diastolic BP maintained at above 120 mm Hg. BP should be lowered cautiously using oral agents. 4. Hypotension

(f) Anxiety and depression. (g) Emotional lability. Management of stroke and TIA: Hospitalization - for patients with suspected stroke Haemorrhage - Surgical evacuation of an intracranial hematoma beneficial in selected cases: (1) Hemorrhage into cerebellum. This is characterised by relative retention of power and sensation (in contradistinction to pontine or capsular lesions), with small pupils, gaze palsy, cerebellar ataxia and peripheral facial palsy. (2) Surgically accessible clot in a patient with good level of consciousness but a persistent neurological deficit after a trial of medical management for a period of one week. (3) When progressive cerebral oedema and coning necessitates surgical decompression. Thrombosis and Embolism - A Supportive therapy -1. Position in bed - Patient should be nursed with the head in a flat position. Disturbance of autoregulation in patients with stroke results in decrease in cerebral blood flow (CBF) if the head is elevated. Semiprone position in order to avoid falling back of the tongue. Frequent change of position to prevent lung congestion and bed sores. 2. Maintenance of airway - if patient is unconscious. The tongue must be kept forward, if necessary by use of an airway and the mouth clear of pillows so that when the patient vomits obstruction is less likely to occur. 3. Maintenance of hydration and nutrition - In the unconscious patient by passing a nasogastric tube. In first 24 hours 5% glucose solution (2000 ml) is adequate. This can be replaced after 24 hours, when the danger of vomiting or active regurgitation is passed, by milk, sugar, eggs, salt and vitamins. Feeds are given 2-houhy preferably just after the patient's position is changed. 4. Care of the skin - Areas of reddening of the skin over heels, ankles, buttocks, shoulders and elbows are an indication of impending pressure necrosis. and indicate that the patient is not being turned frequently enough/ Care of the bladder and bowel - Incontinent patients may require sterile indwelling catheters and bowel care since dampness and infection predispose to the formation of decubitus ulcers. Appropriate antibiotics should be given at the first sign of pyuria. G. Care of the eyes -Antibiotic drops to prevent exposure keratitis/ 7. Passive movements - to be commenced from the first day to prevent contracture (especially at the shoulder) and also to decrease risk of leg vein thrombosis. B. Treatment of associated conditions - 1. Cardiac condition - Treatment of arrhythmias or of left ventricular failure. 2. Diabetes - Care should be taken to avoid hypoglycemia. 3. Hypertension - In acute stage mild to moderate elevation in BP requires no treatment. When associated with hypertensive encephalopathy or diastolic BP maintained at above 120 mm Hg. BP should be lowered cautiously using oral agents. 4. Hypotension-should be corrected by raising the foot of the bed and by fluid replacement. 5. Infection - Appropriate antibiotics for pulmonary or urinary infection. Paracetamol to lower temperature since with rise of body temperature there is an increase in metabolic demands and cerebral oxygen consumption. C. Specific measures - I. Measures to reduce cerebral oedema - (a) Mannitol- 350 ml of 20% aqueous solution IV. over 60-90 minutes. (b) Glycerol -1 5 g/kg of body weight every 24 hours in 3-4 divided doses mixed with fruit juice to mask the unpleasant taste or IV as 500 ml of 10% glycerol in 5% glucose or normal saline over a period of 3-4 hours daily for first 4 to 6 days of acute cerebral infarction. No rebound increase in intracranial. pressure after discontinuation as may occur after mannitol. (c) Steroid therapy - Dexamethasone 16-20 mg. IV or IM for first 5 days, followed by