Stroke monitoring

Fig. 1. Bilateral intraparenchymatous temperature monitoring with representative bladder temperatures in patients showing higher temperatures in the infarcted hemisphere within the first hours after stroke. Monitoring began within 6 h after onset of symptoms. Measurements were taken every 30 min.

Traditional Apparatus. As indicated earlier, liquid delivery systems for controlled rate addition of monomers and initiators have tended to rely upon constant speed piston pumps (19) in which volumetric control is achieved by manual adjustment of stroke length, and monitoring is by discharge from measuring cylinders. 

Expert opinion is a source, frequently elicited by survey, that is used to obtain information where no or few data are available. For example, in our experience with a multicountry evaluation of health care resource utilization in atrial fibrillation, very few country-specific published data were available on this subject. Thus the decision-analytic model was supplemented with data from a physician expert panel survey to determine initial management approach (rate control vs. cardioversion) first-, second-, and third-line agents doses and durations of therapy type and frequency of studies that would be performed to initiate and monitor therapy type and frequency of adverse events, by body system and the resources used to manage them place of treatment and adverse consequences of lack of atrial fibrillation control and cost of these consequences, for example, stroke, congestive heart failure. This method may also be used in testing the robustness of the analysis [30]. 

Schabitz WR, Schade H, Heiland S, Kollmar R, Bardutzky J, Henninger N, Muller H, Carl U, Toyokuni S, Sommer C, Schwab S. Neuroprotection by hyperbaric oxygenation after experimental focal cerebral ischemia monitored by mr-imaging. Stroke 2004 35 1175-1179. 

If a stroke patient receives intravenous (IV) thrombolysis, care often continues in the ED until the patient arrives in the ICU. Close monitoring must continue during this time, with special attention to the blood pressure. The blood pressure is most commonly checked via an arm cuff, since the placement of invasive lines (e.g., arterial catheterization) is relatively contraindicated once the patient has received intravenous thrombolysis (unless the situation is emergent and mandates such treatment). The systolic pressure must not exceed 185 mm Hg, and the diastolic pressure limit should be 110 mm Hg. Should the blood pressure exceed these limits, IV antihypertensive agents should be administered. IV pushes of labetolol (10-20 mg over 1-2 minutes) may be effective, but if patients are refractory to these initial measures then a continuous infusion of labetolol (0.5-2.0 mg/minute), nicardipine (5-15 mg/hour), or nitro-prusside (0.25-10 mg/kg/minute) may be necessary to keep the patient s blood pressure within the range. There will be a more detailed discussion of these antihypertensive agents, including their side effect profiles, later in this chapter. 

Other electrolytes of importance include calcium (especially if the patient is receiving a calcium channel blocker, such as nicardipine) and magnesium, as hypomagnesemia may predispose the patient to seizures, further complicating the ICP management. If the patient received intravenous iodinated contrast as part of their stroke evaluation, then careful monitoring of the blood urea nitrogen (BUN) and creatinine levels is necessary to detect contrast nephropathy. 

Schwab et al. Stroke 1999 30(5) 1153 Prospective pilot study moderate hypothermia in severe stroke and ICP 25 of 25 tx with hypothermia Hypothermia to 33-34°C with cooling blankets in pts with compete MCA infarct and ICP monitor 44% mortality, all by herniation after secondary rise in ICP after rewarming period. Good control of ICP during hypothermia period. Forty percent rate of pneumonia... 

MONITORING OF INTRACRANIAL PRESSURE IN ISCHEMIC STROKE PATIENTS... 

EEG monitoring may be useful in acute stroke patients. Seizures are not uncommon following stroke, occurring in 6-9% of patients in the acute setting. The... 

Silva Y, Puigdemont M, Castellanos M, Serena J, Suner RM, Garcia MM, Davalos A. Semi-intensive monitoring in acute stroke and long-term outcome. Cerebrovasc Dis 2005 19(1) 23-30. 

Cavallini A, Micieli G, Marchesilli S, Quaglini S. Role of monitoring in management of acute ischemic stroke patients. Stroke 2003 34(ll) 2599-2603. 

Berger C, Sakowitz OW, Kiening KL, Schwab S. Neurochemical monitoring of glycerol therapy in patients with ischemic brain edema. Stroke 2005 36 e4—e6. 

Baldauf J, Oertel J, Gaab MR, Schroeder HW. Endoscopic third ventriculostomy for occlusive hydrocephalus caused hy cerehellar infarction. Neurosurgery 2006 59(3) 539-544. Schwab S, Aschoff A, Spranger M, Albert F, Hacke W. The value of intracranial pressure monitoring in acute hemispheric stroke. Neurology 1996 47(2) 393-398. 

Jordan KG. Emergency EEG and continuous EEG monitoring in acute ischemic stroke. J... 

Shafqat S, Kelly PJ, Furie KL. Holier monitoring in diagnosis of stroke mechanism. Inter Med J 2004 34 305-309. 

Schaer BA, Zellweger MJ, Cron TA, Kaiser CA, Osswald S. Value of routine holler monitoring for the detection of paroxysmal atrial HhriUation in patients with cerebral ischemic events. Stroke 2004 35 e68-e70. 

Jabaudon D, Sztajzel J, Sievert K, Landis T, Sztajzel R. Usefulness of amulatory 7 day ECG monitoring for the detection of atrial finrillation and flutter after acute stroke and transient ischemic attack. Stroke 2004 35 1647-1651. 

The telemedicine-based evaluation of acute stroke is especially challenging. It requires a rapid neurological assessment, CT image acquisition and review, and a detailed history for rt-PA exclusion criteria. Low-cost teleradiology systems are now available for the transmission of compressed CT images viewable on a conventional personal computer (PC) monitor, in accordance with published standards. 

Admit patient to an intensive care or stroke unit for monitoring... 

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