Stroke Society of the Philippines

14/F 1403 Cathedral Heights Complex, St. Luke's Medical Center,

E. Rodriguez Sr. Ave., Quezon City
Telephone No: 722-5877/723-0103 loc. 5143
Email: ssp_secretariat@yahoo.com

Board of Trustees 2005-2006

President Abdias V. Aquino, M.D.

1st Vice-President Ester S. Bitanga, M.D.
2nd Vice-President Jose C. Navarro, M.D.
Secretary Artemio A. Roxas Jr., M.D.
Treasurer Betty D. Mancao, M.D.
P.R.O Carlos L. Chua, M.D.

Members Alejandro C. Baroque, M.D.

Fatima R. Collado, M.D.
Ma. Epifania V. Collantes, M.D.
Danilo J. Lagamayo, M.D.
Manuel M. Mariano, M.D.
Dante D. Morales, M.D.
Peter P. Rivera, M.D.
Isabelita C. Rogado, R.N.
Ma. Cristina Z. San Jose, M.D.

Immediate Past President Joven R. Cuanang, M.D.

Stroke: Think Globally, Act Locally

Principles:

1. Stroke is a "brain attack"

...needing emergency management, including specific treatments and secondary and
tertiary prevention.
2. Stroke is an emergency
...where virtually no allowances for worsening are tolerated
3. Stroke is treatable
...optimally, through proven, affordable, culturally-acceptable and ethical means
4. Stroke is preventable
...in implementable ways across all levels of society


 CPM 8TH EDITION acute stroke treatment

Algorithm for Acute Stroke Treatment

Definition of “Stroke”
- Sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathol-

1
4
Stroke Alert patients with any of the ff:
a. mild pure motor weakness of one
3 side of the body defined as can raise
arm above shoulder, clumsy hand, or
2 Transient Ischemic Attack can ambulate without assistance


(TIA):
TIA and Y - deficits resolved within b. pure sensory deficit
mild stroke?  24 hrs including transient  c. slurred speech but intelligible
blindness in one eye
(transient monocular d. vertigo with incoordination, like gait
blindness) disturbance, unsteadiness, or clumsy
hand
e. visual field defects alone
N f. combination of (a) and (b)


See
Awake patient with signifi­ Fig. 2
cant motor and/or sensory
5 and/or language and/or visual


deficit
Moderate Y or See
stroke?
  Fig. 3
Disoriented, drowsy, or stu­
po­rous patient but with pur­
pose­ful response to painful
N stimuli

7


Severe
stroke

8


Comatose patient with

non-purposeful response,
decor­ti­cate, or decerebrate
postu­ring to painful stimuli See
(Ap­pen­dix I)  Fig. 4
or
Comatose patient with no res­
ponse to painful stimuli

Figure 1

8th-Acute Stroke Treatment-Cla.i3 3 06/16/2014 3:28:59 PM

 acute stroke treatment cpm 8TH eDITION

Algorithm for Transient Ischemic Attack (TIA)

and Mild Stroke
2

Management Priorities
Ascertain clinical diagnosis of stroke or TIA - history and physical exam very
1 important
• Exclude common stroke mimickers (Appendix IIA and IIB). Monitor and man-
TIA & mild
 age blood pressure, treat if SBP ≥220 or DBP ≥120 or MAP >130 (appendix
stroke
IIIA).
Precautions:
• Avoid precipitous drop in BP >20% of baseline MAP
• Do not use rapid-acting sublingual agents; when needed use oral or easily
titratable IV anti-hypertensive medications (Appendix IIIB)
Ensure appropriate hydration. If IV fluid is needed, use 0.9 NaCl.

3 
Emergent Diagnostics
• Complete blood count (CBC)
• Blood sugar (CBG, HGT, or RBS)
• Electrocardiogram (ECG)
• PT/PTT (if EKG shows atrial fibrillation or possible cardioembolic
source)
• Plain CT scan of brain as soon as possible
• Computation of volume if hemorrhagic (Appendix VI)

4


Early Specific
Treatment
(Appendix IV)

5


CT scan
confirmed? Y See
(Appendix
 Fig. 2A
VIA)
N
6


CT scan not available

• No specific emergent drug
treatment recommended
• Neuroprotection (Appendix IVD)
• Consult a neurologist, or
neurosurgeon
• Early supportive rehabilitation

Figure 2

8th-Acute Stroke Treatment-Cla.i4 4 06/16/2014 3:28:59 PM

 CPM 8TH EDITION acute stroke treatment
3
• Aspirin 160-325 mg/day start as
Figure 2 early as possible and continue for
14 days (for secondary preven­tion,
1 2 see below under delayed manage-
 Non- ment)
Y Y
Ischemic?  cardioembolic  • Neuroprotection (Appendix IVD)
(Thrombotic, • Early rehabilitation once stable
N N within 72 hrs.
4 5



Hemorrhagic Y • Anticoagulation with IV heparin or
Cardioembolic
(Appendix V)?
 subcutaneous low molecular weight
heparin (LMWH), or
• Aspirin 160-325 mg/day (if heparin
7 N & PTT, or LMWH not available)
8


• Early neurology and/or  • Neuroprotection (Appendix IVD)

neurosurgeon consult for all ICH TIA
recommended • Early rehabilitation within 72 hrs.

• Monitor and Maintain BP: MAP * If infective endocarditis is sus­

>110 mmHg. Avoid precipitous pected, give antibiotics and do not
drop in BP 20% of baseline MAP anticoagulate. Antifibrinolytic
9 agents no available data


• Neuroprotection (Appendix IVD)

• Early rehabilitation once stable
within 72 hrs.
1. Anticonvulsant only if seizures
2. Steroids not recommended
3. Monitor and correct metabolic
parameters
4. Correct coagulation abnormali-
ties
5. Follow recommendations of
surgical intervention (Appen-
dix IVE)
• Aspirin 160-325 mg/day
• If crescendo TIA (multiple events within
hours, increasing severity and duration
of deficits), consider anticoagulation with
intravenous heparin.
Place of Treatment (Appendix VII)
Admit to Hospital (Stroke Unit)
1. Stroke onset within 48 hrs.
2. Patients requiring specific active interventions for any of the fol-
lowing:
a. BP control, monitoring, and stabilization
b. Cardiac stabilization, incl. atrial fibrillation, CHF, acute MI
c. Hydration
d. Anticoagulation, if bleed ruled out by CT scan
3. Rapidly worsening deficits
4. >4 TIA's in 2 weeks prior to consult
5. 1-4 TIA's in 2 weeks with high risk (multiple events within hours,
increasing severity and duration of deficits, cardiac arrhythmia,
carotid bruit)
Urgent Outpatient Work-up
1. Single TIA more than 2 weeks ago
2. 1-4 TIA's in 2 weeks but not high risk (no change in severity and
duration of deficit, cardiac arrhythmia, carotid bruit)
3. Transient monocular blindness alone
4. Stable mild strokes occuring >48 hrs not requiring specific active
intervention.
*Advise immediate re-consult if there is worsening of deficit

Figure 2A


8th-Acute Stroke Treatment-Cla.i5 5 06/16/2014 3:28:59 PM

 acute stroke treatment cpm 8TH eDITION
1
Delayed Management
& Treatment
(Secondary Prevention)
(Appendix VIII)
2 3

Y Y
Ischemic?
N If this reveals >70% ste­no­
5

Hemorrhagic
7

• Long-term blood pressure
monitoring and treatment
• Consider CT angiogram if
age <45 years, normoten­
sive, no clear cause of ICH
and candidate for surgery
8th-Acute Stroke Treatment-Cla.i6 6
4
• Control of risk factors
• Antiplatelets (aspirin,
tic­­lopidine, clopidogrel,
di­­py­ri­damole, cilosta­
 Thrombotic/
Lacunar?
 zol)
• Carotid ultrasound
N sis, refer to neurolo­gist
6 for decision-making re-

garding carotid endar­te­
rec­tomy
Cardio-
embolic
8

• Echocardiography and/or car­dio­
lo­gy consult
• If age <75 and PT/INR available,
anticoagulation with coumadin
(target INR 2-3)
• If age >75, aspirin 80-325 mg/
day or coumadin with target INR
2-2.5 (if PT/INR availa­ble)
Figure 2B
06/16/2014 3:28:59 PM
 CPM 8TH EDITION acute stroke treatment

Algorithm for Moderate Stroke

2
Management Priorities
Neuro-vital signs: BP, PR, CR, RR, Temp, Pupils, Glasgow Coma
Scale (Appendix X)
1
Basic emergent supportive care (ABC of resuscitation)
Monitor and manage blood pressure, treat if SBP ≥220 or DBP ≥120
Moderate or MAP >130 (Appendix IIIA).
stroke 
Precautions:
• Avoid precipitous drop in BP>20% of baseline MAP
• Do not use rapid-acting sublingual agents; when needed use oral
or easily titratable IV anti-hypertensive medication (Appendix
IIIB)
Ascertain clinical diagnosis of stroke-history and physical exam
very important
• Exclude common stroke mimickers (Appendix II)
Identify co-morbidities (cardiac disease, gastric ulcer, etc.)
Recognize and treat early signs and symptoms of increased ICP
(Appendix IX)

3


Emergent Diagnostics
• Complete blood count (CBC)
• Blood sugar (CBG, HGT, or RBS)
• PT/PTT
• Serum Na+ and K+
• Electrocardiogram (ECG)
• Plain CT scan of brain as soon as pos-
sible
• Computation of volume if hemorrhagic
(Appendix VI)

4


Early Specific 5
See
Treatment  Fig. 3A
(Appendix IV)

Figure 3

8th-Acute Stroke Treatment-Cla.i7 7 06/16/2014 3:28:59 PM

 acute stroke treatment cpm 8TH eDITION

1
CT scan
confirmed? Y
Figure 3   See Fig. 3B
(Appendix
VIA)

2


CT scan not available

• Use scoring system
(Appendix VIB) 4
• No specific emergent
drug treatment recom­
3 men­ded


• Neuroprotection (Ap­pen­
Likely Y dix IVD)
ischemic?  • Refer to specialist
• Early supportive rehabi­li­
ta­tion

6
5 • Refer to neurologist neu­


ro­surgeon for further

Likely
 diag­nostic work-ups and/
hemorrhagic
or subsequent sur­gery
• Neuroprotection (Ap­pen­
dix IVD)
• Early supportive reha­bi­­li­
tation

Figure 3A

8th-Acute Stroke Treatment-Cla.i8 8 06/16/2014 3:28:59 PM

 CPM 8TH EDITION acute stroke treatment

Figure 3A 3

1 2 • If within 3 hours of stroke


on­set, consider rtPA treat­ment
Non- and refer to specialist
Y cardioembolic Y
Ischemic?   • Aspirin 160-325 mg/day start
Thrombotic/ as early as possible
Lacunar?
• Neuroprotection (Appendix
N N IVD)
4 5



• Early supportive rehabilita­
Cardio-­ tion
Hemorrhagic em­bolic
(Appendix

6 7



• Medical/surgical • If within 3 hours of stroke onset, consider rtPA
treatment treatment and refer to specialist
(Appendix IVE) • Aspirin 160-325 mg/day start as early as pos-
sible
• If source of embolism can be demonstrated,
consider early anticoagulation
• Neuroprotection (Appendix IVD)
• Early supportive rehabilitation
* If infective endocarditis is suspected, give anti­
biotics and do not anticoagulate

Place of Treatment (Appendix VII): Hospital - Intensive Care Unit or Stroke Unit

Figure 3B

Delayed Management and Treatment (Secondary Prevention) (Appendix VIII)

2 3 4
1
• Control of risk factors
Y Thrombotic/ Y • Antiplatelets (aspirin, ticlopi­dine,
Mild stroke  Ischemic?  
Lacunar? clopidogrel, dipyridamole, cilosta-
zol)
N N • Carotid ultrasound
5 6



If this reveals >70% stenosis, refer

Cardio- to neurologist for decision-making
Hemorrhagic embolic regarding carotid endarterectomy.

7 8



• Long-term blood pressure • Echocardiography and/or cardiology consult

monitoring and treatment
• Consider CT angiogra-
phy, MRA, or angiography
in aneu­­rysm or AVM sus­
pects
• If age <75 and PT/INR available, anticoagulation
with coumadin (target INR 2-3)
• If age >75, aspirin 80-325 mg/ day or coumadin
with target INR 2-2.5 (if PT/INR available)

Figure 3C

8th-Acute Stroke Treatment-Cla.i9 9 06/16/2014 3:28:59 PM

 acute stroke treatment cpm 8TH eDITION

Algorithm for Severe Stroke

2

1 Management Priorities
Basic emergent supportive care (ABC of resuscitation)
Severe
stroke  Neuro-vital signs: BP, PR, CR, RR, Temp, Pupils, Glasgow Coma Scale (Appendix
X)
Recognize and treat early signs and symptoms of increased ICP (Appendix IX)
Monitor and manage blood pressure, treat if SBP ≥220 or DBP ≥120 or MAP>130
(Appendix IIIA).
Precautions:
• Avoid precipitous drop in BP >20% of baseline MAP
• Do not use rapid-acting sublingual agents; when needed use oral or easily titratable
IV anti-hypertensive medication (Appendix IIIB)
Ascertain clinical diagnosis of stroke-history and physical exam very important
• Exclude common stroke mimickers (Appendix II)
Identify co-morbidities (cardiac disease, gastric ulcer, etc.)

3


Emergent Diagnostics
• Complete blood count (CBC)
• Blood sugar (CBG, HGT, or RBS)
• PT/PTT
• Serum Na+ and K+
• Electrocardiogram (ECG)
• Plain CT scan of brain
• C omputation of volume if hemor-
rhagic (Appendix VI)

4


Early Specific
Treatment
(Appendix IV)


See Fig. 4A

Figure 4

10

8th-Acute Stroke Treatment-Cla.i10 10 06/16/2014 3:28:59 PM

 CPM 8TH EDITION acute stroke treatment

Figure 4


CT Scan Y See Figure
confirmed?  4B

N
2


CT Scan not available
• Use scoring system
(Appendix VIB)

3


• No specific emergent drug treat­

ment recommended.
• Neuroprotection (Appen­dix IVD)
• Refer to specialist Figure 4A

Place of Treatment (Appendix VII): Intensive Care Unit

Delayed Management and Treatment (Secondary Prevention) (Appendix VIII)

4
1 2 3
• Control of risk fac-
Severe Y Y
 Ischemic?  Thrombotic?  tors
stroke
• Antiplatelets (aspi­
rin, ticlopidine, clopi­
N N
dogrel, dipyridamole,
5 6 or cilostazol)


Hemorrhagic Cardioembolic

7


• Long term blood pressure • Echocardiography and/or

monitoring and treatment
• Consider CT angiography,
MRA, or angiography in
aneu­rysm or AVM suspects
cardiology consult
• If age <75 and PT/INR avai­
lable, anticoagulation with
cou­madin (target INR 2-3)
• If age >75, aspirin 80-325
mg/day or coumadin with
target INR 2-2.5 (if PT/INR
avai­lable)

* Discuss prognosis with relatives of the patient in most compassionate manner

Figure 4C

11

8th-Acute Stroke Treatment-Cla.i11 11 06/16/2014 3:28:59 PM

 acute stroke treatment cpm 8TH eDITION

Figure 4A

1


CT scan confirmed
(Appendix VIA)

4
3
2 • May give aspirin 160-325 mg/


Non-cardi- day
Y oembolic Y
Ischemic?   • Neuroprotection (Appendix
(Thrombotic)? IVD)
• If cerebellar infarct, consult neu­
rosurgeon as soon as possible
N
N

5 6 7



• May give aspirin 160-325 mg/

Hemorrhagic Cardioembolic
(Appendix V)
 day
• Neuroprotection (Appendix IVD)
• If cerebellar infarct, consult neuro­
surgeon as soon as possible

8


Supportive treatment:
1. Mannitol 20% 0.5 mg/kg BW q 6h for 2-5 days
2. Neuroprotection (Appendix IVD)
Neurosurgery consult if:
1. Patient not herniated, bleed located in putamen, subcortical area,
or cerebellum, and goal is reduction of mortality
2. Herniated patient but family is willing to accept consequences
of high mortality or irreversible coma and persistent vegetative
state
3. ICP monitoring contemplated and salvage surgery is considered

Figure 4B

12

8th-Acute Stroke Treatment-Cla.i12 12 06/16/2014 3:28:59 PM

 CPM 8TH EDITION acute stroke treatment

Guidelines for Acute Stroke Treatment

See Algorithms for Acute Stroke Treatment, Transient 17. Hypertensive encephalopathy
Ischemic Attack (TIA), and Mild Stroke, Moderate 18. Conversion disorder
Stroke and Severe Stroke.
Other conditions to consider:
Appendices for Acute Stroke Treatments
- Bell's palsy
Appendix I - Migraine
- Toxins
Abnormal motor posturing response to painful
stimuli (See Figure 5)
Reference:
A. Localizes pain 1. Libman RB, Wirkowski E, Alvir J, Rao H. Conditions that
mimic stroke in the emergency department. Arch Neurol
B. Decorticate posturing
1995;52: 1119-1122.
C. Decerebrate posturing

Reference: Appendix III

1. Plum F, Posner J. The Diagnosis of Stupor and Coma. 3rd
Ed. F.A. Davis Company, Philadelphia PA, c1982.
Appendix II
Differential Diagnosis of Stroke
A. The presence of any of the following should alert
the physician to consider conditions other than
stroke:
- Gradual progressive course and insidious onset
- Pure hemifacial weakness including forehead
- Trauma
- Fever prior to onset of symptoms
- Recurrent seizures
- Weakness with atrophy
- Recurrent headaches
Blood Pressure Management
A. If SBP is 185-220 mmHg or DBP is 105-120 mmHg,
emergency therapy for blood pressure con­trol should
be deferred unless there is left ven­tri­cular failure,
aortic dissection, or acute myo­cardial ischemia.
Patients who are potential can­didates for rtPA
therapy but who have per­sistent elevations in SBP
>185 mmHg or DBP >110 mmHg may be treated
with small doses of IV anti-hyper­tensive medication
to maintain the BP just below these limits.
B. Mean Arterial Pressure (MAP):
MAP = Systolic BP + 2 (Diastolic BP)
3
C. Locally available intravenous antihypertensives
used in acute stroke. (See Table 1 on pp__)

B. Conditions that mimic stroke in the emer-

References :
gency department (according to decreasing
1. The Brain Matters Stroke Initiative. Acute Stroke
fre­quency): Management Workshop Syllabus. Basic Principles of
1. Seizures Modern Management for Acute Stroke.
2. Marler, JR, Jones PW, Emr M (eds). Setting New
2. Systemic infection Dimensions for Stroke Care. Proceedings of a national
3. Brain tumor symposium on rapid identification and treatment of acute
4. Toxic-metabolic stroke. The National Institute of Neurological Disorders
5. Positional vertigo and Stroke, National Institutes of Health. Bethesda, MD.
6. Cardiac August 1997.
7. Syncope
8. Trauma Appendix IV
9. Subdural hematoma
10. Herpes encephalitis Acute Stroke Treatments
11. Transient global amnesia
A. Risk of treating patient with mild stroke with
12. Dementia
anti-thrombotics:
13. Demyelinating disease
14. Cervical spine fracture - 1% of TIAs are not due to ischemic stroke
15. Myasthenia gravis - 3 to 14% of mild strokes are hemorrhagic
16. Parkinsonism

13

8th-Acute Stroke Treatment-Cla.i13 13 06/16/2014 3:28:59 PM

 acute stroke treatment cpm 8TH eDITION

APPENDIX I
Abnormal motor posturing responses to painful stimuli
Figures. Response elicited by pressure to supraorbital ridge, sternum, or nailbed. A. Localizes pain. B. Decorticate
posturing. C. Decerebrate posturing

Reference
1. Plum F, Posner J. The Diagnosis of Stupor and Coma. 3rd ed. F.A. Davis Company, Philadelphia PA, c1982.

Table 1. Locally Available Intravenous Anti-Hypertensives Used in Acute Stroke

Drug Dose Onset Duration Adverse Effects Special Indications

of Action of Action

Nicardipine 5-15 mg/h IV 5-10 min 1-4 h Tachycardia, head- Most hypertensive
HCl ache, flushing, local emergencies except
phlebitis acute heart failure;
caution with
coronary ischemia

Hydralazine 10-20 mg IV 10-20 min 3-8 h Tachycardia, flush- Eclampsia

HCl ing, headache, vomi-
10-50 mg IM 20-30 min ting, increased angina

Nitroglycerine 5-100 µg/min 2-5 min 3-5 min Headache, vomiting, Coronary ischemia
as IV infusion methemoglobinemia,
tolerance with pro-
longed use

Esmolol 0.5-1 mg/kg 2-10 min 10-30 min Hypotension, brady- Supraventricular
bolus IV over cardia, peripheral tachycardia,
30 sec. or ischemia, agitation, hypertension
0.05/kg/min confusion, headache,
vomiting

14

8th-Acute Stroke Treatment-Cla.i14 14 06/16/2014 3:29:02 PM

 CPM 8TH EDITION acute stroke treatment
References: thrombin time >15 seconds (INR >1.7)
1. The Amaurosis Fugax Study Group. Current manage-­ment
of amaurosis fugax. Stroke 1990;21:201-208.
2. Anzalone N, Landi G. Non-ischaemic causes of lacunar
syndromes: prevalence and clinical findings. J Neurol
Neurosurg Psychiatry 1989;52:1188-1190.
3. Bamford J, Sandercock P, Jones L, Warlow C. The natural
history of lacunar infarction: The Oxfordshire Community
Stroke Project. Stroke 1987;18:545-551.
4. Bamford JM, Warlow CP. Evolution and testing of the
lacunar hypothesis. Stroke 1988;19:1074-1082.
5. Bogousslavsky J, Van Melle G, Regli F. The Lausanne
Stroke Registry: Analysis of 1,000 consecutive pa­tients
with first stroke. Stroke 1988;19:1083-1092.
6. Brown RD Jr, Evans BA, Wiebers DO, Petty GW, Meisner
I, Dale AJD. Transient ischemic attack and minor ischemic
stroke: An algorithm for evaluation and treatment. Mayo
Clin Proc 1994;69:1027-1039.
7. Chimowitz MI, Furlan AJ, Sila CA, Paranandi L, Beck
GJ. Etiology of motor or sensory stroke: A pros­pective
study of the predictive value of clinical and radiological
features. Ann Neurol 1991;30:519-525.
8. Mori E, Tabuchi M, Yamadori A. Lacunar syndrome due
to intracerebral hemorrhage. Stroke 1985;16:454-459.
B. Thrombolytic Therapy
- Thrombolytics is not recommended in mild
strokes.
- Streptokinase and urokinase are not currently
recommended in acute stroke.
- Recombinant tissue plasminogen activator (rtPA)
given within 3 hours of stroke onset may reduce
disability by a third at three months.
Guidelines:
1. Dose of rtPA is 0.9 mg/kg (maximum 90 mg)-
10% of total volume given as bolus, rest as
infusion over 60 minutes.
2. RtPA is recommended as treatment within 3
hours of onset of ischemic stroke. The benefit
of IV rtPA for acute ischemic stroke beyond 3
hours from onset of symptoms is not es­tablished.
Intravenous rtPA is not recom­mended when the
time of onset of stroke cannot be as­cer­tained
reliably, including strokes recog­nized upon
awakening.
3. Thrombolytic therapy is not recommended
unless the diagnosis is established by a physi­
cian with expertise in diagnosis of stroke, and
CT of the brain is assessed by physicians with
expertise in reading this imaging study. If CT
demonstrates early changes of a recent major in-
farction such as sulcal effacement, mass effect,
edema or possible hemorrhage, thrombolytic
therapy should be avoided.
4. Thrombolytic therapy cannot be recommended
for persons with any of the following (NINDS
Study):
a. current use of oral anticoagulants or a pro­
8th-Acute Stroke Treatment-Cla.i15 15
b. use of heparin in the previous 48 hours or a
prolonged partial thromboplastin time
c. a platelet count less than 100,000 mm3
d. another stroke or a serious head injury in the
previous 3 months
e. major surgery within the preceding 14 days
f. pretreatment systolic blood pressure grea­ter
than 185 mmHg or diastolic BP >110 mmHg
(rtPA) may be given if BP is con­trolled using
recommendation in Table 1
g. rapidly improving neurological signs
h. isolated, mild neurological deficits, such as
ataxia alone, sensory loss alone, dysarthria
alone, or minimal weakness
i. prior intracranial hemorrhage
j. blood glucose <50 mg/dL or >400 mg/dL
k. seizure at the onset of stroke
l. gastrointestinal or urinary bleeding within
the preceding 21 days
m. recent myocardial infarction
5. Thrombolytic therapy should not be given un­less
the emergent ancillary care and the facilities
to handle bleeding complications are readily
available.
6. Caution is advised before giving rtPA to persons
with:
a. Severe stroke (NIH Stroke Scale Score >22)
b. Age >77
c. Obtunded patients
d. Major infarct on CT
e. Acute pericarditis
f. Recent trauma
g. Infectious endocarditis
h. High probability of left heart thrombus
i. Significant hepatic disease
j. DM retinopathy or hemorrhagic ophthalmo­
pathy
k. Pregnancy
l. Bleeding hazards
7. Because the use of thrombolytic drugs car-
ries the real risk of major bleeding, whenever
pos­sible the risks of potential benefits of rtPA
should be discussed with the patient and his or
her family before treatment is initiated.
Reference:
1. NINDS rtPA Stroke Study Group Tissue plasminogen
activator for acute ischemic stroke. N Engl J Med
1995;333:1581-1587.
C. Antithrombotic therapy
1. International Stroke Trial (IST)
- Multicenter randomized clinical trial of 19,435
patients
- Regimen:
Aspirin 300-325 mg/day vs. no aspirin
Heparin subcutaneous vs. no heparin
15
06/16/2014 3:29:02 PM
 acute stroke treatment cpm 8TH eDITION
5,000 units bid or 12,500 units bid
- Started within 48 hours of stroke onset for 14
days or until discharge
- Results:
a. Aspirin
- fewer recurrent stroke within 14 days
- fewer deaths and dependency at 6 months
b. Heparin
- no benefit even at 6 months
- if used, should not exceed 5,000 units bid
2. Chinese Acute Stroke Trial (CAST)
- 21,106 patients randomized
- Aspirin 160 mg/day vs. placebo
- Started within 48 hours of stroke onset
- Results:
Risk of recurrent stroke or vascular
death:
Aspirin 5.3%
Placebo 5.9% (p=0.03)
3. 846 patients in the IST and 2,521 patients in the
CAST (total 3,367 patients) did not have a CT
scan done. Giving aspirin within 48 hours of stroke
onset among these patients without CT scan did not
significantly affect outcome at 4 weeks (recur­rent
stroke, CAST) and at 6 months (functional status,
IST)
References: especially in lobar hematomas.
1. Chinese Acute Stroke Trial Collaborative Group. CAST:
randomised placebo-controlled trial of early aspirin use
in 20,000 patients with acute ischaemic stroke. Lancet
1997;349:1641-1649.
2. International Stroke Trial Collaborative Group. The
International Stroke Trial: a randomised trial of aspirin,
subcutaneous heparin, both or neither among 19,435
patients with acute ischemic stroke. Lancet 1997;349:1569-
1581. i. Prevention and treatment of infections
4. A trial on the use of nadroparin started within 48
hours of stroke onset given at 0.4 mL subcutaneously
once or twice a day for 10 days showed improvement
in functional outcome at 6 months compared to
placebo.
Reference: a. There is definite evidence of increase in hemato­
1. Kay R, Wong KS, Yu YL, et al. Low-molecular-weight
heparin for the treatment of acute ischemic stroke. N Engl
J Med 1995;333:1588-1593.
D. Neuroprotection
1. Avoid hypotension, hypoxemia (aspiration pneu­
monia), hyperglycemia, hyponatremia, and fever
during acute stroke in an effort to “salvage” the
is­chemic penumbra.
2. Several neuroprotectants for acute ischemic stroke
have been investigated or are currently under in­
vestigation. Some results have been encouraging.
16
8th-Acute Stroke Treatment-Cla.i16 16
References:
1. Clark WM, Warachi SJ, Pettigrew LC, et al for the
Citicoline Stroke Study Group. A randomized dose-
response trial of citicoline in acute ischemic stroke
patients. Neurology 1997;29:671-678.
2. De Deyn PP, Reuck JD, Deberdt W, et al for the Piracetam
in Acute Stroke Study Group. Treatment of acute ischemic
stroke with piracetam. Stroke 1997;28:2347-2352.
3. Davalos A, et al. Oral Citicoline in Acute Ischemic Stroke:
An Individual Patient Data Pooling Analysis of Clinical
Trials. Stroke 2002;33:2850-2857
4. Mohr JP, Orgogozo JM, Harrison MJG, et al. Meta-
analysis of oral nimodipine trials in acute ischemic stroke.
Cerebrovasc Dis 1994;4:197-203.
E. Treatment of intracerebral hemorrhage (ICH)
1. Medical Treatment: Goal is to prevent complica­tions
and careful management of blood pressure
a. Maintain MAP <130, but not lower than 110
mmHg
i. Sustained hypertension may alter cerebral
au­toregulation, promote progression of bleed,
and increase edema
ii. Hypotension may result in cerebral hypoper­
fusion especially in the setting of increased
intracranial pressure (ICP)
b. Manage increased ICP accordingly (see Appen­
dix X)
c. Consider prophylactic use of anticon­vulsants
i. There is higher incidence of seizures in ICH
ii. Role of prophylactic anticonvulsants in
deep hemorrhages is unclear. It is justified
to with­hold anticonvulsants until clinically
indicated.
d. Prevention and treatment of respiratory com­
plications
e. Maintenance of adequate nutrition
f. Early rehabilitation once stable, bedsore precau­
tions, DVT prophylaxis (Ted hose stockings or
com­pres­sion boots)
2. Surgical treatment: Role depends on size, location,
and extent of hematoma
ma size (26-107%); about half of which is at-
tributable to impaired coagulation (patients with
liver disease, alcoholics, etc). Early hemato­ma
removal contributes to overall improvement or
morbidity and mortality.
b. There is good evidence of functional recovery
after surgery of hematoma size 10-30 mL with
reversible hemiplegia or severe hemiparesis.
c. There is available evidence to show that about
1/3 of patients with significant hematoma size
(30 mL) will deteriorate and may die (47%
morta­lity) from ischemia (perifocal) and not
06/16/2014 3:29:03 PM
 CPM 8TH EDITION acute stroke treatment
from clot enlargement.
d. There is acceptable evidence to show that mor­
ta­li­ty rate in patients with larger hematomas but
not herniated can be reduced with surgery.
References: 3. Activated partial thromboplastin time (PTT) or
1. Aver LM, et al. Endoscopic surgery versus medical
treat­ment for spontaneous intracerebral hematoma: a
randomized study. J Neurosurg 1989;70:530-535.
2. Barnett HJM, Mohr JP, Stein BM, Yatsu FM (eds). Stroke -
Pathophysiology, Diagnosis, and Management, 2nd edition.
Churchill Livingstone, New York, 1992.
3. Broderick JP, et al. Ultra-early evaluation of intrace-reb­ral
hemorrhage. J Neurosurg 1990;72:195-199.
4. Brott T, et al. Early hemorrhage growth in patients with
intracerebral hemorrhage. Stroke 1997;28:1-5
5. Caplan L. Intracerebral hemorrhage revisited. Neuro-logy
1988;38:624-7.
6. Fujii Y, et al. Hematoma enlargement in spontaneous
intracerebral hemorrhage. J Neurosurg 1994;80:51-57.
7. Juvela S, et al. The treatment of spontaneous intrace-
rebral hemorrhage: randomized clinical trial. J Neuro-surg
1989;70:755-788.
8. Kazui S, et al. Enlargement of spontaneous intracerebral
hemorrhage: incidence and time course. Stroke 1996;
27:1783-1787.
9. Mayer SA, Sacco RL, Shi T, Mohr JP. Neurologic de-
teriora­tion in noncomatose patients with supra-tentori­-al
intracerebral hemorrhage. Neurology 1994; 44: 1379-84.
10. Mendelon AD. Mechanisms of ischemic brain damage
with intracerebral hemorrhage. Stroke 1993;24 (Suppl
12):1115-1117.
11. Sacco RL, Wolf PA, Bharucha NE, et al. Subarachnoid and
intracerebral hemorrhage: Natural history, progno-sis, and
precursive factors in the Framingham Study. Neurology
1984;34:847-54.
12. Welch KMA, Caplan LR, Reis DJ. Siesjo BK, Weir B (eds).
Primer on Cerebrovascular Diseases. Academic Press. San
Diego, 1997.
Appendix V
Cardiogenic Sources of Embolism
1. Atrial fibrillation/flutter
2. Valvular heart disease (including rheumatic heart
disease)
3. Bacterial endocarditis
4. Cardiac thrombus
5. Cardiomyopathy
6. Recent myocardial infarction
7. Atrial myxoma
8. Right-to-left shunts
9. Pulmonary vein thrombosis
References:
1. Foulkes MA, Wolf PA, Price TR, Mohr JP, Hier DB.
The Stroke Data Bank: design, methods, and baseline
characteristics. Stroke 1988;19:547-54.
2. Mohr JP, Caplan LR, Melski JW, et al. The Harvard
Cooperative Stroke Registry: A prospective registry.
Neurology 1978;754-762.
8th-Acute Stroke Treatment-Cla.i17 17
A. Requirements for intravenous anticoagulation of
patients with cardiogenic source of embo­lism:
1. Heparin sodium in D5W
2. Infusion pump, if available
clotting time
B. Procedure
a. Start intravenous infusion at 800 units heparin/ hour
ideally using infusion pump.
b. Monitor infusion closely. If using soluset instead of
infusion pump, intensive monitoring is required.
c. Perform aPTT as often as necessary, every 6
hours if needed, to keep aPTT at 1.5 - 2.3 times
control. Risk for major hemorrhage, including
intracranial bleed, progressively increases as the
aPTT becomes prolonged above 80 seconds.
d. Intermittent intravenous heparin administration is
not recommended.
e. Infusion may be discontinued once oral anti­coa­­gu­
la­­tion with coumadin is adequate or once antiplate-
let medication is started for secondary pre­ven­tion.
See section on Secondary Prevention of Stroke
(Appendix VIII).
C. If using low-molecular-weight heparin
(LMWH), give nadroparin at 0.4 mL (4,100
units) subcutaneously once or twice a day for 10
days. There is no need for aPTT monitoring.
Appendix VI
Differentiating Ischemic from Hemorrhagic
Stroke
A. Gold standard is plain CT scan
- Hyperdense (bright) lesion = bleed or intra­
cerebral hemorrhage
- Normal = Acute infarction or TIA
- Hypodense (dark) = Infarction
B. Computation of Hematoma Volume (Kothari
Method)
Hematoma Volume (in mL) = A x B x C
2
where: A = Largest diameter of hematoma (in cm)
B = Diameter perpendicular to A (in cm)
C = Number of slices on CT scan X slice
thickness (in cm)
• Count slice as 1 if size of hematoma is >75% of
largest hematoma
• Count slice as 0.5 if size of hematoma is 25-75%
of largest hematoma
• Disregard slice if size of hematoma is <25% of
largest hematoma
17
06/16/2014 3:29:03 PM
 acute stroke treatment cpm 8TH eDITION
C. Scoring systems have been used in the absence Absent 0
of CT scan 3. Loss of Present 1
- Not recommended for use in mild stroke Consciousness Absent 0
- False negative rate for bleed most probably high II. Physical Examination
in mild strokes
1. Systolic BP >200 mmHg 5
Diaz Stroke Scale
sensitivity 100% 160-200 mmHg 1
specificity 86% <160 mmHg 0
accuracy 93% 2. Diastolic BP >90 mmHg 2
<90 mmHg 0
A. Vomiting +4
3. Level of Stuporous-coma 3
B. Level of Consciousness
consciousness Drowsy 1
Unarousable +4
Awake 0
Drowsy - arousable +2
Awake 0 4. Nuchal rigidity Present 2
Absent 0
C. Fever +3
5. Preferential gaze Present 1
D. Respiratory Pattern
Absent 0
Ataxic or apneustic (rapid irregular) +3
Hyperventilation (rapid regular) +2 TOTAL SCORE
Cheyne-Stokes (slow irregular) +1 Interpretation:
Normal or regular 0 Score
11-17 = definitely hemorrhagic
E. Upper GI Bleeding +3
8-10 = most probably hemorrhagic
F. Neurologic deficit maximal onset +2 0-7 = unlikely hemorrhagic
G. Headache +2
H. Nuchal rigidity +2 Siriraj Score
I. Diastolic Blood Pressure (mmHg) sensitivity 68%
specificity 64%
≤90 −2 accuracy 64%
91-99 0
≥100 +2 Consciousness (X 2.5) Alert 0
J. Systolic Blood Pressure (mmHg) Drowsy, stupor 1
≤150 −2 Semicoma, coma 2
151-169 −1
170-180 0 Vomiting (X 2) No 0
181-199 +1 Yes 1
≥200 +2 Headache within No 0
TOTAL SCORE 2 hours (X 2) Yes 1
Interpretation Diastolic blood DBP X 0.1
Score ≥7 = >90% probability of bleed
Atheroma markers None 0
Score <7 = probably infarct
(X 3): diabetes, One or more 1
angina, intermit-
Ilano Scoring System tent claudication
Constant -12

I. History
TOTAL SCORE
1. Vomiting Present 2 Interpretation:
Absent 0 Score ≤1 = infarct
>1 = hemorrhage
2. Headache Present 1
18

8th-Acute Stroke Treatment-Cla.i18 18 06/16/2014 3:29:03 PM

 CPM 8TH EDITION acute stroke treatment

Allen (Guy's Hospital) Score 2. Diaz A. A scoring system to differentiate cerebral

hemorrhage from infarction. Santo Tomas J Med
sensitivity 70-88%
1986;35:168-174.
specificity 64-78% 3. Ilano F, Yu C. A clinical score system to differentiate
accuracy 64-82% hemorrhagic from non-hemorrhagic strokes. MJDLSU
1993;9:47-53.
Apoplectic onset None 0 4. Poungvarin N, Viryavejakul A, Komontri C, Siriraj
Loss of consciousness 2 or more 21.9 stroke score and validation study to distinguish sup­ra-
Headache within ­tentorial intracerebral hemorrhage from infarction. BMJ
2 hours 1991;302:1565-1567.
Vomiting 5. Sandercock PAG, Allen CMC, Corston RN, Harrison MJG,
Warlow CP. Clinical diagnosis of intracranial hemor­rhage
Neck stiffness
using Guy's Hospital score. BMJ 1985; 291:1675-1677.
Level of consciousness Alert 0 6. Weir CJ, Murray GD, Adams FG, Muir KW, Grosset DG,
24 hours after admission Drowsy 7.3 Lees KR. Poor accuracy of stroke scoring system for
Unconscious differential clinical diagnosis of intracranial hemor-rhage
and infarction. Lancet 1994;334:999-1002.
Plantar response Both flexor 14.6
or single
extensor 0 Appendix VII
Both extensor 7.1
Place of Treatment
Diastolic blood DBP X
A. Mayo algorithm for management of TIA's and
24 hours after 0.17
admission minor stroke.

Atheroma markers: None 0 Reference:

diabetes, angina, One or more -3.7 1. Brown RD Jr, Evans BA, Wiebers DO, Petty GW, Meissner
intermittent claudication I, Dale AJD. Transient ischemic attack and minor ischemic
stroke: An algorithm for evaluation and treatment. Mayo
Hypertension Present -4.1 Clin Proc 1994;69:1027-1039.
None 0
Previous event: TIA Any no. of -6.7 B. Admission to an organized Stroke Unit or man-
previous agement by a Stroke Team has been shown to:
event - improve functional outcome
Heart disease None 0 - reduce mortality and morbidity by 21-28%
Aortic or -4.3 - hasten recovery after a stroke
mitral
murmur - shorten hospital stay
Cardiac -4.3
References:
failure
1. Indredavik B, Slordahl SA, Bakke F, Rokseth R, Haheim
Cardiomyo- -4.3
LL. Stroke unit treatment. Stroke 1997;28:1861-1866.
pathy 2. Langhorne P, Williams BO, Gilchrist W. Do stroke units
Atrial -4.3 save lives? Lancet 1993;342:395-398.
fibrillation 3. Ronning OM, Guldvog B. Stroke unit versus general
MI within 4.3 medical wards, II: Neurological deficits and activities of
6 months daily living. Stroke 1998;29:586-590.
4. Stroke Unit Trialists' Collaboration. How do stroke units
Constant -12 improve patient outcome? Stroke 1997;28:2139-2144.
TOTAL SCORE

Interpretation: C. Requirements for a Stroke Team
Score <4 = infarct
1. WHY (Objectives)
4-24 = uncertain
>24 = hemorrhage To reduce mortality and morbidity of stroke through
efficient delivery of effective therapy for acute stroke
after urgent transport and evaluation.
References:
1. Allen CMC. Clinical diagnosis of the acute stroke 2. WHAT (Components)
syndrome. Quarterly J Med, New Series LII 1983;
208:515-523. a. Facilities:
19

8th-Acute Stroke Treatment-Cla.i19 19 06/16/2014 3:29:03 PM

 acute stroke treatment cpm 8TH eDITION
- Nursing: Vital signs, suction, IV hydration,
intubation, ventilation, cardiac monitor
- Diagnostics: CT scan, EKG, laboratory for
hematology, chemistry, coagulation
- Therapy: Pharmacy, stroke treatment area/unit
b. Guidelines:
- Guidelines on Acute Brain Attack as published
by the Stroke Society of the Philippines and
Department of Health Non-communicable Di­
sease Service
c. Communication system:
- Early warning system by direct communica­tion
link
3. WHO (Personnel)
a. Neurologists/neurosurgeon or stroke physi­
cians
b. Stroke nurses
c. Radiologist or physician experienced in reading
CT scans in acute stroke
References: References:
1. Grotta J. How to organize a stroke team. American
Academy of Neurology Syllabus on Disk 1998.
2. Rudd A, Wolfe CDA. Developing a district stroke service.
Cerebrovasc Dis 1996;6:89-96.
Appendix VIII
Secondary Prevention for Stroke
I. Ischemic
A. Antithrombotics
1. Aspirin
• Antiplatelet Trialists Collaboration:
- 145 trials with almost 100,000 patients
- 23% risk reduction for stroke, myocardial
infarc­tion (MI), and vascular death
2. Ticlopidine events (CAPRIE). Lancet 1996; 348:1329-1339.
• Canadian American Ticlopidine Study
(CATS)
- 23% risk reduction vs. placebo for stroke, MI,
or vascular death
• Ticlopidine Aspirin Stroke Study (TASS)
- 12% risk reduction vs. aspirin for stroke or
death at 3 years
3. Clopidogrel
• Clopidogrel vs. Aspirin in Patients at Risk of
Ischemic Events (CAPRIE)
- 19,185 patients with prior stroke, MI, or PVD
- Clopidogrel 75 mg/day vs. aspirin 325 mg/
day
- 8.7% relative risk reduction in stroke, MI, and
vascular death over aspirin
4. Cilostazol
20
8th-Acute Stroke Treatment-Cla.i20 20
• Cilostazol Stroke Prevention Study (CSPS)
- 1,095 patients with cerebral infarction at
1-6 months
- Cilostazol 100 mg bid vs. placebo
- Relative risk reduction of 41.7%
5. Dipyridamole-Aspirin Combination
• European Stroke Prevention Study 2 6,602
patients randomized to:
- Aspirin 25 mg bid
- Extended release Dipyridamole 200 mg bid
- Aspirin 25 mg bid + extended release dipyri­
damole 200 mg bid
- Placebo
Results:
- Aspirin better than placebo
- Dipyridamole better than placebo
- Combination aspirin and dipyridamole better
than either one alone
1. Antiplatelet Trialists' Collaboration. Collaborative
overview of randomized trials of antiplatelet therapy, I:
prevention of death, myocardial infarction, and stroke
by prolonged antiplatelet therapy in various categories of
patients. BMJ 1994;308:81-106.
2. Diener HC, Cunha L, Forbes C, Sivenius J, Smets P,
Lowenthal A. European Stroke Prevention Study 2.
Dipyridamole and acetylsalicylic acid in the secondary
prevention of stroke. J Neurol Sci 1996;143:1-13.
3. Gent M, Blakely JA, Easton JD, et al. The Canadian
American Ticlopidine Study (CATS) in thromboembolic
stroke. Lancet 1989;1:1215-1220.
4. Hass WK, Easton JD, Adams HP, et al. A randomized trial
comparing ticlopidine hydrochloride with aspirin for the
prevention of stroke in high-risk patients. N Engl J Med
1989;321:501-507.
5. CAPRIE Steering Committee. A randomized, blinded trial
of clopidogrel versus aspirin in patients at risk of ischemic
6. Gotoh F, Tohgi H, Hirai S, et al. Secondary prevention of
cerebral infarction with cilostazol - a multicenter, double-
blinded, placebo controlled, long term, ran­domized study
(Cilostazol Stroke Prevention Study, CSPS) (abstract).
Presented at the International Stroke Society Regional
Meeting, Yokohama, Japan, April 22-24, 1999.
B. Carotid endarterectomy
The North American Symptomatic Carotid Endarte­
rectomy Trial (NASCET), European Carotid Surgery
Trial (ECST), and the Veterans Adminis­tration Symp-
tomatic Carotid Surgery Trial all showed benefit in
reducing risk of recurrent stroke in patient with severe
internal carotid artery stenosis (≥70%) who had a TIA
or minor stroke.
References:
1. European Carotid Surgery Trialists' Collaborative Group.
06/16/2014 3:29:03 PM
 CPM 8TH EDITION acute stroke treatment
MRC European Carotid Surgery Trial: Interim results for
symptomatic patients with severe (70-99%) or with mild
(0-29%) carotid stenosis. Lancet 1991;337:1235-1243.
2. Mayberg MR, Wilson SE, Yatsu F, et al. Carotid
endarterectomy and prevention of cerebral ischemia in
symptomatic carotid stenosis. JAMA 1991;266-3289-
3294.
3. North American Symptomatic Carotid Endarterectomy Trial
Collaborators. Beneficial effect of carotid endarterectomy
in symptomatic patients with high-grade carotid stenosis.
N Engl J Med 1991;325:445-453.
C. Anticoagulant
The benefit of oral anticoagulation with coumadin
(target INR=2.0-3.0) has been shown in patients with
non-valvular atrial fibrillation who are at high risk
(hypertension, poor left ventricular function, previous
TIA, stroke, or thrombo­embolic events).
References: Philadelphia PA: 1995.
1. Ezekowitz MD, Levine JA. Preventing stroke in patients
with atrial fibrillation. JAMA 1999;281:1830-1835.
2. Quality Standards Subcommittee of the American
Academy of Neurology. Practice Parameter: Stroke pre­
vention in patients with non-valvular atrial fibril­-lation.
Neurology 1998;51:671-673.
D. Statins
Appendix IX
Increased Intracranial Pressure (ICP)
A. Signs and symptoms of increased ICP:
• Deteriorating sensorium
• Cushing's triad
1.Hypertension
2.Bradycardia
3.Bradypnea (late)
• Anisocoria
B. Management options for increased ICP:
1. Manage headache and other pains.
2. Manage combative behavior and agitation
- search for source of pain, e.g. bladder disten-
tion
- appropriate sedation if necessary
3. Elevate head to approximately 30 o from hori­
zontal
4. Hyperventilate to pCO2 of low 30's (maximum of 6
hours)
5. Osmotic agents: goal is serum osmolality of 310-
320
Mannitol 0.25 - 2.0 g/kg bolus; may give 0.25 -
0.5g/kg every 3 - 5 hours
- expect response in 20 minutes
- effect may last for 6 hours
- difference of <10 between measured and com­
puted osmolality means additional doses are
8th-Acute Stroke Treatment-Cla.i21 21
needed
computed = 2 (Na+) + glucose + BUN
osmolality 18 2.8
6. Other options (use with caution):
- Furosemide + albumin
- Hypertonic saline 3% (50 mL in 5 min)
- Pentobarbital 10-20 mg/kg loading dose then 1-3
mg/kg/hr
C. Precautions
- avoid straining
- laxative
- gentle suctioning
- appropriate intubation by exprienced person
References:
1. Wijdick EFM. Neurology of Critical Illness. F.A. Davies,
2. Davis SM (ed). Interventional Therapy in Acute Stroke.
Blackwell Science, Inc. Carlton, Victoria: 1998.
Appendix X
Glasgow Coma Scale
Category Score
Eye opening
Spontaneous 4
To speech 3
To pain 2
None 1
Best motor response
Obeys 6
Localizes 5
Withdraws 4
Abnormal flexion 3
Abnormal extension 2
None 1
Best verbal response
Oriented conversation 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Circle one score in each category; add the three scores
to obtain total score. Lowest possible GCS score is 3.
Highest score is 15.
Reference:
1. The Brain Matters Stroke Initiative. Acute Stroke
Management Workshop Syllabus. Basic Principles of
Modern Management for Acute Stroke.
21
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 CPM 8TH EDITION acute stroke treatment

Drugs Mentioned in the Treatment Guideline

This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing Information of these
drugs can be found in PPD reference systems.

Albumin Cilazapril/Hydrochlorothiazide Irbesartan/Hydrochlorothiazide

Albuman Berna Vascace plus CoAprovel
Albuminar Delapril Losartan
Buminate Cupressin Bepsar
Anticoagulants/Antiplatelets Enalapril maleate Cozaar
Thrombolytics Hypace Lifezar
Aspirin Naprilate Losartan/Hydrochlorothiazide
Asaped Renitec Combizar
Aspilets Vasopress Hyzaar/Hyazaar DS
Bayer Aspirin Enalapril/Hydrochlorothiazide Olmesartan
Cor-30 Co-Renitec Olmetec
Drugmaker's Biotech Aspirin Fosinopril sodium Telmisartan
BPNorm Micardis
Cilostazol
Imidapril Pritor
Ciletin
Norten Telmisartan/Hydrochlorothiazide
Pletaal
Vascor Micardis plus
Clopidogrel
Imidapril HCl/ Pritor plus
Plavix
Hydrochlorothiazide Valsartan
Dipyridamole
Norplus Diovan
Drugmaker's Biotech
Vascoride Valsartan/Hydrochlorothiazide
Dipyridamole Lisinopril dihydrate Co-Diovan
Persantin Sinolip
Dipyridamole/aspirin β-blockers
Zestril Atenolol
Aggrenox Lisinopril/Hydrochlorothiazides
Enoxaparin Atestad
Zestoretic Cardioten
Clexane Moexipril HCl
Heparin Drugmaker's Biotech Atenolol
Univasc Durabeta
Biomedis Heparin Perindopril
Heparin Leo Ritemed Atenolol
Coversyl Tenormin
Nadroparin Perindopril/Indapamide
Fraxiparine Tenostat
Bipreterax Therabloc
Fraxiparine Forte Preterax Atenolol/Chlorthalidone
Recombinant human tissue-type Quinapril Tenoretic
plasminogen activator Accupril Betaxolol HCl
Actilyse Quinapril/Hydrochlorothiazide Kerlone
Sulodexide Accuzide Bisoprolol
Vessel Due-F Ramipril Concore
Ticlopidine Tritace Bisoprolol hemifumarate/
Clotidone Verapamil HCl/Trandolapril Hydrochlorthiazide
Ticlid Tarka Ziac
Warfarin Alpha Blockers Carteolol HCl
Coumadin Terazosin HCl Mikelan
Antihypertensives Conmy Carvedilol
Ace Inhibitors Hytrin Dilatrend
Benazepril Angiotensin II antagonists Esmolol
Cibacen Candesartan Brevibloc
Captopril Blopress Metoprolol
Capoten Candesartan cilexetil/ Betaloc
Captace Hydrochlorothiazide Betazok
Drugmaker's Biotech Captopril Blopress plus Cardiosel
Novopharm Captopril Eprosartan Cardiostat
Primace Teveten Cardiotab
Tensoril Eprosartan/Hydrochlorothiazide Drugmaker's Biotech
Vasostad Teveten plus Metoprolol
Cilazapril Irbesartan Metostad
Vascace Aprovel Neobloc
23

8th-Acute Stroke Treatment-Cla.i23 23 06/16/2014 3:29:03 PM

 acute stroke treatment cpm 8TH eDITION

Pharex Metoprolol Heblopin Ismo 20

Prolohex Nelapine Isomonit
Ritemed Metoprolol Nifestad Schwarz Isosorbide mononitrate
Metoprolol/ Hydrochlorothiazide Normadil Isosorbide dinitrate
Betazide Nimodipine Isoket/Isoket IV/Isoket spray
Pindolol Nimotop Isordil
Visken Verapamil Mannitol
Pindolol/Clopamide Isoptin/Isoptin SR Osmofundin 20%
Viskaldix Verelan Potassium-Sparing Diuretics
Propranolol Verapamil/Trandolapril Spirinolactone
Bedranol Tarka Aldactone
Drugmaker's Biotech Spirinolactone/Butizide
Propranolol Centrally-Acting drugs
Aldazide
Duranol Clonidine
Thiazides (Benzothiadiazines)
Inderal Catapres
Candesartan/Hydrochlorothiazide
Phanerol Drugmaker's Biotech Clonidine Blopress plus
Ritemed Propranolol Melzin Cilazapril/Hydrochlorothiazide
Methyldopa Vascace plus
Calcium Antagonists
Aldomet Enalapril/Hydrochlorothiazide
Amlodipine besylate
Moxonidine Co-Renitec
Norvasc
Physiotens Eprosartan/Hydrochlorothiazide
Amlodipine/Atorvastatin
Envacar Rilmenidine Teveten plus
Barnidipine Hyperdix Imidapril/Hydrochlorothiazide
Hypoca CNS Stimulants/Neurotonics Norplus
Benidipine Citicoline Vascoride
Coniel Nicholin Indapamide hemihydrate
Diltiazem Somazine Natrilix
Angiozem Piracetam Irbesartan/Hydrochlorothiazide
Cordazem Irahex CoAprovel
Dilatam Nootropil Lisinopril/Hydrochlorothiazide
Diltac Pyritinol HCl Zestoretic
Diltelan Encephabol/Encephabol forte Losartan/Hydrochlorothiazide
Dilzem/Dilzem SA/Dilzem SR Sulbutiamine Combizar
Drugmaker's Biotech Diltiazem Arcalion Hyzaar/Hyzaar DS
Mono-Tildiem Metoprolol/Hydrochlorothiazide
Diuretics
Ritemed Diltiazem Betazide
Carbonic Anhydrase Inhibitors
Tildiem Perindopril/Indapamide
Zandil Acetazolamide
Bipreterax
Felodipine Diamox Preterax
Dilahex Brinzolamide Quinapril/Hydrochlorothiazide
Felop ER Tab Azopt Accuzide
Plendil ER Dorzolamide Telmisartan/Hydrochlorothiazide
Versant XR Trusopt Micardis plus
Felodipine/Metoprolol Loop Diuretics Pritor plus
Logimax Furosemide Valsartan/Hydrochlorothiazide
Lacidipine Am-Europharma Furosemide Co-Diovan
Lacipil Drugmaker's Biotech
Nitroglycerin
Lercanidipine Furosemide
Deponit NT 5/Deponit NT 10
Zanidip Edemann
Minitran TDP
Manidipine Flexamide
Nitrostat
Caldine Frusema
Perlinganit
Minadil Furoscan injection
Transderm-Nitro
Nicardipine Lasix
Cardepine Pharmix Parenteral Electrolytes
Nifedipine Piplen 0.9 NaCl
Adalat Bumetanide B. Braun NaCl 0.9% Soln for Inj
Calcheck Burinex B. Braun NaCl 0.9% Soln
Calcibloc/Calcibloc OD Osmotic Diuretics Hizon 0.9% Sodium Chloride
Calcigard-5 Isosorbide-5-mononitrate LVP S9
Denkifed Angistad/Angistad SR Vasodilators
Drugmaker's Biotech Elantan/Elantan Long Hydralazine HCl
Nifedipine Imdur Durules Apresoline
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8th-Acute Stroke Treatment-Cla.i24 24 06/16/2014 3:29:03 PM