special value in patients with LV failure in whom mannitol would be risky

First 4 To 6 days of acute cerebral Infarction. No rebound Increase In Intracranial. pressure alrer discontinuation as may occur after mannitol.(c) Steroid Therapy - Dexamethasone 16-20 mg. IV or IM for first 5 days, lollowed by gradual withcfrawal over The next few days. Antaclcte should be given simultaneously. (d) Frusemide - 40-80 mg. dairy IV. Of special value in patients with LV failure in whom mannitol would be risky.. 2. Anticoagulatlon - Indications - Valvular heart disease particularly MS, recent myocardial infarction, atria] or ventricular thrombus, atrial fibrillation, acuta internal carotid artery or basilar artery thrombosis, internal carotid artery ejection, prolhrombotic stales (e.g. protein C or protein S deficiency), recurrent TlAs or stroke, cerebral venous thrombosis. It is best initiated gradually with warfarin Low dose subcutaneous hearin helpful in prevention. 3. Antiplatelel drugs- have been successfully used in male patients with TIAs. while the response in females has been poor They may be tried in prosthetic valve replacement or cardiac valvular disease, if anticoagulants cannot be prescribed Drug combination of Aspirin 12 mg/kg/day and Dipyridamcle 2 mg/kg/day or Tclopidne 25 mg b d with food D URGENT NEUROSURGERY - (a) In all cases of sub arachnoid or intracerebral hemorrhage (b) Evacuation of cerebellar hemaloma, supratentorial hematoma if causing mass effect (c) Supratentorial bleeds in younger patient with superficial cortical hematomas and deteriorating level of consciousness E PHYSIOTHERAPY AND REHABILITATION - During the acute phase. The aim should be prevenlion of deformities. The patient limbs should be maintained in optimal position Passive physiotherapy started alter 36 to 48 hours. Joints should oe moved through full range ol motion Muscle re-education and joint exercises initiated when the lirst signs of recovery are noted Massage fe given as acjuvant to active exercises. It is importani to introduce standng as an exercise soon since weight bearing stimulates the maintenance ol extensor lone in ihe lower limbs and on this the ability to walk depends. II Ihe patient can sland.. unsupported, he is ready for gait training. F. TREATMENT OF APHASiA -Language training, training of left hand in performance ol voluntary movement In right handed patients. Secondary prevention 1. GENERAL MEASURES - Stopping smoking, regular exercise. Control of hypertension, dabetes and treatment ol hyperllpidemia.. 2. ANTICOAGULANTS - Indications - have already been mentioned Aspirin has been shown to be of benelit in presenting stroke and vascular death in palients who have had a TtA Dose 75 mg/day. 3. PREVENTIVE NEUROSURGERY - for recurrent subaracrtnokl and Intracerebral bfeedng from aneurysm and arterlai malformations. 4. CAROTID ENDARTERECTOMY - Indications - la) Moderate degree of stenosis. (b) TIA, amauroste lugax, stroke or retinal infarct within 6 months and with good recovery. (c) Significant stenosis in patient schedufedfor major surgery such aa coronary bypass Contrain dieations - (a) Racant Ml fb) CCF. (cj Uncontrolled hypertension. (d) Age over 80 years. Venous Infarction Thrombosis of cortical veins and/or dural sinuses is less common than central arterial occlusion Causes - Dehydration, pyogenic middle ear or sinus infection, pregnancy and p uerperium, polycythemia, hyperviscosrty syndromes, septicemia.