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Table of Contents
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 71-90

Stroke: The old, the new and the novel diagnostic and management strategies

1 Professor, College of Nursing, CMC, Vellore, India
2 Assoc Professor, College of Nursing, CMC, Vellore, India
3 Junior Lecturer, College of Nursing, CMC, Vellore, India
4 Tutor, College of Nursing, CMC, Vellore, India

Date of Web Publication11-Jun-2020

Correspondence Address:
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Source of Support: None, Conflict of Interest: None

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Stroke is a preventable health problem. If stroke has occurred and treatment is delivered on time, the risk of developing complications and disabilities can be minimized. The first responders and community should be able to recognize the signs and symptoms of stroke and seek medical help at the earliest. In addition, the tertiary care centres or hospitals which have dedicated stroke units must be equipped with facilities required to diagnose and provide treatment. The treatment for stroke depends on the type, co-morbidities, and time within which the intervention is done. Stroke causes varying degrees of impairment in mobility, sensory perception, cognition, and perfusion.

Keywords: stroke, Transient Ischemic Attack, impairment

How to cite this article:
Bai RS, Jesudoss M, Snegalatha D, Sathianathan P, Ipe DM. Stroke: The old, the new and the novel diagnostic and management strategies. Indian J Cont Nsg Edn 2018;19:71-90

How to cite this URL:
Bai RS, Jesudoss M, Snegalatha D, Sathianathan P, Ipe DM. Stroke: The old, the new and the novel diagnostic and management strategies. Indian J Cont Nsg Edn [serial online] 2018 [cited 2023 May 31];19:71-90. Available from: https://www.ijcne.org/text.asp?2018/19/1/71/286498

  Introduction Top

Stroke occurs when oxygen supply to the localized area in the brain is interrupted, resulting in a series of intricate processes that lead to the destruction of neurons and subsequent brain damage. The risk for death is high among stroke patients. Stroke is so called because of the way it strikes people down. Secondary stroke risk is significantly higher among people with a previous history of stroke. The National Stroke Association (NSA) uses the term brain attack to convey to public the urgency of recognizing the warning signs and to seek treatment similar to that provided for myocardial infarction (heart attack). Stroke is a medical emergency and it should be treated within minutes to hours from the onset of symptoms in order to decrease disability and the risk of death (World Health Organization [WHO], 2018). India is estimated to have lost 8.7 billion dollars in 2005 due to coronary heart disease (CHD), stroke, and diabetes. This is to increase to 54 billion dollars by 2015 and is estimated to fall by 1% because of the combined economic impact of CHD, stroke, and diabetes (WHO, 2005).

  Definitions Top

Cerebrovascular Accident

Stroke is a heterogeneous neurological syndrome characterized by gradual or rapid, non-convulsive onset of neurological deficit that fit a known vascular territory and that last for 24 hours or more (Hickey, 2013).

Transient Ischemic Attack (TIA)

TIA is a brief episode of neurological dysfunction caused by a focal disturbance of brain or retinal ischemia, with clinical symptoms lasting less than one hour and without evidence of infarction (Barker, 2008).

  Morbidity and Mortality associated with Stroke Top

A global estimate by World Health Organization has reported that 15 million people worldwide suffer a stroke. Of these, 5 million die and another 5 million are left permanently disabled, placing a burden on family and community (WHO 2018).

In India, according to the stroke fact sheet which was updated in 2012, the estimated age-adjusted prevalence rate for stroke ranges between 84 to 262/100,000 in rural and between 334 to 424/100,000 in urban areas. The epidemiological studies from India reported an annual incidence rate between 13 and 842/100,000 populations (Pandian & Sudhan, 2013).

The mortality related to stroke had increased by 7.8% from 1998 to 2004. It is also reported that stroke incidence and mortality are higher in Asian countries than in western world (Ministry of Health and Family Welfare, 2005).

  Risk Factors Top

The major risk factors that increase the likelihood for stroke can be divided into modifiable and non-modifiable factors. The modifiable risk factors are Hypertension, Cardiac diseases, Diabetes mellitus, Hypercholesterolemia, cigarette smoking, excessive alcohol, physical inactivity, use of oral contraceptives and substance use (particularly cocaine), and obesity. The risk factors and the therapeutic goals are listed in [Table 1]. The non-modifiable risk factors are age, gender, race or ethnicity, and familial history. The risk for stroke increases with age, doubling each decade after 55 years of age and is more common in men than women, but the mortality rate in women is higher due to late occurrence of stroke (Centre Disease Control [CDC], 2018b). For better understanding, risk factors can be further divided into three groups. They are risk factors that cannot be changed (e.g., Gender), risk factors that can be changed with medical treatment (e.g., Diabetes mellitus), and risk factors that can be changed with lifestyle modifications (e.g.,Obesity).
Table 1: Risk Factors and Therapeutic Goals (Adams et al., 2003)

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  Types and Characteristics of Stroke Top

The two main types of stroke are Ischemic (85%) and hemorrhagic strokes (15%). The ischemic stroke is further classified into embolic and thrombotic types. The manifestations in ischemic stroke progress in the first 72 hours as the infarction and cerebral oedema increases (Lewis et al., 2017). In haemorrhagic stroke, the vessel integrity is interrupted and bleeding occurs into the brain tissue and sub arachnoid space. The prognosis is poor in patients with intracerebral haemorrhage. The 30 day mortality rate is 40% 80% and fifty percent of deaths occur within the first 48 hours (CDC, 2018a). The characteristics of specific stroke types and clinical courses are tabulated for easy understanding in [Table 2].
Table 2: Types and Characteristics of Stroke

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  Anatomy of Cerebral Circulation Top

Blood is supplied to the brain by two major pairs of rteries:

  • The internal carotid arteries (anterior circulation)
  • The vertebral arteries (posterior circulation)

The carotid arteries branch to supply most of the frontal, 3arietal and temporal lobes; the basal ganglia and part of the diencephalon (thalamus and hypothalamus). The major branches of the carotid arteries are the middle cerebral and anterior cerebral arteries. The vertebral arteries join to form the basilar artery, which branches to supply the middle and lower parts of the temporal lobes, occipital lobes, cerebellum, brainstem and part of the diencephalon. The main branch of the basilar artery is the posterior cerebral artery. The collateral circulation formed by these arteries is termed as Circle of Willis (Lewis et al., 2015).

  Pathophysiology Top

The brain’s response to acute ischemia is influenced by the extent and size of the injury, the degree of reduction in blood flow and the duration of the loss of blood flow. In short, the starving, swollen brain cells cease the electrical activity that characterised their function and they die. This extends the area of infarction (Lewis et al., 2016).

In AIS, a core of profoundly ischemic tissue is surrounded by a much larger penumbra of less ischemic tissue that is recruited progressively with time into the infarct the so called “ischemic cascade” (Barker, 2008).

Ischemia severe enough to cause neuronal death of cerebral cells is called ischemic necrosis or cerebral infarction.

  Thresholds of Cerebral Ischemia Top

The critical level for ischemia to develop is when cerebral blood flow (CBF) falls below 18ml/100gm/min; lethal levels are below 10ml/100mg/min. When CBF falls below 15ml/100gm/min, electrical activity of the affected neurones ceases due to insufficient energy substrates being delivered to fuel the sodium-potassium ATP pumps but the structural integrity is retained. If reperfusion occurs quickly, it is possible for cells in the affected zones to recover. This zone of ischemia has been termed as the ischemic penumbra and is derived from the Latin word paene ‘almost’ + umbra ‘shadow’. The penumbra region may recover completely if good cerebral blood flow is re-established, e.g., following thrombolysis. This highlights the importance of rapid recognition and treatment.

The critical time period during which the penumbra is at risk is referred to as the “window of opportunity” because the neurological deficits created by the ischemia can be partly or completely reversed if reperfusion of the ischemic area occurs within a critical time frame of 2 to 4 hours. The penumbra is the target for pharmacologic interventions to reestablish adequate perfusion, thus salvaging neuronal cells from infarction (Hickey, 2013).
Figure 1: Cerebral blood flow

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  Clinical Manifestations in Stroke Top

The manifestations are related to location of stroke and the area of damage in the brain. Stroke symptoms occur any time of the day or night and five most common symptoms are

  • Sudden confusion or trouble speaking or understanding others
  • Sudden numbness or weakness of the face, arm, or leg
  • Sudden trouble seeing in one or both the eyes
  • Sudden dizziness, trouble walking, or loss of balance or coordination
  • Sudden severe headache with no known cause (CDC, 2018b)

  Motor Deficits Top


Weakness of the face, arm and leg on same side (due to lesion in the opposite hemisphere) and it indicates a stroke involving on one cerebral hemisphere since the motor nerve fibers cross in the medulla before entering the spinal cord and periphery.


Paralysis of the face, arm and leg on same side (due to lesion in the opposite hemisphere).


Staggering, unsteady gait and the patient is unable to keep foot together hence, assumes a broad base to stand. Involvement of the brain stem and cerebellum results in ataxia.


Muscles of speech are impaired and there is difficulty in forming words. The patient may experience difficulty with pronunciation, articulation and phonation. The mechanics of speech are affected rather than the meaning of communication or comprehension of language.


Muscles of swallowing are impaired and patient has difficulty in swallowing. The patient has difficulty in chewing or swallowing liquids or foods.

  Sensory Deficits Top

Visual field deficits

Homonymous hemianopsia

There is bilateral visual loss involving half of each field due to damage in the optic tract or occipital lobe. Patient has decreased visual acuity and is unaware of persons or objects on side of visual loss. Usually, in homonymous hemianopsia, there is blindness in the same side of both eyes (see [Figure 2]a). The patient eats only half of a meal because that is the only portion seen (see [Figure 3]). This results in neglect of one side of the body and this deficit is termed as unilateral neglect.
Figure 2: Right and left eye with Homonymous hemianopsia

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Figure 3: Unilateral Neglect

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Double vision is present if the patient cannot move the eyeball in a particular direction due to paralysis of the extra ocular muscles. It commonly occurs in brain stem strokes. There is difficulty with spatial orientation such as judging distances (see Figure 4).
Figure 4: Vision perceived in diplopia

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Amaurosis fuga

There is brief episode of blindness in one eye, usually due to retinal ischemia caused by ophthalmic or carotid artery insufficiency.

Loss of peripheral vision

Decreased ability in seeing at night and patient is unaware of objects or borders of objects.

  Other Sensory Deficits Top


Occurs on the side opposite to the lesion. Patient experiences absent or diminished response to superficial sensations such as touch, pain, pressure, heat, cold. They also have absent or diminished response to proprioception (knowledge of position of body parts)

Perceptual deficits

Patient has disturbance in perceiving and interpreting self and/ or the environment.

Body scheme disturbance

The patient denies the paralysed extremities which manifests as unilateral neglect syndrome.

Disorientation to time, place and person

Disorientation is often accompanied with agitation, confusion, delirum. Typically, disorientation is first in time, then in place and finally in person


The patient has the inability to carry out previously learned action or learned sequential movements on command. There is loss of ability to use objects correctly. E.g., The patient may try to comb hair with a toothbrush or does not know how to use a comb (see [Figure 5] & [Figure 6]).
Figure 5: Patient combing hair with opposite side of the comb

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Figure 6: Patient with apraxia combing hair with tooth brush

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This is termed as the inability to identify and recognize an object by sight, touch or hearing (see [Figure 7]).
Figure 7: Visual agnosia

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Visiospatial disturbances

Patient experiences defects in localising objects in space, estimating their size, and judging distance.

Impaired memory

Inability in recalling spatial location of objects or places

Right to left disorientation

Right-left orientation includes discrimination and recognition as well as identification, the former two differentiating between symmetrical cues and the latter using the words right and left.

  Language Deficits Top

Broca’s or Non fluent aphasia (Motor/Expressive aphasia)

Patients experiences difficulty in transforming sound into patterns of understandable speech; they can speak using single word responses. E.g., Patient may say ‘book book two table’ meaning; there are two books on the table. This results from damage to frontal lobe of brain in the dominant hemisphere. These patients are often aware of their difficulties and can become easily frustrated.

Wernicke’s or Fluent aphasia (Sensory/Receptive aphasia)

Patient has impairment of comprehension of the spoken word; they are able to speak, but uses words incorrectly and is unaware of these errors. Patient may speak in long sentences that have no meaning, add unescessary words, or even create made up words. The damage occurs in the left temporal lobe although it can result from damage to right lobe.

Global aphasia

This is a combination of expressive and receptive aphasia, where the patient is unable to communicate at any level.


Patient is unable to understand the written word and have reading difficulties


Here the patient is unable to express ideas in writing.


Patient has difficulty with mathematic calculation

Intellectual deficits

They may experience memory loses, have decreased attention span, they have increased distractibility and poor judgment. They are unable to perform calculations, reason out and think abstractly.

  Emotional Deficits Top

Emotional lability

Patient exhibits reactions easily or inappropriately. Often patient tends to cry out loud especially when questioned or requested to perform a task. Over a period of time, patients become hostile, fearful, frustrated and angered easily and experience confusion and despair, withdrawal and feelings of isolation.

Loss of self-control and social inhibitions

Patient may speak inappropriately, swear, expose self, or make sexual advances towards the caregiver or nurse and often becomes depressed too.

Bladder control

Unilateral lesion from stroke results in partial sensation and control of the bladder patient experiences frequency, urgency and incontinence. If stroke lesion is in the brainstem, there will be bilateral damage, resulting loss of all control of micturition. The good is that the possibility of establishing normal bladder function is excellent.

Bowel control

Altered bowel function in a stroke patient is attributable to altered level of consciousness, dehydration and immobility. Constipation is the most common problem along with potential impaction.

  Diagnostic Procedures Top

Computed tomography scan (CT) without contrast

A CT scan should be done within one hour of onset of symptoms. It also helps to differentiate between ischemic and hemorrhagic stroke.

Computed tomography scan with contrast

Hypodense areas on CT can suggest infarction. This scan also helps to rule out lesions that may mimic a transient ischemic attack.

Magnetic Resonance Imaging (MRI)

It is useful for diagnosis of stroke in first 72 hours.

Magnetic Resonance Angiography (MRA)

It helps in non-invasive imaging of blood vessels. It is useful for clot visualisation and the disadvantage is the high cost and the lesser availability.

Carotid ultrasonography

It is an economic, safe, non-invasive, reproducible procedure to diagnose large artery thrombosis. This type of thrombosis is seen in patients with history of carotid artery stenosis and diabetes.

Transcranial Doppler (TCD)

This is a non-invasive procedure done at the bedside. It measures the blood flow velocity in the brain following thrombolysis. It is useful to detect severe intra cranial stenosis. It also helps in assessing patterns and extent of collateral circulation in patient with known arterial stenosis or emboli and detects micro emboli.

Cerebral angiography

It is useful in patients with carotid artery stenosis to define precisely the percentage of occlusion. An cerebral angiogram can be used to help treating some of the conditions involving the blood vessels of the neck and brain. Cerebral angiography can help diagnosing aneurysm, arteriosclerosis, arteriovenous malformation, vasculitis, blood clots and tears in the lining of an artery.

Transthoracic Echocardiography (TTE)

Commonly used in patients with ischemic stroke or TIA to rule out the potential sources of cardiogenic emboli.

Transesophageal Echocardiography (TEE)

TEE is proved superior to TTE for diagnosing cardiac embolic origin ofTIA or stroke.

Electrocardiogram (ECG)

Useful when cardiogenic embolic stroke or coronary artery disease and atrial fibrillation, a risk factor for stroke.

Ambulatory ECG monitoring

It is usually reserved for patients with suspicious palpitations, arrhythmias, hypertension or enlarged left atrium.

Prothrombotic States

It is a routine laboratory test in ischemic stroke and additional testing for factor V Leiden, prothrombin 20210A, antithrombin, protein C and protein S may be indicated for patients less than 50 years of age and those with paradoxical cerebral embolism.
Table 3: Comparison of Signs and Symptoms Associated with Right and Left Hemispheric Stroke

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FAST assessment in Stroke

The FAST is an acronym to identify stroke signs and to enable the victim to reach hospital on time.

  Medical Management Top

A person experiencing stroke typically loses 1.9 million neurons each minute that a stroke is not treated and the ischemic brain ages 3.6 years each hour without treatment. Thus it is essential to remove the clot that is obstructing the CBF, recannulate the vessel and reperfuse the brain as quickly as possible (Barker, 2008).

The FAST is an acronym to identify stroke signs and to enable the victim to reach hospital on time.

The modern management of patients with ischemic stroke begins by having a system in place that organizes the provision of preventive, acute treatment, and rehabilitative services. In the acute care setting, initial evaluation is aimed at rapidly establishing a diagnosis by excluding stroke mimics, distinguishing between ischemic and hemorrhagic strokes, and determining if the patient is a candidate for treatment with intravenous recombinant tissue plasminogen activator (IV-rtPA, alteplase, actilyse) (Goldstein 2016). Many patients, particularly women, have non-traditional symptoms such as general malaise, fatigue, and some cognitive changes that can make it difficult for a rapid diagnosis. Common stroke mimics include seizures, sepsis, space-occupying lesions, and toxic/metabolic conditions. Even in patients who have had a stroke, distinguishing between ischemic and hemorrhagic causes is critical.

According to Powers et al. (2018) guidelines for the early management of patients with Acute Ischemic Stroke (AIS), it has been recommended that Centres should attempt to achieve door-to-needle time of <60 minutes in >50% of stroke patients treated with IV rtPA. The modern medical management strategy for AIS focuses on limiting the extent of brain injury, avoiding stroke related complications, instituting appropriate secondary prevention and facilitating post stroke recovery. The ASA 2018 guideline for stroke management algorithm is given in [Figure 5].
Figure 8: The stroke management algorithm (Source : American Stroke Association, 2018)

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Acute stroke therapies try to stop a stroke while it is happening by quickly dissolving or removing the blood clot or by stopping the bleeding of a hemorrhagic stroke. Medications or drug therapy is the most common treatment for stroke. The most commonly used classes of drugs are thrombolytic (clot busters) and antithrombotic which are anticoagulants and antiplatelet agents.

Thrombolytics- Reperfusion therapy

Thrombolytics restore cerebral blood flow in some patients with AIS and may lead to improvement or resolution of neurologic deficits. Thrombolytic therapy is of proven and substantial benefit for selected patients with acute cerebral ischemia. Thrombolytic therapy involves administration of lytics to dissolve blood clots that have acutely blocked major arteries or veins.
Figure 9: Cerebral angiogram pre and post Thrombolysis (Rt MCA infarct)

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The US Food and Drug Administration (FDA) approved IV tPA for treating AIS within 3 hours of symptom onset in 1996. However, numerous studies have been conducted to evaluate the efficacy and safety of extending the time window beyond 3 hours, including the pivotal European Cooperative Acute Stroke Study III (ECASS-III), which directly led to regulatory approvals for an expanded treatment time window of <4.5 hours in Europe and many other countries (Cheng, & Kim, 2015). ). Intravenous rtPA is the mainstay of treatment for AIS, provided that treatment is initiated within 4.5 hours of clearly defined symptom onset since the benefit of reperfusion is time-dependent. Hence, it is critical to treat patients as quickly as possible (del Zoppo, Saver, Jauch, & Adams, 2009 ).

The National Institute of Health Stroke Scale is a standardised neurologic examination for patients with Acute

Ischemic Stroke (AIS). The scale quantifies the severity of a stroke in the acute setting and predicts clinical outcome and determine the neurological deficits. It also helps to consider a patient as a candidate to receive recombinant tissue Plasminogen Activator (rtPA) if they have a NIHSS scores > 4 and < 22 and a sustained neurologic deficit that does not improve. The patient is assessed using NIHSS on admission and the score serves as the baseline. Ongoing assessment is performed at 2 hours and 24 hours post thrombolysis. The reassessment is done at discharge and during the follow up at third month (Kasner, 2006).

Intravenous administration of rtPA

The recommended dosage of Inj. rtPA is 0.9mg per kg body weight. The total treatment should not exceed a total of 90mg. Reconstitution of the vial is done using the transfer device provided in the drug kit. The available 50 mg or 100 mg drug powder should be diluted in the given 50ml or 100ml sterile water respectively.

Side effects of Thrombolytic therapy

The risk of serious internal bleeding (intracranial bleeding occurs in less than 1% of patients) is a possibility. Other possible risks include

  • Bruising or bleeding at the access site
  • Damage to the blood vessel
  • Migration of the blood clot to another part of vascular system
  • Kidney damage in patients with diabetes or other preexisting kidney disease

Interventional Radiological Procedures for Ischemic Stroke

The only treatment for AIS was intravenous thrombolysis with recombinant tissue-type plasminogen activator (IV r-tPA) but recently newer techniques have been instituted to care for patients with acute ischemic stroke due to large vessel occlusion.

Mechanical Thrombectomy

Mechanical thrombectomy is considered a breakthrough in stroke treatment. Removing blood clots from the brain leads to better outcomes for stroke patients, including greater independence and mobility. When used in conjunction with rtPA and medical treatments, this method significantly reduces stroke-related disability and mortality. Research studies have proved that the clinical outcome of patients who underwent mechanical thrombectomy is good (Smith et al., 2005 ; Smith et al., 2008). The window period for mechanical thrombectomy may be extended from 6 to 16 hours or in some conditions even 24 hours from the onset of symptoms and is more efficient than systemic thrombolysis.

The use of first generation devices namely Mechanical Embolus Retrieval Cerebral Ischemia (MERCI) retriever system and penumbra aspiration device achieved high rates of recanalization whilst the second generation devices such as stent retrievers were created with the goal of achieving faster revascularization of occluded vessels and improved rates of favourable clinical outcomes.
Figure 10: MERCI device finding (A),engaging (B) and retrieving (C) the clot

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  Other Surgical Procedures Top

1. Cerebral revascularization

Also called bypass surgery, may be used if a stroke or mini-stroke was caused by “cerebrovascular insufficiency,” or a reduction in oxygen to the brain due to a blocked or narrowed carotid artery. Cerebral revascularization surgery provides new blood supply that can help prevent strokes and TIAs.

2. Carotid Endarterectomy

Also called carotid artery surgery, is a procedure in which blood vessel blockage (fatty plaque) is surgically removed from the carotid artery.

3. Angioplasty/Stents

Physicians sometimes use balloon angioplasty and implantable steel screens called stents to treat cerebrovascular disease and help open up the blocked blood vessel.

  Stroke Prevention Top

The good news is that 80 percent of all strokes are preventable. It starts with managing key risk factors, including high blood pressure, cigarette smoking, atrial fibrillation and physical inactivity. More than half of all strokes are caused by uncontrolled hypertension or high blood pressure, making it the most important risk factor to control. Medical treatments may be used to control high blood pressure and/or manage atrial fibrillation among high- risk patients.

Those medicines include: Anticoagulants

Anticoagulants (blood thinners) are a class of drugs commonly used to prevent the blood from forming dangerous clots that could result in a stroke.


Heparin is given via intravenous or sub-cutaneous access. Heparin is sometimes used to reduce acute stroke damage or stroke risk in hospitalized patients. Patients are monitored for Heparin Induced Thrombocytopenia (HIT).

Warfarin Sodium (Coumadin and others)

Warfarin is an oral anticoagulant drug. Use of warfarin requires careful monitoring, and regular medical check-up. Patients receiving Coumadin need to be very careful about their diet and activities to prevent problems while taking the medication. The levels of the drug in the body can be affected by the amount of Vitamin K in the diet. Foods high in Vitamin K include leafy green vegetables, green teas, as well as pork and beef liver. Patients should avoid large amounts of broccoli, cauliflower, cabbage, spinach, lettuce and turnip greens.

Antiplatelet therapy

The antiplatelet medicines Aspirin, Clopidogrel, and the combination of Aspirin plus extended-release Dipyridamole (Aggrenox) are all acceptable options for preventing recurrent ischemic stroke for patients other than those who have a stroke caused by embolism from the heart.


Antihypertensive medications treat high blood pressure. Depending on the type of medication, they lower blood pressure by opening the blood vessels, decreasing blood volume or decreasing the rate and/or force of heart contraction.

  Complications of Stroke Top

According to Ishida (2013) the rates of reported medical complications of stroke are high. In a prospective study that analyzed the placebo group of the Randomized Trial of Tirilazad Mesylate in Acute Stroke (RANTTAS) database (n = 279), at least one medical complication occurred in 95 percent of patients, and at least one serious medical complication (defined as prolonged, immediately life threatening, or resulting in hospitalization or death) occurred in 24 percent. The most common serious medical complications were pneumonia (5%), gastrointestinal bleeding (3%), congestive heart failure (3%), and cardiac arrest (2%).

Complications of Ischemic Stroke

  • Due to immobility - pressure sores and DVT
  • Due to dysphagia - choking, aspiration and undernutrition
  • Infection - urinary tract and/or respiratory tract
  • Due to weakness of limbs falls, accidents
  • Fatigue
  • Cognitive - memory
  • Communication - dysarthria, aphasia
  • Sensory impairments, visual problems, incoordination, imbalance,
  • Post stroke depression and social withdrawal

  Prognosis Top

According to Edwardson and Dromerick (2016), wide variety of factors influence stroke prognosis, including age, stroke severity, stroke mechanism, infarct location, comorbid conditions, clinical findings, and related complications. In addition, interventions such as thrombolysis, stroke unit care, and rehabilitation play a major role in the outcome of ischemic stroke.

The patient prognosis after an ischemic stroke is much more positive than after a hemorrhagic stroke. In addition to neuronal death, hemorrhagic stroke increases the risk of dangerous complications such as increased intracranial pressure or spasms in the brain vasculature.

Many people who survive a stroke recover their independence, although around one quarter are left living with minor disability and around 40% have more severe disabilities. Stroke outcome can be calculated using the National Institutes of Health Stroke Scale, which includes 11 factors ranging from facial movement through to consciousness level, to predict and assess how favourable the patient’s outlook is. If patients score less than 10, the outlook is generally favourable after one year, while a score of more than 20 suggests a less positive prognosis (Kasner, 2006).

  Nursing Management of Patients with Stroke Top

All patients with stroke should be treated by Specialists Stroke Teams within designated Stroke units. A collaborative multidisciplinary team approach facilitates an individualized treatment programme in order to identify and assess the needs of patients and their families throughout the illness trajectory. Nurses play an integral role in the management of stroke. A key attribute of stroke nursing is its holistic approach. Nurses are increasingly involved in identifying stroke and Transient Ischemic Attacks, undertaking acute assessments of eligibility for thrombolysis on admission to hospital and fast- tracking patients into an acute stroke unit. Other key elements in stroke nursing include physiological monitoring, pain management, facilitating rehabilitation through emotional support, motivation and education on care and prevention of a secondary stroke.

  Acute Care Management Top

Monitoring of acutely ill stroke patient is vital in order to reduce the risk of death and disability (Jones, Leathley, McAdam, & Watkins, 2007). Manifestations related to acute changes in cerebral perfusion should be closely monitored. Nurses need to monitor and assess vital signs as often as every 15 minutes and analyze the trends, and if the patient is deteriorating should report to physician. Manifestations of progressing deterioration include decreasing level of consciousness, changes in motor and sensory function, pupillary changes, respiratory difficulty and development of visual or perceptual deficits or aphasia.

  Nursing Interventions During Acute Phase of Stroke Top

  During Acute Phase of Stroke Top

Objective 1: To promote and maintain Cerebral Tissue Perfusion

During the acute phase continuous monitoring of vital parameters is essential. Perform periodic Glasgow Coma Scale (GCS) assessments and neurologic checks in order to monitor for stroke in evolution. A well-documented baseline neurologic status and frequent neurologic checks are critical in detecting worsening deficits. Maintain blood pressure within the range prescribed by the physician to ensure optimal cerebral perfusion without promoting cerebral odema. The patient needs to be evaluated for hypoxia, hypercarbia, or hypothermia as this may lead to elevated intracranial pressure (ICP). Maintain normothermia to reduce cerebral blood glucose and oxygen consumption.

The head of bed is elevated to 30 degrees in order to reduce cerebral odema. If the patient has a lower risk of increased ICP and is not at risk for aspiration, the head-down position has been shown to be beneficial (Wojner-Alexander, Garami, Chernyshev, & Alexandrov, 2005). Maintain head and neck in neutral position to improve venous drainage. It is advised to cluster nursing activities in order to reduce unnecessary movement and stimulation.

The nurse prepares to administer drugs to reduce ICP- Osmotic Diuretics (20% Mannitol), Hypertonic solutions (3% Normal Saline), and Loop diuretics (Frusemide). Administer medications to improve Cerebral Perfusion

Pressure (CPP), anticoagulants to reduce the risk of further thrombus, and Nimodipine, a calcium channel blocker to treat vasospasm secondary to subarachnoid hemorrhage. The patients are assessed for restlessness and if they are restless administer sedatives as ordered. Ensure that the restlessness is not related to treatable causes like hypoxia, full bladder, bowel impaction, or pain. Avoid restraints during acute illness period as this may cause agitation and increase ICP. Teach patients to avoid straining at stools, excessive coughing, vomiting, lifting, or use of arms to change position. These activities involve valsalva maneuver and increases ICP. Administer mild laxatives and stool softeners as prescribed.

Objective 2: To ensure intravenous access and optimal fluid management

Establish at least 2 to 3 intravenous sites if an acute stroke patient will receive thrombolytic therapy for administration of intravenous fluids, thrombolytic therapy, and intravenous medications. Do not cannulate the affected limbs since patient may have hemiparesis or paralysis. Draw blood for diagnostic laboratory studies before intravenous fluids are started. This will help to allow simultaneous processing of both laboratory and imaging data and facilitates rapid turnaround. Prepare to administer intravenous fluid boluses if the patient presents with hypotension. Administer normotonic solutions and ensure an infusion rate of 75 to 100mL/hr. Avoid solutions with 5% dextrose as it is detrimental in acute stroke.

Objective 3: Evaluate and manage bloodpressure

Ensure blood pressure is checked every 15 min for 2 hours, then every 30 min for 6 hours, and then every hour for 16 hours. Report physician if any blood pressure reading is above 185/110mmHg for patients who are eligible for thrombolysis.

Objective 4: Promote adequate oxygenation

Supplemental oxygen is administered to patients with an oxygen saturation of <95% and a decreased level of consciousness. Maintain saturation above 95% at all times by either making patient sit up or providing oxygen.

Objective 5: To maintain optimal blood glucose levels

The nurse prepares to administer rapid-acting Insulin for a blood glucose level >140 mg/dL (Adams, 2017). The nurse should monitor blood glucose level at the time of admission and continue to monitor glucose every 1 to 2 hours, because there is evidence that these patients are more prone to intracerebral haemorrhage. Carry out treatment orders for hyperglycemia depending on individual hospital insulin or oral hypoglycemic treatment protocols. In patients who have not received thrombolysis, glucose may be monitored every 6 hours in the first 24 to 48 hours and continued if the patient is known to have diabetes.

The nurse should monitor blood glucose level at the time of admission and continue to monitor glucose every 1 to 2 hours, because there is evidence that these patients are more prone to intracerebral haemorrhage. Carry out treatment orders for hyperglycemia depending on individual hospital Insulin or oral hypoglycemic treatment protocols. In patients who have not received thrombolysis, glucose may be monitored every 6 hours in the first 24 to 48 hours and continued if the patient is known to have diabetes.

Objective 6: To prevent hemorrhage

Ensure the following interventions are carried out in order to prevent systemic bleeding in the first 24 hours after primary thrombolysis a. Arterial punctures b. Insertions of nasogastric tubes c. Urinary catheterization d. Rectal temperature monitoring and rectal medications. If there be need, the above mentioned procedures are carried prior to thrombolysis. Continue to monitor all puncture sites and body fluids for manifestations of bleeding. Maintain bed rest for 24 hours after completion of infusion. Monitor aPTT, INR and ensure adjusted doses of anticoagulants are administered as prescribed.

Objective 7: To minimize risk and prevent aspiration

Assess for manifestations of aspiration like fever, dyspnea, crackles and rhonchi, confusion, and decreased PaO2 in Arterial Blood Gases. Ensure the patient remains nil by mouth during the acute phase -which means no ice chips, no oral medications, no water and only on normotonic intravenous infusions. Perform a swallow assessment using the Massey Bedside Swallowing Screening test. Also, assess swallowing by direct observation, looking for the presence of choking, coughing, a wet voice, a delay in initiating swallow, uncoordinated chewing or swallowing, extended time eating or drinking, pocketing of food, and loss of food from the mouth. When oral intake is authorized, encourage patient to concentrate while eating with minimal distractions.

For patients on tube feeds and tracheostomy

  • Perform subglottic suctioning
  • Ensure feeds are given after suctioning
  • Elevate head of the bed following feeds

  Ongoing Management Top

Objective 8: To ensure optimal Nutrition

Feeding patients with partial paralysis of the tongue, mouth, and throat requires patience and care for prevention of choking and aspiration. Patients may feel embarrassed and sometimes frustrated by eating difficulties. The following interventions may be helpful. Initiate tube-feeding if the patient is unable to swallow. Support and teach caregivers on basic feeding techniques. Assess gag reflex to determine if the patient is able to swallow. Make meal times pleasant and unhurried and serve food attractively and at an appropriate temperature. Place hand over the forehead during feeding for patients who have lack of head control. The head should be midline and slightly flexed. Position upright and as close as 90 degrees and hold head to avoid hyperextension which may lead to aspiration.

Stroke muscles under the chin without crossing the midline helps in mouth opening. Stimulate mouth closing by stroking the lips with finger or ice or by applying gentle pressure above upper lip. Feed slowly with small amounts of food that require no chewing and easy swallowing in the beginning and proceed as tolerated. Alternate liquids with solids to prevent food being left in the mouth and avoid unthickened foods. Place food in the unaffected side and after swallowing teach patients to check for food on the paralyzed side by turning the head to unaffected side and sweeping the mouth with tongue. Provide teaching on tube feeding if the patient is likely to be discharged on NG feeds. Continue to monitor weight and serum albumin levels.

Objective 9: To enhance bed and physical mobility

The nurse should assess for patients Range of Motion (ROM) in both affected and unaffected joints. Perform twice daily ROM after 24 hours unless otherwise contraindicated. If spasm is present in the affected limb, do not force extremities beyond the point where the patient experiences pain or continuous spasms. Always support the joint and move smoothly while performing passive ROM. Teach patient to use unaffected arm to lif t the weak arm and put it through ROM, exercising each finger separately.

Encourage patients to remain in upright positions only for short period of time as this may contribute to hip and knee deformities. Do not flex hip if patient is on one side. Avoid placing pillows below the unaffected knee (supine) as this may impede blood circulation. If knee tends to hyperextend, place a folded towel under the knee for short periods. Place patient in prone for 15 to 30 mins to avoid hip hyperextension. Place foot boards, apply ankle foot orthosis, and place the feet flat while sitting in order to avoid foot drop. Prevent abduction of the affected shoulder by placing a pillow in the axilla, keep the arms slightly flexed and in neutral position. Avoid squeezing rubber ball exercise to fingers as it promotes flexion when extension is desired in these patients.
Figure 11: Positioning for stroke

Click here to view

Objective 10: To facilitate verbal communication

When nurses interact or communicate with the patients, they need to speak slowly and clearly. Do not shout since the patient can hear. Use gestures (non-verbal cues) and one step commands. The nurse has to listen actively, watch carefully and give plenty of time when an aphasic patient tries to communicate to avoid frustration. In order to retain their focus or attention, limit distractions as much as possible.

Also, the nurse should stand within 6 feet and face directly while speaking, point to objects and name the object and ask patient to repeat, use nonverbal methods to reinforce her speech. Begin with simple words and progress to simple sentences. Use communication charts if the patient has expressive aphasia and always point to the picture to communicate. Constantly encourage communication at every encounter. Offer calm reassurance and demonstrate use of call lights or bells to call for help. Liaise with speech therapist in case of dysarthria or aphasia. Reinforce teachings of the speech language pathologists.

While working with stroke survivors who have communication or language deficits, the survivor should always be treated as an adult. Survivors after Broca’s or transcortical motor aphasia should be asked yes or no questions or provided with the opportunity to complete a sentence with a one or two word response. Melodic intonation therapy- presents the non fluent aphasic survivor with a hierarchy of sentences that are musically intoned.

Objective 11: To enhance coping in Unilateral Neglect

The nurse must ensure that all personal care items are kept on the unaffected side of the body. Food has to be served on the unaffected side. Position extremities in correct alignment. Gradually shift care to the affected side. Encourage patient to care for the affected side and to scan the environment in the affected side. Lightly touch and stimulate the affected side during care and encourage patient to do so. Use a full length mirror to help patient reintegrate an intact body image and to assist with posture and balance.

  Conclusion Top

Stroke is a complex health event yet preventable if risk factors among people are identified and enabled to maintain therapeutic goals. The diagnosis of stroke is an emotional and very discouraging event for both the individual having stroke and their family. A stroke victim may deteriorate from a state of complete independence to complete dependence in a matter of seconds to hours which means a person from apparently normal to being severely neurologically compromised. Nevertheless, the good is that stroke is treatable if identified earlier, diagnosed timely and treated promptly. Advances in intense treatment are lifesaving and improves patient outcome in present days. Post stroke therapy involves Medical, Surgical and Nursing management including rehabilitation. A team approach is vital to enhance the quality of living both social and financial.

Conflicts of Interest: The authors have declared no conflicts of interest.

  Continuing Education Series No: 34 Top

Stroke: The Old, the New and the Novel Diagnostic and Management Strategies

CE Test - 34 IJCNE


After reading the preceding article and taking this test, you should be able to :

  • Define stroke
  • List the risk factors for the development of stroke
  • Identify the signs and symptoms of stroke
  • Explain the diagnostic features of stroke
  • Discuss the medical management and complications of stroke
  • Brief the nursing management of patient with stroke

  1. The significant modifiable risk factor for stroke is

    1. Diabetes mellitus
    2. Hypercholesterolemia
    3. Hypertension
    4. Obesity

  2. Mr. K is recovering in the high dependency unit following an acute ischemic stroke. When Mr.K was given paper and pen to write, he used the pen to brush his teeth. This deficit is termed as

    1. Aphasia
    2. Agnosia
    3. Alexia
    4. Apraxia

  3. Patients living with a pre-existing cardiac condition like atrial fibrillation or Rheumatic Heart Disease are more prone to develop type of ischemic stroke.

    1. Thrombotic
    2. Hemorrhagic
    3. Embolic
    4. Cryptogenic

  4. The following are the clinical features of a patient with right hemispheric stroke EXCEPT

    1. Inability to recognize faces
    2. Visual spatial deficits
    3. Lack of awareness of neurologic deficits
    4. Deficits in right visual field

  5. The manifestations in ischemic stroke progress in the first hours as the infarction and cerebral edema increases

    1. 24
    2. 48
    3. 72
    4. 9

  6. The emergent radiological investigation performed to diagnose stroke is

    1. Computed Tomography
    2. Trans Cranial Doppler
    3. Magnetic Resonance Imaging
    4. Magnetic Resonance Angiography

  7. The recommended dosage of Intravenous rtPA is mg / kg body weight.

    1. 0.3
    2. 0.6
    3. 0.9
    4. 1.2

  8. As a nurse, you would use the following means to communicate to a patient with expressive (Wernicke’s) aphasia

    1. Gestures
    2. Speech
    3. Facial expressions
    4. Communication chart

  9. As a nurse you will encourage a patient with dysphagia to follow this technique in order to enhance swallowing

    1. Flex the neck
    2. Hyper extend the neck
    3. Turn toward unaffected side
    4. Turn towards affected side.

  10. The most commonest and serious medical complication of stroke is

    1. Gastrointestinal bleeding
    2. Congestive heart failure
    3. Aspiration pneumonia
    4. Cardiac arrest

  11. The calcium channel blocker used to treat vasospasm in a patient with sub-arachnoid hemorrhage is

    1. Amlodipine
    2. Nimodipine
    3. Nifedipine
    4. Diltiazem

  12. Thrombolysis with IV rtPA should be performed within hours from the onset of symptoms

    1. 4.5
    2. 5.5
    3. 6.5
    4. 7.5

  13. Carotid endarterectomy is considered as a surgical treatment modality for a patient with stroke. This surgery is performed to

    1. Restore blood flow in the carotid artery
    2. Anastomose extracranial & intracranial arteries
    3. Remove an atherosclerotic plaque in the carotid artery
    4. Widen the stenosis in the carotid artery

  14. The scale used for the assessment of severity of stroke is

    1. Global Disability Scale
    2. Modified Rankin Scale
    3. National Institute of Health Stroke Scale
    4. Canadian Neurological Scale

  15. The letter ‘S’ in acronym FAST denotes

    1. Sound
    2. Speech
    3. Smile
    4. Skill

  16. Patients on Tab. Warfarin (Coumadin) are discouraged to consume foods rich in the following vitamin

    1. A
    2. D
    3. E
    4. K

  17. Mr. J has been diagnosed with right hemispheric stroke and has unilateral neglect. Early in the care of the patient, the nurse should

    1. Approach the patient from left side to encourage head turning
    2. Place objects on the patient’s left side
    3. Place objects on the patient’s right side
    4. Initiate range of motion exercise on the affected side

  18. Irreversible brain damage occurs if the cerebral blood flow is reduced to

    1. 0 - 10 ml/ 100gm/ min
    2. 10 - 12 ml/ 100gm/min
    3. 12 - 30 ml/ 100gm/min
    4. 31 - 40 ml/ 100gm/ min

  19. The goal for therapeutic blood pressure in order to prevent the occurrence of stroke in a hypertensive patient with diabetes and chronic kidney disease is

    1. < 150/100 mmHg
    2. < 140/ 90 mmHg
    3. < 130/ 80 mmHg
    4. < 120/ 70 mmHg

  20. Physical restraints are avoided during the acute phase of stroke since it

    1. increases intracranial pressure
    2. increases the risk of bleeding
    3. reduces blood flow
    4. increases heart rate

CE Test No : 34


Select the best answer and shade the circle against the suitable alphabet in the answer form provided.


Evaluation : Listed below are statements about the CNE on ‘‘Stroke : The Old, the New and the Novel Diagnostic and Management Strategies” Please circle the number that best indicates your response.

Strongly Disagree Disagree Agree Strongly Agree

The stated objectives were met 1 2 3 4

The content was clearly presented 1 2 3 4

The content was related to the objectives 1 2 3 4

The test questions were clearly stated 1 2 3 4



Cut out orphotocopy this form, fill and mail before December 31, 2018 to The Editor-in-Chief, IJCNE, College of Nursing, CMC, Vellore - 632 004, along with a Demand Draft for Rs. 100/- (Rupees hundred only), drawn in favour of CMC, Vellore Association. A certificate will be awarded to all the participants and a merit certificate to those who secure marks 80% and above. Participants who secure 100% will be awarded one issue free subscription of IJCNE. Also, all those who score marks 80% and above will be awarded 2 credit hours (1 credit point).

  References Top

Adams, H. P., Del Zoppo, G., Alberts, M. J., Bhatt, D. L., Brass, L., Furlan, A., … & Lyden, P. D. (2007). Guidelines for the early management of adults with ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation, 115(20), e478-e534.  Back to cited text no. 1
Adams, R. J., Chimowitz, M. I., Alpert, J. S., Awad, I. A., Cerqueria, M. D., Fayad, P., & Taubert, K. A. (2003). Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: A scientific statement for healthcare professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association /American Stroke Association. Circulation, 108(10), 1278-1290.  Back to cited text no. 2
American stroke association. (2018). Strroke Management Algoirithm. Retrieved from http:// www. strokeassociation.org/STROKEORG/  Back to cited text no. 3
Barker, E. (2008). Neuroscience nursing: A spectrum of care . St. Louis, MO: Mosby.  Back to cited text no. 4
Cheng, N. T., & Kim, A. S. (2015). Intravenous thrombolysis for acute ischemic stroke within 3 hours versus between 3 and 4.5 hours of symptom onset. The Neurohospitalist, 5(3), 101-109.  Back to cited text no. 5
Centre for Disease Control [CDC]. (2018a). Chronic Disease Prevention and Health Promotion. Retrieved from https://www.cdc.gov/ chronicdisease/ resources/publications/aag/heart-disease-stroke.htm  Back to cited text no. 6
Centre for Disease Control [CDC]. (2018b). Stroke. Retrieved from https://www.cdc.gov/stroke/ signs_ symptoms.htm del Zoppo, G. J., Saver, J. L., Jauch, E. C., & Adams, H. P. (2009). Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke, 40(8), 2945-2948.  Back to cited text no. 7
Edwardson, M., & Dromerick, A. (2016). Ischemic stroke prognosis in adults. Retrieved from https:// www.uptodate.com/contents/ischemic-stroke- prognosis-in-adults  Back to cited text no. 8
Goldstein, L. B. (2016). IV tPA for acute ischemic stroke: Times are changing. Neurology, 87(21), 2178-2179. doi: 10.1212/WNL. 0000000000003366.  Back to cited text no. 9
Hickey, J. (2013). Clinical practice of neurological & neurosurgical nursing. Philadelphia: Lippincott Williams & Wilkins.  Back to cited text no. 10
Ishida, K. (2013). Medical complications of stroke. Retrieved from https://www.uptodate.com/ contents/medical- complications-of-stroke/print  Back to cited text no. 11
Jones, S. P., Leathley, M. J., McAdam, J. J., & Watkins, C. L. (2007). Physiological monitoring in acute stroke: A literature review. Journal of Advanced Nursing, 60(6), 577-594.  Back to cited text no. 12
Kasner, S. E. (2006). Clinical interpretation and use of stroke scales. The Lancet Neurology, 5(7), 603-612.  Back to cited text no. 13
Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume. St.Louis: Elsevier Health Sciences.  Back to cited text no. 14
Ministry of Health and Family Welfare. (2005). Burden of disease in India. Retrieved from http://www.who.int/ macrohealth/action/NCMH_Burden of disease_(29 Sep 2005).pdf  Back to cited text no. 15
National Stroke Association. (2018). Act FAST. Retrieved fromhttp://www.stroke.org/understand-stroke/ recognizing-stroke/act-fast  Back to cited text no. 16
Pandian, J. D., & Sudhan, P. (2013). Stroke epidemiology and stroke care services in India. Journal of stroke, 15(3), 128.  Back to cited text no. 17
Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., … & Jauch, E. C. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49(3), e46-e110.  Back to cited text no. 18
Smith, W. S., Sung, G., Saver, J., Budzik, R., Duckwiler, G., Liebeskind, D. S., … & Gobin, Y. P. (2008). Mechanical thrombectomy for acute ischemic stroke: Final results of the Multi MERCI trial. Stroke, 39(4), 1205-1212.  Back to cited text no. 19
Smith, W. S., Sung, G., Starkman, S., Saver, J. L., Kidwell, C. S., Gobin, Y. P., … & Silverman, I. E. (2005). Safety and efficacy of mechanical embolectomy in acute ischemic stroke: Results of the MERCI trial. Stroke, 36(7), 14321438.  Back to cited text no. 20
World Health Organization. (2005). Preventing chronic diseases: a vital investment: WHO global report. In Preventing chronic diseases: a vital investment: WHO global report?. Retrieved from https://books. google .co .in/books?hl=en&lr=&id=dF00DgAAQBAJ &oi=fnd&pg=PR3&dq=World+Health+Organization.+ (2005).+Preventing+chronic+diseases:+a+vital+invest ment:+WHO+global+report.  Back to cited text no. 21
World Health Organization [WHO]. (2018). Global burden of Stroke. Retrieved from http://www.who.int/ cardiovascular_diseases/en/cvd_atlas_15_burden_strok e.pdf?ua=1  Back to cited text no. 22
Wojner-Alexander, A. W., Garami, Z., Chernyshev, O. Y., & Alexandrov, A. V. (2005). Heads down flat positioning improves blood flow velocity in acute ischemic stroke. Neurology, 64(8), 1354-1357.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

  [Table 1], [Table 2], [Table 3]


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  In this article
Morbidity and Mo...
Risk Factors
Types and Charac...
Anatomy of Cereb...
Thresholds of Ce...
Clinical Manifes...
Motor Deficits
Sensory Deficits
Other Sensory De...
Language Deficits
Emotional Deficits
Diagnostic Proce...
Medical Management
Other Surgical P...
Stroke Prevention
Complications of...
Nursing Manageme...
Acute Care Manag...
Nursing Interven...
During Acute Pha...
Ongoing Management
Continuing Educa...
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