
Management Workshop Syllabus. Basic Principles of
Modern Management for Acute Stroke.
2. Marler, JR, Jones PW, Emr M (eds). Setting New
Dimensions for Stroke Care. Proceedings of a national
symposium on rapid identification and treatment of acute
stroke. The National Institute of Neurological Disorders
and Stroke, National Institutes of Health. Bethesda, MD.
August 1997.
Appendix IV
Acute Stroke Treatments
A. Risk of treating patient with mild stroke with
anti-thrombotics:

- 1% of TIAs are not due to ischemic stroke

- 3 to 14% of mild strokes are hemorrhagic
13
06/16/2014 3:28:59 PM
APPENDIX I
Abnormal motor posturing responses to painful stimuli
Figures. Response elicited by pressure to supraorbital ridge, sternum, or nailbed. A. Localizes pain. B. Decorticate
posturing. C. Decerebrate posturing
Reference
1. Plum F, Posner J. The Diagnosis of Stupor and Coma. 3rd ed. F.A. Davis Company, Philadelphia PA, c1982.
Table 1. Locally Available Intravenous Anti-Hypertensives Used in Acute Stroke

Drug
Dose

Onset
of Action
Duration
of Action
Adverse Effects
Nicardipine
5-15 mg/h IV
5-10 min
1-4 h
Tachycardia, head-
HCl

ache, flushing, local

phlebitis

Special Indications
Most hypertensive
emergencies except
acute heart failure;
caution with
coronary ischemia
Hydralazine
10-20 mg IV
10-20 min
3-8 h
HCl

10-50 mg IM
20-30 min
Tachycardia, flush- Eclampsia

ing, headache, vomi-
ting, increased angina
Nitroglycerine 5-100 g/min

2-5 min
3-5 min

as IV infusion

Headache, vomiting, Coronary ischemia

methemoglobinemia,
tolerance with prolonged use
Esmolol
0.5-1 mg/kg
2-10 min
10-30 min

bolus IV over

30 sec. or

0.05/kg/min

14
Hypotension, brady- Supraventricular

cardia, peripheral
tachycardia,
ischemia, agitation, hypertension
confusion, headache,
vomiting
06/16/2014 3:29:02 PM
CPM 8TH EDITION
thrombin time >15 seconds (INR >1.7)

b. use of heparin in the previous 48 hours or a
prolonged partial thromboplastin time
c. a platelet count less than 100,000 mm3
d. another stroke or a serious head injury in the
previous 3 months
e. major surgery within the preceding 14 days
f. pretreatment systolic blood pressure greater
than 185 mmHg or diastolic BP >110 mmHg
(rtPA) may be given if BP is controlled using
recommendation in Table 1
g. rapidly improving neurological signs
h. isolated, mild neurological deficits, such as
ataxia alone, sensory loss alone, dysarthria
alone, or minimal weakness
i. prior intracranial hemorrhage
j. blood glucose <50 mg/dL or >400 mg/dL
k. seizure at the onset of stroke
l. gastrointestinal or urinary bleeding within
the preceding 21 days
m. recent myocardial infarction
References:
1. The Amaurosis Fugax Study Group. Current manage-ment
of amaurosis fugax. Stroke 1990;21:201-208.
2. Anzalone N, Landi G. Non-ischaemic causes of lacunar
syndromes: prevalence and clinical findings. J Neurol
Neurosurg Psychiatry 1989;52:1188-1190.
3. Bamford J, Sandercock P, Jones L, Warlow C. The natural
history of lacunar infarction: The Oxfordshire Community
Stroke Project. Stroke 1987;18:545-551.
4. Bamford JM, Warlow CP. Evolution and testing of the
lacunar hypothesis. Stroke 1988;19:1074-1082.
5. Bogousslavsky J, Van Melle G, Regli F. The Lausanne
Stroke Registry: Analysis of 1,000 consecutive patients
with first stroke. Stroke 1988;19:1083-1092.
6. Brown RD Jr, Evans BA, Wiebers DO, Petty GW, Meisner
I, Dale AJD. Transient ischemic attack and minor ischemic
stroke: An algorithm for evaluation and treatment. Mayo
Clin Proc 1994;69:1027-1039.
7. Chimowitz MI, Furlan AJ, Sila CA, Paranandi L, Beck
GJ. Etiology of motor or sensory stroke: A prospective
study of the predictive value of clinical and radiological
features. Ann Neurol 1991;30:519-525.
8. Mori E, Tabuchi M, Yamadori A. Lacunar syndrome due
to intracerebral hemorrhage. Stroke 1985;16:454-459.
5. Thrombolytic therapy should not be given unless

the emergent ancillary care and the facilities
to handle bleeding complications are readily
available.
B. Thrombolytic Therapy
- Thrombolytics is not recommended in mild
strokes.
- Streptokinase and urokinase are not currently
recommended in acute stroke.
6. Caution is advised before giving rtPA to persons

with:
- Recombinant tissue plasminogen activator (rtPA)

given within 3 hours of stroke onset may reduce
disability by a third at three months.

a. Severe stroke (NIH Stroke Scale Score >22)

b. Age >77
c. Obtunded patients
d. Major infarct on CT
e. Acute pericarditis
f. Recent trauma
g. Infectious endocarditis
h. High probability of left heart thrombus
i. Significant hepatic disease
j. DM retinopathy or hemorrhagic ophthalmo
pathy
k. Pregnancy
l. Bleeding hazards
Guidelines:
1. Dose of rtPA is 0.9 mg/kg (maximum 90 mg)10% of total volume given as bolus, rest as
infusion over 60 minutes.
2. RtPA is recommended as treatment within 3
hours of onset of ischemic stroke. The benefit
of IV rtPA for acute ischemic stroke beyond 3
hours from onset of symptoms is not established.
Intravenous rtPA is not recommended when the
time of onset of stroke cannot be ascertained
reliably, including strokes recognized upon
awakening.
3. Thrombolytic therapy is not recommended
unless the diagnosis is established by a physi
cian with expertise in diagnosis of stroke, and
CT of the brain is assessed by physicians with
expertise in reading this imaging study. If CT
demonstrates early changes of a recent major infarction such as sulcal effacement, mass effect,
edema or possible hemorrhage, thrombolytic
therapy should be avoided.
4. Thrombolytic therapy cannot be recommended
for persons with any of the following (NINDS
Study):
a. current use of oral anticoagulants or a pro
7. Because the use of thrombolytic drugs carries the real risk of major bleeding, whenever
possible the risks of potential benefits of rtPA
should be discussed with the patient and his or
her family before treatment is initiated.
Reference:
1. NINDS rtPA Stroke Study Group Tissue plasminogen
activator for acute ischemic stroke. N Engl J Med
1995;333:1581-1587.
C. Antithrombotic therapy
1. International Stroke Trial (IST)
- Multicenter randomized clinical trial of 19,435
patients

- Regimen:
Aspirin 300-325 mg/day vs. no aspirin

Heparin subcutaneous vs. no heparin
15
06/16/2014 3:29:02 PM
5,000 units bid or 12,500 units bid

- Started within 48 hours of stroke onset for 14
days or until discharge
- Results:
a. Aspirin
- fewer recurrent stroke within 14 days
- fewer deaths and dependency at 6 months
b. Heparin

2.

- no benefit even at 6 months

- if used, should not exceed 5,000 units bid
Chinese Acute Stroke Trial (CAST)
- 21,106 patients randomized
- Aspirin 160 mg/day vs. placebo
- Started within 48 hours of stroke onset
- Results:

Risk of recurrent stroke or vascular

death:
Aspirin 5.3%
Placebo 5.9%
(p=0.03)
3. 846 patients in the IST and 2,521 patients in the

CAST (total 3,367 patients) did not have a CT
scan done. Giving aspirin within 48 hours of stroke
onset among these patients without CT scan did not
significantly affect outcome at 4 weeks (recurrent
stroke, CAST) and at 6 months (functional status,
IST)
References:
1. Chinese Acute Stroke Trial Collaborative Group. CAST:
randomised placebo-controlled trial of early aspirin use
in 20,000 patients with acute ischaemic stroke. Lancet
1997;349:1641-1649.
2. International Stroke Trial Collaborative Group. The
International Stroke Trial: a randomised trial of aspirin,
subcutaneous heparin, both or neither among 19,435
patients with acute ischemic stroke. Lancet 1997;349:15691581.
4. A trial on the use of nadroparin started within 48

hours of stroke onset given at 0.4 mL subcutaneously
once or twice a day for 10 days showed improvement
in functional outcome at 6 months compared to
placebo.
Reference:
1. Kay R, Wong KS, Yu YL, et al. Low-molecular-weight
heparin for the treatment of acute ischemic stroke. N Engl
J Med 1995;333:1588-1593.
D. Neuroprotection
1. Avoid hypotension, hypoxemia (aspiration pneu
monia), hyperglycemia, hyponatremia, and fever
during acute stroke in an effort to salvage the
ischemic penumbra.
2. Several neuroprotectants for acute ischemic stroke
have been investigated or are currently under in
vestigation. Some results have been encouraging.
References:
1. Clark WM, Warachi SJ, Pettigrew LC, et al for the
Citicoline Stroke Study Group. A randomized doseresponse trial of citicoline in acute ischemic stroke
patients. Neurology 1997;29:671-678.
2. De Deyn PP, Reuck JD, Deberdt W, et al for the Piracetam
in Acute Stroke Study Group. Treatment of acute ischemic
stroke with piracetam. Stroke 1997;28:2347-2352.
3. Davalos A, et al. Oral Citicoline in Acute Ischemic Stroke:
An Individual Patient Data Pooling Analysis of Clinical
Trials. Stroke 2002;33:2850-2857
4. Mohr JP, Orgogozo JM, Harrison MJG, et al. Metaanalysis of oral nimodipine trials in acute ischemic stroke.
Cerebrovasc Dis 1994;4:197-203.
E. Treatment of intracerebral hemorrhage (ICH)

1. Medical Treatment: Goal is to prevent complications
and careful management of blood pressure
a. Maintain MAP <130, but not lower than 110
mmHg

i. Sustained hypertension may alter cerebral

autoregulation, promote progression of bleed,
and increase edema
ii. Hypotension may result in cerebral hypoper
fusion especially in the setting of increased
intracranial pressure (ICP)
b. Manage increased ICP accordingly (see Appen
dix X)
c. Consider prophylactic use of anticonvulsants

i. There is higher incidence of seizures in ICH

especially in lobar hematomas.
ii. Role of prophylactic anticonvulsants in
deep hemorrhages is unclear. It is justified
to withhold anticonvulsants until clinically
indicated.
d. Prevention and treatment of respiratory com
plications
i. Prevention and treatment of infections
e. Maintenance of adequate nutrition
f. Early rehabilitation once stable, bedsore precau
tions, DVT prophylaxis (Ted hose stockings or
compression boots)
2. Surgical treatment: Role depends on size, location,
and extent of hematoma
a. There is definite evidence of increase in hemato
ma size (26-107%); about half of which is attributable to impaired coagulation (patients with
liver disease, alcoholics, etc). Early hematoma
removal contributes to overall improvement or
morbidity and mortality.
b. There is good evidence of functional recovery
after surgery of hematoma size 10-30 mL with
reversible hemiplegia or severe hemiparesis.
c. There is available evidence to show that about
1/3 of patients with significant hematoma size
(30 mL) will deteriorate and may die (47%
mortality) from ischemia (perifocal) and not
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06/16/2014 3:29:03 PM
CPM 8TH EDITION
from clot enlargement.

d. There is acceptable evidence to show that mor
tality rate in patients with larger hematomas but
not herniated can be reduced with surgery.
References:
1. Aver LM, et al. Endoscopic surgery versus medical
treatment for spontaneous intracerebral hematoma: a
randomized study. J Neurosurg 1989;70:530-535.
2. Barnett HJM, Mohr JP, Stein BM, Yatsu FM (eds). Stroke Pathophysiology, Diagnosis, and Management, 2nd edition.
Churchill Livingstone, New York, 1992.
3. Broderick JP, et al. Ultra-early evaluation of intrace-rebral
hemorrhage. J Neurosurg 1990;72:195-199.
4. Brott T, et al. Early hemorrhage growth in patients with
intracerebral hemorrhage. Stroke 1997;28:1-5
5. Caplan L. Intracerebral hemorrhage revisited. Neuro-logy
1988;38:624-7.
6. Fujii Y, et al. Hematoma enlargement in spontaneous
intracerebral hemorrhage. J Neurosurg 1994;80:51-57.
7. Juvela S, et al. The treatment of spontaneous intracerebral hemorrhage: randomized clinical trial. J Neuro-surg
1989;70:755-788.
8. Kazui S, et al. Enlargement of spontaneous intracerebral
hemorrhage: incidence and time course. Stroke 1996;
27:1783-1787.
9. Mayer SA, Sacco RL, Shi T, Mohr JP. Neurologic deterioration in noncomatose patients with supra-tentori-al
intracerebral hemorrhage. Neurology 1994; 44: 1379-84.
10. Mendelon AD. Mechanisms of ischemic brain damage
with intracerebral hemorrhage. Stroke 1993;24 (Suppl
12):1115-1117.
11. Sacco RL, Wolf PA, Bharucha NE, et al. Subarachnoid and
intracerebral hemorrhage: Natural history, progno-sis, and
precursive factors in the Framingham Study. Neurology
1984;34:847-54.
12. Welch KMA, Caplan LR, Reis DJ. Siesjo BK, Weir B (eds).
Primer on Cerebrovascular Diseases. Academic Press. San
Diego, 1997.
Appendix V
A. Requirements for intravenous anticoagulation of

patients with cardiogenic source of embolism:
1. Heparin sodium in D5W
2. Infusion pump, if available
3. Activated partial thromboplastin time (PTT) or
clotting time
B. Procedure
a. Start intravenous infusion at 800 units heparin/ hour
ideally using infusion pump.
b. Monitor infusion closely. If using soluset instead of
infusion pump, intensive monitoring is required.
c. Perform aPTT as often as necessary, every 6
hours if needed, to keep aPTT at 1.5 - 2.3 times
control. Risk for major hemorrhage, including
intracranial bleed, progressively increases as the
aPTT becomes prolonged above 80 seconds.
d. Intermittent intravenous heparin administration is
not recommended.
e. Infusion may be discontinued once oral anticoagu
lation with coumadin is adequate or once antiplatelet medication is started for secondary prevention.
See section on Secondary Prevention of Stroke
(Appendix VIII).
C. If using low-molecular-weight heparin
(LMWH), give nadroparin at 0.4 mL (4,100
units) subcutaneously once or twice a day for 10
days. There is no need for aPTT monitoring.
Appendix VI
Differentiating Ischemic from Hemorrhagic
Stroke
A. Gold standard is plain CT scan
Cardiogenic Sources of Embolism
- Hyperdense (bright) lesion = bleed or intra

cerebral hemorrhage
1. Atrial fibrillation/flutter
2. Valvular heart disease (including rheumatic heart
disease)
3. Bacterial endocarditis
4. Cardiac thrombus
5. Cardiomyopathy
6. Recent myocardial infarction
7. Atrial myxoma
8. Right-to-left shunts
9. Pulmonary vein thrombosis
References:
1. Foulkes MA, Wolf PA, Price TR, Mohr JP, Hier DB.
The Stroke Data Bank: design, methods, and baseline
characteristics. Stroke 1988;19:547-54.
2. Mohr JP, Caplan LR, Melski JW, et al. The Harvard
Cooperative Stroke Registry: A prospective registry.
Neurology 1978;754-762.
- Normal = Acute infarction or TIA

- Hypodense (dark) = Infarction
B. Computation of Hematoma Volume (Kothari
Method)

Hematoma Volume (in mL) = A x B x C

2
where: A = Largest diameter of hematoma (in cm)

B = Diameter perpendicular to A (in cm)

C = Number of slices on CT scan X slice

thickness (in cm)
Count slice as 1 if size of hematoma is >75% of
largest hematoma
Count slice as 0.5 if size of hematoma is 25-75%
of largest hematoma
Disregard slice if size of hematoma is <25% of
largest hematoma
17
06/16/2014 3:29:03 PM
C. Scoring systems have been used in the absence

of CT scan
- Not recommended for use in mild stroke
- False negative rate for bleed most probably high
in mild strokes
Vomiting
B.
Level of Consciousness
+4
Unarousable
+4
Drowsy - arousable
+2
Awake
Absent
3. Loss of
Present
Absent
Consciousness
II. Physical Examination
Diaz Stroke Scale

sensitivity 100%

specificity 86%

accuracy 93%
A.
1. Systolic BP
>200 mmHg
160-200 mmHg
<160 mmHg
2. Diastolic BP
>90 mmHg
<90 mmHg
Stuporous-coma
3. Level of
Drowsy
Awake
4. Nuchal rigidity
Present
Absent
+3
consciousness
C.
Fever
D.
Respiratory Pattern
Ataxic or apneustic (rapid irregular)
+3
Hyperventilation (rapid regular)
+2
TOTAL SCORE
Cheyne-Stokes (slow irregular)
+1
Normal or regular 0
E.
Upper GI Bleeding
+3
F.
Neurologic deficit maximal onset
+2
Interpretation:
Score
11-17 = definitely hemorrhagic
8-10 = most probably hemorrhagic
0-7 = unlikely hemorrhagic
G.
Headache
+2
H.
Nuchal rigidity
+2
I.
Diastolic Blood Pressure (mmHg)
90
91-99
100
+2
J.
Absent
Siriraj Score

sensitivity 68%

specificity 64%

accuracy 64%
Systolic Blood Pressure (mmHg)
5. Preferential gaze Present
150
2
151-169
1
170-180 0
181-199
+1
200
+2
TOTAL SCORE
Interpretation

Score 7 = >90% probability of bleed

Score <7 = probably infarct
Consciousness (X 2.5)
Alert
Drowsy, stupor
Semicoma, coma
Vomiting (X 2)
No
Yes
Headache within
No
2 hours (X 2)
Yes
Diastolic blood
Ilano Scoring System

I. History
1. Vomiting
Present
Absent
2. Headache
Present
DBP X 0.1
Atheroma markers
None
(X 3): diabetes,
angina, intermittent claudication
One or more
Constant
-12
TOTAL SCORE
Interpretation:
Score 1 = infarct

>1 = hemorrhage
18
06/16/2014 3:29:03 PM
CPM 8TH EDITION
2. Diaz A. A scoring system to differentiate cerebral

hemorrhage from infarction. Santo Tomas J Med
1986;35:168-174.
3. Ilano F, Yu C. A clinical score system to differentiate
hemorrhagic from non-hemorrhagic strokes. MJDLSU
1993;9:47-53.
4. Poungvarin N, Viryavejakul A, Komontri C, Siriraj
stroke score and validation study to distinguish supratentorial intracerebral hemorrhage from infarction. BMJ
1991;302:1565-1567.
5. Sandercock PAG, Allen CMC, Corston RN, Harrison MJG,
Warlow CP. Clinical diagnosis of intracranial hemorrhage
using Guy's Hospital score. BMJ 1985; 291:1675-1677.
6. Weir CJ, Murray GD, Adams FG, Muir KW, Grosset DG,
Lees KR. Poor accuracy of stroke scoring system for
differential clinical diagnosis of intracranial hemor-rhage
and infarction. Lancet 1994;334:999-1002.
Allen (Guy's Hospital) Score

sensitivity 70-88%
specificity 64-78%
accuracy 64-82%
Apoplectic onset
Loss of consciousness
Headache within
2 hours
Vomiting
Neck stiffness
None
0
2 or more 21.9
Level of consciousness
Alert
24 hours after admission Drowsy

Unconscious
0
7.3
Plantar response
Both flexor 14.6
or single

extensor
0

Both extensor 7.1
Diastolic blood
24 hours after
admission
Place of Treatment
DBP X
0.17
Atheroma markers:
None
diabetes, angina,
One or more
intermittent claudication
0
-3.7
Hypertension

-4.1
0
Present
None
Appendix VII
A. Mayo algorithm for management of TIA's and
minor stroke.
Reference:
1. Brown RD Jr, Evans BA, Wiebers DO, Petty GW, Meissner
I, Dale AJD. Transient ischemic attack and minor ischemic
stroke: An algorithm for evaluation and treatment. Mayo
Clin Proc 1994;69:1027-1039.
Previous event: TIA

Any no. of
-6.7
previous
event
B. Admission to an organized Stroke Unit or management by a Stroke Team has been shown to:

improve functional outcome
Heart disease
None

Aortic or
mitral
murmur

Cardiac
failure

Cardiomyo pathy

Atrial

fibrillation

MI within
6 months
reduce mortality and morbidity by 21-28%
hasten recovery after a stroke
shorten hospital stay
Constant
0
-4.3
-4.3
References:
1. Indredavik B, Slordahl SA, Bakke F, Rokseth R, Haheim
LL. Stroke unit treatment. Stroke 1997;28:1861-1866.
2. Langhorne P, Williams BO, Gilchrist W. Do stroke units
save lives? Lancet 1993;342:395-398.
3. Ronning OM, Guldvog B. Stroke unit versus general
medical wards, II: Neurological deficits and activities of
daily living. Stroke 1998;29:586-590.
4. Stroke Unit Trialists' Collaboration. How do stroke units
improve patient outcome? Stroke 1997;28:2139-2144.
-4.3
-4.3
4.3
-12
TOTAL SCORE
Interpretation:
Score <4 = infarct

4-24 = uncertain

>24 = hemorrhage
References:
1. Allen CMC. Clinical diagnosis of the acute stroke
syndrome. Quarterly J Med, New Series LII 1983;
208:515-523.
C. Requirements for a Stroke Team

1. WHY (Objectives)

To reduce mortality and morbidity of stroke through

efficient delivery of effective therapy for acute stroke
after urgent transport and evaluation.
2. WHAT (Components)

a. Facilities:
19
06/16/2014 3:29:03 PM
- Nursing: Vital signs, suction, IV hydration,

intubation, ventilation, cardiac monitor
- Diagnostics: CT scan, EKG, laboratory for
hematology, chemistry, coagulation
- Therapy: Pharmacy, stroke treatment area/unit

b. Guidelines:
- Guidelines on Acute Brain Attack as published
by the Stroke Society of the Philippines and
Department of Health Non-communicable Di
sease Service
c. Communication system:
- Early warning system by direct communication
link
3. WHO (Personnel)
a. Neurologists/neurosurgeon or stroke physi
cians
b. Stroke nurses
c. Radiologist or physician experienced in reading
CT scans in acute stroke
References:
1. Grotta J. How to organize a stroke team. American
Academy of Neurology Syllabus on Disk 1998.
2. Rudd A, Wolfe CDA. Developing a district stroke service.
Cerebrovasc Dis 1996;6:89-96.
Appendix VIII
Secondary Prevention for Stroke
I. Ischemic
A. Antithrombotics
1. Aspirin
Antiplatelet Trialists Collaboration:

- 145 trials with almost 100,000 patients

- 23% risk reduction for stroke, myocardial
infarction (MI), and vascular death

2. Ticlopidine
Canadian American Ticlopidine Study
(CATS)

- 23% risk reduction vs. placebo for stroke, MI,
or vascular death
Ticlopidine Aspirin Stroke Study (TASS)

- 12% risk reduction vs. aspirin for stroke or
death at 3 years

3. Clopidogrel
Clopidogrel vs. Aspirin in Patients at Risk of
Ischemic Events (CAPRIE)

- 19,185 patients with prior stroke, MI, or PVD

- Clopidogrel 75 mg/day vs. aspirin 325 mg/
day

- 8.7% relative risk reduction in stroke, MI, and
vascular death over aspirin
4. Cilostazol
Cilostazol Stroke Prevention Study (CSPS)

- 1,095 patients with cerebral infarction at

1-6 months
- Cilostazol 100 mg bid vs. placebo
- Relative risk reduction of 41.7%
5. Dipyridamole-Aspirin Combination
European Stroke Prevention Study 2 6,602

patients randomized to:

- Aspirin 25 mg bid
- Extended release Dipyridamole 200 mg bid
- Aspirin 25 mg bid + extended release dipyri
damole 200 mg bid
- Placebo
Results:
- Aspirin better than placebo
- Dipyridamole better than placebo
- Combination aspirin and dipyridamole better
than either one alone
References:
1. Antiplatelet Trialists' Collaboration. Collaborative
overview of randomized trials of antiplatelet therapy, I:
prevention of death, myocardial infarction, and stroke
by prolonged antiplatelet therapy in various categories of
patients. BMJ 1994;308:81-106.
2. Diener HC, Cunha L, Forbes C, Sivenius J, Smets P,
Lowenthal A. European Stroke Prevention Study 2.
Dipyridamole and acetylsalicylic acid in the secondary
prevention of stroke. J Neurol Sci 1996;143:1-13.
3. Gent M, Blakely JA, Easton JD, et al. The Canadian
American Ticlopidine Study (CATS) in thromboembolic
stroke. Lancet 1989;1:1215-1220.
4. Hass WK, Easton JD, Adams HP, et al. A randomized trial
comparing ticlopidine hydrochloride with aspirin for the
prevention of stroke in high-risk patients. N Engl J Med
1989;321:501-507.
5. CAPRIE Steering Committee. A randomized, blinded trial
of clopidogrel versus aspirin in patients at risk of ischemic
events (CAPRIE). Lancet 1996; 348:1329-1339.
6. Gotoh F, Tohgi H, Hirai S, et al. Secondary prevention of
cerebral infarction with cilostazol - a multicenter, doubleblinded, placebo controlled, long term, randomized study
(Cilostazol Stroke Prevention Study, CSPS) (abstract).
Presented at the International Stroke Society Regional
Meeting, Yokohama, Japan, April 22-24, 1999.
B. Carotid endarterectomy
The North American Symptomatic Carotid Endarte
rectomy Trial (NASCET), European Carotid Surgery
Trial (ECST), and the Veterans Administration Symptomatic Carotid Surgery Trial all showed benefit in
reducing risk of recurrent stroke in patient with severe
internal carotid artery stenosis (70%) who had a TIA
or minor stroke.
References:
1. European Carotid Surgery Trialists' Collaborative Group.
20
06/16/2014 3:29:03 PM
CPM 8TH EDITION
MRC European Carotid Surgery Trial: Interim results for

symptomatic patients with severe (70-99%) or with mild
(0-29%) carotid stenosis. Lancet 1991;337:1235-1243.
2. Mayberg MR, Wilson SE, Yatsu F, et al. Carotid
endarterectomy and prevention of cerebral ischemia in
symptomatic carotid stenosis. JAMA 1991;266-32893294.
3. North American Symptomatic Carotid Endarterectomy Trial
Collaborators. Beneficial effect of carotid endarterectomy
in symptomatic patients with high-grade carotid stenosis.
N Engl J Med 1991;325:445-453.
needed
computed = 2 (Na+) + glucose + BUN
osmolality
18
2.8
6. Other options (use with caution):

- Furosemide + albumin
- Hypertonic saline 3% (50 mL in 5 min)
- Pentobarbital 10-20 mg/kg loading dose then 1-3
mg/kg/hr
C. Precautions
C. Anticoagulant
The benefit of oral anticoagulation with coumadin
(target INR=2.0-3.0) has been shown in patients with
non-valvular atrial fibrillation who are at high risk
(hypertension, poor left ventricular function, previous
TIA, stroke, or thromboembolic events).
References:
1. Ezekowitz MD, Levine JA. Preventing stroke in patients
with atrial fibrillation. JAMA 1999;281:1830-1835.
2. Quality Standards Subcommittee of the American
Academy of Neurology. Practice Parameter: Stroke pre
vention in patients with non-valvular atrial fibril-lation.
Neurology 1998;51:671-673.
D. Statins
Appendix IX
Increased Intracranial Pressure (ICP)
- avoid straining
- laxative
- gentle suctioning
- appropriate intubation by exprienced person
References:
1. Wijdick EFM. Neurology of Critical Illness. F.A. Davies,
Philadelphia PA: 1995.
2. Davis SM (ed). Interventional Therapy in Acute Stroke.
Blackwell Science, Inc. Carlton, Victoria: 1998.
Appendix X
Glasgow Coma Scale

Category
Score
Eye opening

Spontaneous
A. Signs and symptoms of increased ICP:
To speech
Deteriorating sensorium
To pain
Cushing's triad
None
1.Hypertension
2.Bradycardia
Best motor response

Obeys
3.Bradypnea (late)
Localizes
Anisocoria
Withdraws
Abnormal flexion
B.
1.
2.

Abnormal extension

3.
4.
5.

Management options for increased ICP:

Manage headache and other pains.
Manage combative behavior and agitation
- search for source of pain, e.g. bladder distention
- appropriate sedation if necessary
Elevate head to approximately 30 o from hori
zontal
Hyperventilate to pCO2 of low 30's (maximum of 6
hours)
Osmotic agents: goal is serum osmolality of 310320
Mannitol 0.25 - 2.0 g/kg bolus; may give 0.25 0.5g/kg every 3 - 5 hours
- expect response in 20 minutes
- effect may last for 6 hours
- difference of <10 between measured and com
puted osmolality means additional doses are
None
Best verbal response

Oriented conversation
Confused conversation
Inappropriate words
Incomprehensible sounds
None
Circle one score in each category; add the three scores

to obtain total score. Lowest possible GCS score is 3.
Highest score is 15.
Reference:
1. The Brain Matters Stroke Initiative. Acute Stroke
Management Workshop Syllabus. Basic Principles of
Modern Management for Acute Stroke.
21
06/16/2014 3:29:03 PM
CPM 8TH EDITION
Drugs Mentioned in the Treatment Guideline

This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing Information of these
drugs can be found in PPD reference systems.
Albumin
Albuman Berna
Albuminar
Buminate
Anticoagulants/Antiplatelets
Thrombolytics
Aspirin
Asaped
Aspilets
Bayer Aspirin
Cor-30
Drugmaker's Biotech Aspirin
Cilostazol
Ciletin
Pletaal
Clopidogrel
Plavix
Dipyridamole
Drugmaker's Biotech
Dipyridamole
Persantin
Dipyridamole/aspirin
Aggrenox
Enoxaparin
Clexane
Heparin
Biomedis Heparin
Heparin Leo
Nadroparin
Fraxiparine
Fraxiparine Forte
Recombinant human tissue-type
plasminogen activator
Actilyse
Sulodexide
Vessel Due-F
Ticlopidine
Clotidone
Ticlid
Warfarin
Coumadin
Antihypertensives
Ace Inhibitors
Benazepril
Cibacen
Captopril
Capoten
Captace
Drugmaker's Biotech Captopril
Novopharm Captopril
Primace
Tensoril
Vasostad
Cilazapril
Vascace
Cilazapril/Hydrochlorothiazide
Vascace plus
Delapril
Cupressin
Enalapril maleate
Hypace
Naprilate
Renitec
Vasopress
Enalapril/Hydrochlorothiazide
Co-Renitec
Fosinopril sodium
BPNorm
Imidapril
Norten
Vascor
Imidapril HCl/
Hydrochlorothiazide
Norplus
Vascoride
Lisinopril dihydrate
Sinolip
Zestril
Lisinopril/Hydrochlorothiazides
Zestoretic
Moexipril HCl
Univasc
Perindopril
Coversyl
Perindopril/Indapamide
Bipreterax
Preterax
Quinapril
Accupril
Quinapril/Hydrochlorothiazide
Accuzide
Ramipril
Tritace
Verapamil HCl/Trandolapril
Tarka
Alpha Blockers
Terazosin HCl
Conmy
Hytrin
Angiotensin II antagonists
Candesartan
Blopress
Candesartan cilexetil/
Hydrochlorothiazide
Blopress plus
Eprosartan
Teveten
Eprosartan/Hydrochlorothiazide
Teveten plus
Irbesartan
Aprovel
Irbesartan/Hydrochlorothiazide
CoAprovel
Losartan
Bepsar
Cozaar
Lifezar
Losartan/Hydrochlorothiazide
Combizar
Hyzaar/Hyazaar DS
Olmesartan
Olmetec
Telmisartan
Micardis
Pritor
Telmisartan/Hydrochlorothiazide
Micardis plus
Pritor plus
Valsartan
Diovan
Valsartan/Hydrochlorothiazide
Co-Diovan
-blockers
Atenolol
Atestad
Cardioten
Drugmaker's Biotech Atenolol
Durabeta
Ritemed Atenolol
Tenormin
Tenostat
Therabloc
Atenolol/Chlorthalidone
Tenoretic
Betaxolol HCl
Kerlone
Bisoprolol
Concore
Bisoprolol hemifumarate/
Hydrochlorthiazide
Ziac
Carteolol HCl
Mikelan
Carvedilol
Dilatrend
Esmolol
Brevibloc
Metoprolol
Betaloc
Betazok
Cardiosel
Cardiostat
Cardiotab
Drugmaker's Biotech
Metoprolol
Metostad
Neobloc
23
06/16/2014 3:29:03 PM
Pharex Metoprolol
Prolohex
Ritemed Metoprolol
Metoprolol/ Hydrochlorothiazide
Betazide
Pindolol
Visken
Pindolol/Clopamide
Viskaldix
Propranolol
Bedranol
Drugmaker's Biotech
Propranolol
Duranol
Inderal
Phanerol
Ritemed Propranolol
Calcium Antagonists
Amlodipine besylate
Norvasc
Amlodipine/Atorvastatin
Envacar
Barnidipine
Hypoca
Benidipine
Coniel
Diltiazem
Angiozem
Cordazem
Dilatam
Diltac
Diltelan
Dilzem/Dilzem SA/Dilzem SR
Drugmaker's Biotech Diltiazem
Mono-Tildiem
Ritemed Diltiazem
Tildiem
Zandil
Felodipine
Dilahex
Felop ER Tab
Plendil ER
Versant XR
Felodipine/Metoprolol
Logimax
Lacidipine
Lacipil
Lercanidipine
Zanidip
Manidipine
Caldine
Minadil
Nicardipine
Cardepine
Nifedipine
Adalat
Calcheck
Calcibloc/Calcibloc OD
Calcigard-5
Denkifed
Drugmaker's Biotech
Nifedipine
Heblopin
Nelapine
Nifestad
Normadil
Nimodipine
Nimotop
Verapamil
Isoptin/Isoptin SR
Verelan
Verapamil/Trandolapril
Tarka
Centrally-Acting drugs
Clonidine
Catapres
Drugmaker's Biotech Clonidine
Melzin
Methyldopa
Aldomet
Moxonidine
Physiotens
Rilmenidine
Hyperdix
CNS Stimulants/Neurotonics
Citicoline
Nicholin
Somazine
Piracetam
Irahex
Nootropil
Pyritinol HCl
Encephabol/Encephabol forte
Sulbutiamine
Arcalion
Diuretics
Carbonic Anhydrase Inhibitors
Acetazolamide
Diamox
Brinzolamide
Azopt
Dorzolamide
Trusopt
Loop Diuretics
Furosemide
Am-Europharma Furosemide
Drugmaker's Biotech
Furosemide
Edemann
Flexamide
Frusema
Furoscan injection
Lasix
Pharmix
Piplen
Bumetanide
Burinex
Osmotic Diuretics
Isosorbide-5-mononitrate
Angistad/Angistad SR
Elantan/Elantan Long
Imdur Durules
Ismo 20
Isomonit
Schwarz Isosorbide mononitrate
Isosorbide dinitrate
Isoket/Isoket IV/Isoket spray
Isordil
Mannitol
Osmofundin 20%
Potassium-Sparing Diuretics
Spirinolactone
Aldactone
Spirinolactone/Butizide
Aldazide
Thiazides (Benzothiadiazines)
Candesartan/Hydrochlorothiazide
Blopress plus
Cilazapril/Hydrochlorothiazide
Vascace plus
Enalapril/Hydrochlorothiazide
Co-Renitec
Eprosartan/Hydrochlorothiazide
Teveten plus
Imidapril/Hydrochlorothiazide
Norplus
Vascoride
Indapamide hemihydrate
Natrilix
Irbesartan/Hydrochlorothiazide
CoAprovel
Lisinopril/Hydrochlorothiazide
Zestoretic
Losartan/Hydrochlorothiazide
Combizar
Hyzaar/Hyzaar DS
Metoprolol/Hydrochlorothiazide
Betazide
Perindopril/Indapamide
Bipreterax
Preterax
Quinapril/Hydrochlorothiazide
Accuzide
Telmisartan/Hydrochlorothiazide
Micardis plus
Pritor plus
Valsartan/Hydrochlorothiazide
Co-Diovan
Nitroglycerin
Deponit NT 5/Deponit NT 10
Minitran TDP
Nitrostat
Perlinganit
Transderm-Nitro
Parenteral Electrolytes
0.9 NaCl
B. Braun NaCl 0.9% Soln for Inj
B. Braun NaCl 0.9% Soln
Hizon 0.9% Sodium Chloride
LVP S9
Vasodilators
Hydralazine HCl
Apresoline
24
06/16/2014 3:29:03 PM

Stroke Society of the Philippines: Guide for Stroke Treatment

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Stroke Society of the Philippines

14/F 1403 Cathedral Heights Complex, St. Luke's Medical Center,

Board of Trustees 2005-2006

Immediate Past President

Abdias V. Aquino, M.D.

Stroke: Think Globally, Act Locally

8th-Acute Stroke Treatment-Cla.i1 1

CPM 8TH EDITION

acute stroke treatment

Algorithm for Acute Stroke Treatment

Alert patients with any of the ff:

a. mild pure motor weakness of one

Transient Ischemic Attack

b. pure sensory deficit

c. slurred speech but intelligible

f. combination of (a) and (b)

Awake patient with signifi

Comatose patient with

Comatose patient with no res

8th-Acute Stroke Treatment-Cla.i3 3

acute stroke treatment cpm 8TH eDITION

Algorithm for Transient Ischemic Attack (TIA)

Complete blood count (CBC)

CT scan not available

8th-Acute Stroke Treatment-Cla.i4 4

CPM 8TH EDITION

acute stroke treatment

Early rehabilitation once stable

Neuroprotection (Appendix IVD)

Neuroprotection (Appendix IVD)

Early neurology and/or

Anticoagulation with IV heparin or

subcutaneous low molecular weight

Aspirin 160-325 mg/day (if heparin

Aspirin 160-325 mg/day

3. Monitor and correct metabolic

Place of Treatment (Appendix VII)

1. Stroke onset within 48 hrs.

Admit to Hospital (Stroke Unit)

Urgent Outpatient Work-up

8th-Acute Stroke Treatment-Cla.i5 5

acute stroke treatment cpm 8TH eDITION

Control of risk factors

Long-term blood pressure

Echocardiography and/or cardio

8th-Acute Stroke Treatment-Cla.i6 6

CPM 8TH EDITION

acute stroke treatment

Algorithm for Moderate Stroke

Basic emergent supportive care (ABC of resuscitation)

8th-Acute Stroke Treatment-Cla.i7 7

acute stroke treatment cpm 8TH eDITION

CT scan not available

Refer to neurologist neu

8th-Acute Stroke Treatment-Cla.i8 8

CPM 8TH EDITION

acute stroke treatment

If within 3 hours of stroke

If within 3 hours of stroke onset, consider rtPA

Delayed Management and Treatment (Secondary Prevention) (Appendix VIII)

Control of risk factors

Long-term blood pressure