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The main objective in these forms of cerebrovascular disease is the prevention of stroke Ideally this should be accomplished by nding patients in the asymptomatic stage of atherosclerosis However, the medical profession has no ef cient means of screening large populations at risk of developing stroke and only limited methods for altering the progression of the atherosclerotic process, even if discovered in its early stages The widespread use of cholesterollowering statin medications has been shown to reduce the incidence of stroke and will probably be more widely prescribed to normal older adults For all practical purposes, treatment is directed to patients who have already begun to have symptoms, either TIAs or ischemic lesions that are reversible to some extent The current treatment of atherothrombotic disease may be divided into four parts: (1) management in the acute phase, (2) measures to restore the circulation and arrest the pathologic process, (3) physical therapy and rehabilitation, and (4) measures to prevent further strokes and progression of vascular disease Management in the Acute Phase The relative advantages of placing the seriously ill acute stroke patient in a neurologic special care or stroke unit have been the subject of many articles It is our impression that the outcome in terms of morbidity and mortality in the seriously ill stroke patient is improved, though admittedly this is dif cult to document (for details, see Ropper and also Brott and Reed) Like the well-organized coronary care unit, stroke units have the capability of expediting the evaluation and early rehabilitation of these patients As already emphasized, the prevention of aspiration and of pneumonia are paramount, and probably avoidable Also deserving attention are the prevention of venous thrombosis in the legs, pulmonary embolism, and coronary syndromes Patients with impaired consciousness require special care of skin, eyes, mouth, bladder, and bowel These measures are best provided in a unit with trained clinical staff and the technology to monitor blood pressure, pulmonary function, blood gases, and, when appropriate, intracranial pressure (page 740) Measures to Restore the Circulation and Arrest the Pathologic Process Once a thrombotic stroke has developed fully (ie, the completed stroke), none of the therapeutic measures so far devised has proved to be consistently effective in restoring the damaged cerebral tissue to a functional state The in uence of anticoagulants and thrombolysis at an early stage of stroke are discussed below One s efforts must be directed to making a diagnosis of thrombosis at the earliest possible stage and circumventing the full catastrophe by all means available without risking the safety of the patient Even when the symptoms and signs have become persistent, it is conceivable that some of the affected tissue, particularly at the edges of the infarct, has not been irreversibly damaged and will survive if perfusion can be re-established On the assumption that. install barcode font excel 2007 Barcode Add-In for Word & Excel Download and Installation
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How to Create a Barcode List cerebral perfusion might be diminished by assuming the upright position, it is probably advisable for patients with a major stroke to remain nearly horizontal in bed for the rst day When sitting and walking begin, special attention should be given to maintenance of normal blood pressure (patients should avoid standing quietly or sitting with the feet down for prolonged periods, etc) Several studies have con rmed the prevalence of new or exaggerated hypertension following an ischemic stroke and its tendency to decline within days even without medications The treatment of previously unappreciated hypertension is preferably deferred until the neurologic de cit has stabilized We agree with Britton and colleagues that it is prudent to avoid antihypertensive drugs in the rst few days unless there is active myocardial ischemia or the blood pressure is high enough to pose a risk to other organs, particularly the kidneys, or there is a special risk of cerebral hemorrhage as a result of the use of thrombolytic drugs Thrombolytic Agents Tissue plasminogen activators (recombinant t-PA and streptokinase), when administered intravenously, convert plasminogen to plasmin, the latter being a proteolytic enzyme capable of hydrolyzing brin, brinogen, and other clotting proteins These drugs are effective in the treatment of coronary artery occlusion (but are associated with a 1 percent risk of cerebral hemorrhage), and they also have now been shown to have a role in the treatment of stroke The multicenter study organized by the National Institute of Neurological and Communicative Disorders and Stroke (see the NINCDS and Stroke rt-PA Stroke Study Group in the References) has provided evidence of bene t from intravenous t-PA Treatment within 3 h of the onset of symptoms led to a 30 percent increase in the number of patients who remained with little or no neurologic de cit when re-examined 3 months after the stroke and when assessed 1 year later in the study by Kwiatkowski et al It is not easy to comprehend why the bene ts apparently extended to all types of ischemic stroke, including those due to occlusion of small vessels (lacunes), and why improvement was not at all apparent in the days immediately following treatment, only much later The t-PA was administered in a dose of 09 mg/kg, 10 percent of which was given as an initial bolus, followed by an infusion of the remainder over 1 h A dose of 90 mg was not exceeded, this being lower than the dose used for myocardial infarction The relative improvement in neurologic state came at the expense of a 6 percent risk of symptomatic cerebral hemorrhage, ie, a far lower rate than in most previous studies (some of the hemorrhages were into the area of infarction without causing symptomatic worsening) Patients with massive infarcts (ones that encompassed more than two-thirds of the territory of the middle cerebral artery) or with high scores on a clinical stroke scale devised for the National Institutes of Health (NIH) study or with uncontrolled hypertension or who were more than 80 years of age or who had recently received anticoagulants (except aspirin) were excluded from this study Further analysis of the NINCDS trial has revealed that patients who were treated earlier within the 3-h time frame had more bene t than those treated later; indeed, the administration of t-PA in the time period between 25 and 3 h after the stroke was of little value Comparable data from the randomized European Cooperative Acute Stroke Study (ECASS; see Hacke et al), which included 620 patients, identi ed two situations in which t-PA administered intravenously within 6 h, at a slightly higher dose than in the above trial (11 mg/kg, to a maximum of 100 mg), led to an improved neurologic outcome, but the overall results of this trial were con-. barcode wizard excel Barcodes in Excel 2016, Excel 2013 and Excel 365 - ActiveBarcode
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