Front Panel Painting “LIFE” By William T Chua MD

Acute Stroke
Treatment
Avoid Hypoglycemia or Hyperglycemia
Background: Hyperglycemia can increase the severity of ischemic injury (causes lactic
acidosis, increases production of free radicals, worsens cerebral edema and weakens
blood vessels), whereas hypoglycemia can mimic a stroke.
• Prompt determination of blood glucose should be done in all stroke patients
• Ensure glycemic control at 110-180 mg/dL preferably within the first 6 hours
and maintain up to 3-5 days. May start intervention with insulin if
CBG>180mg/dL
• Avoid glucose-containing (D5) IV fluids. Use isotonic saline (0.9% NaCl)
Avoid Hyperthermia
Backgound: Fever in acute stroke is associated with poor outcome possibly related to
increased metabolic demand, increased free radical production and enhanced
neurotransmitter release.
Hyperthermia increases the relative risk of 1 year mortality by 3.4 times.
• For every 1°
C increase in body temperature, the relative risk of death or
disability increases by 2.
2
Hypothermia can reduce infarct size by 44% in animal studies.
• Search for the source of fever
• Treat fever with antipyretics and cooling blankets
• Maintain normothermia
B. NEUROPROTECTANT DRUGS:
Neuroprotectants are drugs with multi-modal action:
• Protect against excitotoxins and help prolong neuronal survival
• Block the release of glutamate and inflammatory cytokines, inhibit the
formation of free radicals and apoptosis
Over 50 neuroprotective agents such as glutamate, NMDA/AMPA antagonists, calcium
channel blockers, free radical scavengers have undergone phase III clinical trials but most have
failed. Several reasons have been raised to explain the apparent disappointments: animal
models were wrong, human trials were not done optimally (e.g., determination of time window,
patient heterogeneity, “targeted” neuroprotection which addresses single mechanism of
neuronal injury at a time, exclusion of concomitant treatment with thrombolytic agents).
Among the various pharmacologic agents investigated, CDP-choline (Citicoline) has shown
great promise as evidenced by numerous experimental studies showing consistent improved
functional outcome and reduced infarct size in animal models of stroke. Several trials in
ischemic and hemorrhagic strokes conducted worldwide have documented its excellent safety
profile. In individual patient data pooling analysis (4 trials, 1652 patients) oral citicoline given
within the first 24 hours of moderate to severe ischemic stroke significantly increased the
probability of global recovery by 30% at 3 months. Similar positive result in reduction in death
and disability from acute ischemic stroke was obtained in the latest meta-analysis in 2008.
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