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Physical therapy has an important role in the management of patients with impaired motor function Passive movements at an early stage will help prevent contractures As cooperation increases and some recovery begins, active movements will improve strength and coordination In all cases, early mobilization and active rehabilitation are important Occupational therapy may improve morale and motor skills, while speech therapy may be beneficial in patients with expressive dysphasia or dysarthria When there is a severe and persisting motor deficit, a device such as a leg brace, toe spring, frame, or cane may help the patient move about, and the provision of other aids to daily living may improve the quality of life

The prognosis for survival after cerebral infarction is better than after cerebral or subarachnoid hemorrhage The only proved effective therapy for acute stroke requires initiation within 3 hours after stroke onset, and the prognosis therefore depends on the time that elapses before arrival at the hospital Patients receiving such treatment with tissue plasminogen activator are at least 30% more likely to have minimal or no disability at 3 months than those not treated by this means Loss of consciousness after a cerebral infarct implies a poorer prognosis than otherwise The extent of the infarct governs the potential for rehabilitation Patients who have had a cerebral infarct are at risk for additional strokes and for myocardial infarcts Statin therapy to lower serum lipid levels may reduce this risk Antiplatelet therapy reduces the recurrence rate by 30% among patients without a cardiac cause for the stroke who are not candidates for carotid endarterectomy Nevertheless, the cumulative risk of recurrence of noncardioembolic stroke is still 3 7% annually A 2-year comparison did not show benefit of warfarin (INR 14 28) over aspirin (325 mg daily), and higher doses of warfarin should be avoided as they lead to an increased incidence of major bleeding Patients with massive strokes from which meaningful recovery is unlikely should receive palliative care (see 5)

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Amarenco P et al; Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators High-dose atorvastatin after stroke or transient ischemic attack N Engl J Med 2006 Aug 10;355(6):549 59 [PMID: 16899775] Di Carlo A et al; European BIOMED Study of Stroke Care Group Risk factors and outcome of subtypes of ischemic stroke Data from a multicenter multinational hospital-based registry The European Community Stroke Project J Neurol Sci 2006 May 15;244(1 2):143 50 [PMID: 16530226] Edgell R et al Acute endovascular stroke therapy Curr Neurol Neurosci Rep 2006 Nov;6(6):531 8 [PMID: 17074290] Hart RG et al Lessons from the Stroke Prevention in Atrial Fibrillation trials Ann Intern Med 2003 May 20;138(10): 831 8 [PMID: 12755555] Subramaniam S et al Massive cerebral infarction Neurologist 2005 May;11(3):150 60 [PMID: 15860137]

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Spontaneous intracerebral hemorrhage in patients with no angiographic evidence of an associated vascular anomaly (eg, aneurysm or angioma) is usually due to hypertension The

A complete blood count, platelet count, bleeding time, prothrombin and partial thromboplastin times, and liver and renal function tests may reveal a predisposing cause for the hemorrhage Lumbar puncture is contraindicated because it may precipitate a herniation syndrome in patients with a large hematoma, and CT scanning is superior in detecting intracerebral hemorrhage

pathologic basis for hemorrhage is probably the presence of microaneurysms that develop on perforating vessels of 100 300 mcm in diameter in hypertensive patients Hypertensive intracerebral hemorrhage occurs most frequently in the basal ganglia and less commonly in the pons, thalamus, cerebellum, and cerebral white matter Hemorrhage may extend into the ventricular system or subarachnoid space, and signs of meningeal irritation are then found Hemorrhages usually occur suddenly and without warning, often during activity In addition to its association with hypertension, nontraumatic intracerebral hemorrhage may occur with hematologic and bleeding disorders (eg, leukemia, thrombocytopenia, hemophilia, or disseminated intravascular coagulation), anticoagulant therapy, liver disease, cerebral amyloid angiopathy, high alcohol intake, and primary or secondary brain tumors There is also an association with advancing age and male sex Bleeding is primarily into the subarachnoid space when it occurs from an intracranial aneurysm or arteriovenous malformation (see below), but it may be partly intraparenchymal as well In some cases, no specific cause for cerebral hemorrhage can be identified

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