PHYSIOTHERAPY AND REHABILITATION - During the acute phase, the aim should be

gradual withdrawal over the next few days Antacids should be given simultaneously. (d) Frusemide - 40-80 mg. daily IV. Of special value in patients with LV failure in whom mannitol would be risky. 2. Anticoagulation -Indications - Valvular heart disease particularly MS, recent myocardial infarction, atrial or ventricular thrombus, atrial fibrillation, acute internal carotid artery or basilar artery thrombosis, internal carotid artery dissection, prothrombotic states (e.g. protein C or protein S deficiency), recurrent TIAs or stroke, cerebral venous thrombosis It is best initiated gradually with warfarin. Low dose subcutaneous hearin helpful in prevention. 3. Antiplatelet 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 Dipyridamole 2 mg/kg/day or Ticlopidine 25 mg b.d. with food D URGENT NEUROSURGERY - (a) In all cases of subarachnoid or intracerebral hemorrhage (b) Evacuation of cerebellar hematoma, 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 beprevention of deformities. The patient's limbs should be maintained in optimal position Passive physiotherapy started after 36 to 48 hours. Joints should be moved through full range of motion. Muscle re education and joint exercises initiated when the first signs of recovery are noted Massage is given as adjuvant to active exercises. It is important to introduce standing as an exercise soon since weight bearing stimulates the maintenance of extensor tone in the lower limbs and on this the ability to walk depends. If the patient can stand unsupported, he is ready for gait training. F. TREATMENT OF APHASIA - Language training, training of left hand in performance of voluntary movement in right handed patients. Secondary prevention 1. GENERAL MEASURES - Stopping smoking, regular exercise. Control of hypertension, diabetes and treatment of hyperlipidemia. 2. ANTICOAGULANTS - Indications have already been mentioned Aspirin has been shown to be of benefit in presenting stroke and vascular death in patients who have had a TIA. Dose 75 mg/day 3 PREVENTIVE NEUROSURGERY – for recurrent subarachnoid and intracerebral bleeding from aneurysms and arterial malformations. 4. CAROTID ENDARTERECTOMY - Indications - (a) Moderate degree of stenosis. (b) TIA, amaurosis fugax, stroke or retinal infarct within 6 months and with good recovery (c) Significantstenosis in patient scheduled for major surgery such as coronary bypass Contraindications - (a) Recent Ml (b) CCF. (c) 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, hyperviscosity syndromes, septicemia, ulcerative colitis, severe iron deficiency anaemia, head injury, extracranial malignancy. Clinical features - Onset is sudden commonly with focal epilepsy. Raised intracranial pressure develops rapidly if obstruction of the dural sinuses A focal neurological deficit develops which can be clinically indistinguishable from a stroke due to arterial occlusion. Investigations - An enhanced CT scan may show a clot within the superior sagittal sinus, but this is