Stroke

I63.0-6/I63.8-9/I64

GENERAL MEASURES

Optimise hydration and nutrition; insert nasogastric tube if patient cannot swallow. Take precautions to ensure an open airway if patient is unconscious.

Physiotherapy and good nursing care. Consider rehabilitation for suitable patients, refer if necessary.

Do an ECG to rule out an acute coronary event or atrial fibrillation as precipitants.

Do serology to exclude meningovascular syphilis.

Check lipid profile in ischaemic strokes.

Ischaemic stroke in young adults (<45 years of age) may be due to atherosclerosis, but also consider:

  • Embolic: e.g. rheumatic heart disease, atrial fibrillation, cardiomyopathy, previous myocardial infarction, and, very rarely, patent foramen ovale: history, careful clinical cardiac examination, ECG/CXR, and echocardiography.
  • Vessel wall disease: e.g. syphilis, HIV infection, collagen-vascular diseases, TB or bacterial meningitis and extracranial arterial dissection. Investigate as dictated by clinical presentation, but at least syphilis and HIV serology, urine dipstix (haematuria and/or proteinuria), and ANF/RF. ANCA, and cerebral angiography or carotid Doppler may be indicated. Note that absence of a carotid bruit does not exclude significant carotid stenosis.
  • Hypercoagulable states: e.g. antiphospholipid antibody syndrome, thrombotic thrombocytopenic purpura. Useful screening investigations are FBC and, in women, PTT/Anti-phospholipid Ab. Testing for thrombophilias and their management should only be done in consultation with an expert.

MEDICINE TREATMENT

Hyper-acute management:

Symptom onset ≤ 3 hours:

  • Do not give aspirin.
  • Refer immediately to hospital that can provide thrombolytic therapy:
  • Alteplase, IV, 0.9 mg/kg.
    • 10 % of total dose given as a bolus and the remainder continued as an infusion over an hour.

LoEI [1]

Symptoms >3 hours:

  • Aspirin, oral, 300 mg, immediately.

LoEI [2]

Followed by:

  • Aspirin, oral, 150 mg daily.

If patient is unable to swallow, administer through a naso-gastric tube.

Do not administer aspirin if there are symptoms suggestive of a sub-arachnoid bleed, e.g. headache, stiff neck, etc.

AND

DVT prophylaxis see Venous thrombo-embolism.

Treat secondary pulmonary and urinary tract infections appropriately.

Secondary prevention:

Measures for secondary prevention may not be appropriate for patients with severe disability.

All patients with a thrombotic stroke, not on anticoagulation and irrespective of the LDL level:

  • Aspirin, oral, 150 mg daily.

LoEI [3]

AND

  • HMGCoA reductase inhibitors (statins), e.g.:
  • Simvastatin, oral, 40 mg at night.

LoEI [4]

Patients on protease inhibitor:

  • Atorvastatin, oral, 10 mg at night.

LoEI [5]

Patients on amlodipine (and not on a protease inhibitor):

  • Simvastatin, oral, 10 mg at night.

LoEII [6]

If patient complains of muscle pain:

Reduce dose:

  • HMGCoA reductase inhibitors (statins), e.g.:
  • Simvastatin, oral, 10 mg at night.

OR

Consult specialist for further management.

LoEIII [7]

In patients with cardio embolic strokes (e.g. secondary to atrial fibrillation) with no evidence of haemorrhage on CT scan, the optimal time to start anticoagulation therapy is likely to vary among individual patients; this can be from 7 to 14 days and up to 21 days and is dependent on the infarct size (>1/3 of the hemisphere) and the patient’s risk factors for recurrent events.

LoEI [8]

Bridging anticoagulation with heparin, or earlier initiation of warfarin, is not recommended because, although it reduces ischaemic stroke recurrence, it increases symptomatic intracranial haemorrhage.

LoEIII

Blood pressure management

A transient increase in BP is common after an acute stroke. Do not actively lower a systolic BP <220 mm Hg or diastolic BP <120 mm Hg in the first few days after stroke as this may be associated with an increased risk of death.

In patients presenting with stroke and BP >220/120 mmHg, lower BP to about 180/110 mm Hg in the first 24 hours.

Lowering BP during the acute phase of stroke (within 6 hours of onset) may not improve morbidity. Antihypertensive medicines may be withheld until patients have suitable oral or enteral access. Cautious incremental reintroduction of treatment is advised to achieve long-term standard BP control. See Hypertensive crisis, hypertensive emergency.

LoEI [9]

If BP > 220/120 mm Hg :

  • Long-acting calcium channel blocker, e.g.:
  • Amlodipine, oral, 5 mg daily.

LoEII [10]

OR

If adequate fluid intake can be ensured :

  • Hydrochlorothiazide, oral, 12.5 mg daily.

LoEIII

Note:

  • There is some evidence of harm from BP reduction within 7 days of acute stroke; after 7 days cautious incremental re-introduction of treatment is advised to achieve long term standard BP control.

LoEI [11]

  • Antihypertensive medicines should be stopped in acute stroke unless the BP is >220/120 mm Hg (see above).
  • The need for re-initiating the patients previous antihypertensive regimen should be reassesed. See Hypertension.

LoEIII [12]

REFERRAL

To a facility with a CT scan:

  • Patients with atypical clinical presentation.
  • Selected patients with suspected ischaemic stroke who may benefit from thrombolysis with tissue plasminogen activator if initiated within 3 hours of onset of symptoms.
  • Patients with suspected posterior cerebral fossa haemorrhage who may require surgical decompression.
  • If there is a history suggestive of subarachnoid haemorrhage or if there is neck stiffness.
  • Patients with aspirin intolerance.