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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-.

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To begin setting up the Small Web Template with Analysis Web Item and 1 DP (IP_1IT_ ANALYSIS_1DP), select it in the list and then click OK at the bottom of the dialog box Figure 2-1 shows the list of all of the available templates for the BI Patterns with Pattern Wizard We will refer to this figure during the rest of the chapter