section name header

Information ⬇

Author(s): Tony Rudd and Ajay Bhalla

Stroke typically causes rapidly-developing neurological symptoms or coma. About 85% of strokes are due to cerebral infarction (Appendix 65.1), for which thrombolysis should be considered. Headache, vomiting and coma at onset are more common in haemorrhagic stroke, but accurate differentiation requires computed tomography (CT), which should be done immediately in suspected stroke. Management is summarized in Figure 65.1.

Priorities ⬆ ⬇

Outline

  1. If the patient is unconscious, initial resuscitation is as for coma from any cause (Chapter 3). Check blood glucose to exclude hyper- or hypoglycaemia.
  2. Is this a stroke and not another disease mimicking stroke?
    • The clinical assessment of the patient with suspected stroke is summarized in Tables 65.1 and 65.2, and investigations needed urgently in Table 65.3.
    • Differentiation of stroke from stroke-like presentations of other diseases can sometimes be difficult. The acute onset (or presence on waking from sleep) of asymmetric face, arm or leg weakness, speech disturbance or visual field defect support a diagnosis of stroke. Fever at presentation, prominent headache, or neck stiffness should make you consider alternative diagnoses. Syncope or seizure activity suggest against the diagnosis.
    • The disorders which are most commonly misdiagnosed as stroke are summarized in Table 65.4, and atypical presentations of stroke in Table 65.5.
  3. If the working diagnosis is stroke due to cerebral infarction, is thrombolysis or thrombectomy indicated?

Thrombolysis!!navigator!!

  • This should only be considered when the patient is in a hospital with a well-organized stroke service, which has trained staff, immediate access to neuroimaging, protocols in place to manage complications, and systems to audit outcomes. Indications for thrombolysis are:
    • Any patient, regardless of age or stroke severity, where treatment can be started within 3h of known symptom onset and who has been shown not to have an intracerebral haemorrhage or other contraindications (Table 65.6).
    • Between 3 and 4.5h of known symptom onset, patients under 80 years who have been shown not to have an intracerebral haemorrhage or other contraindication.
    • Between 4.5 and 6h of known symptom onset, patients should be considered on an individual basis, recognizing that the benefits to treatment are likely to be smaller but that the risks of a worse outcome, including death, will not be increased.
  • Table 65.7 summarizes how to administer alteplase for thrombolysis.

Thrombectomy!!navigator!!

  • Clot retrieval for selected patients with proximal anterior and middle cerebral artery occlusion is beneficial, and while few centres currently offer this service, it should be considered if thrombolysis is ineffective.
  • Thrombectomy is time-critical and should be undertaken in centres with the relevant expertise within a maximum of 6h of the onset of symptoms.

Anti-Platelet Therapy!!navigator!!

  • Aspirin 300 mg once daily for 14 days should be started 24h after thrombolysis, or as soon as possible within 48h of the onset of symptoms in patients who do not receive thrombolysis.
  • Patients with aspirin hypersensitivity, or those intolerant of aspirin despite co-administration of a proton pump inhibitor, should receive clopidogrel 75 mg once daily.

Further Management ⬆ ⬇

Outline

All stroke patients should be managed on a stroke unit unless other conditions requiring specialist care dominate (e.g. need for intensive care).

Supportive Care!!navigator!!

  • Rehabilitation should start early, although intensive mobilization within the first few hours of the stroke should be avoided.
  • Maintain close observation and management of normal homeostasis, for example hydration, electrolytes, nutrition, oxygenation, temperature.
  • Patients with primary intracerebral haemorrhage presenting within the first 6h of the onset and with a systolic blood pressure of over 150 mmHg should have their blood pressure lowered to 140 mmHg for at least 7 days unless there is any contraindication. Patients with ischaemic stroke should have their blood pressure kept below 185/110 mmHg.
  • Screen for swallowing abnormalities before any food or fluid is given and certainly within 4h of admission. This should be done using a standardized screening protocol such as one that first checks the ability of the patient to cough and then goes on to test the ability to swallow teaspoons of water, followed by a glass of water. If a patient is unable to swallow safely, start feeding with a nasogastric tube within 24h of admission. If intravenous fluids are required (and enteral hydration is preferred) then avoid the use of glucose solutions as hyperglycaemia may worsen outcomes.
  • Venous thrombo-embolism is common. Do not use anticoagulants even in low dose for prophylaxis. Evidence shows that intermittent pneumatic compression devices are safe and effective at preventing DVT in patients with hemiparetic legs. TED stockings (both short and long) should not be used. At best they are useless, uncomfortable and expensive, at worst harmful.
  • Patients should be carefully monitored for infection, which should be treated early. This requires monitoring of temperature, pulse, blood pressure and oxygen saturation, at least daily examination of the chest, and monitoring for urinary tract infection. There is no evidence to support the use of prophylactic antibiotics after stroke.
  • Depression is very common after stroke and can be difficult to identify, particularly in dysphasic patients. All patients should be screened for depression. Cognitive behavioural therapy is usually the treatment of first choice.
  • All patients should be screened for cognitive impairment using a validated score after stroke.
  • Urinary catheterization should be avoided. It is rarely indicated for the management of incontinence.
  • Constipation is common in immobile patients. Manage initially by early mobilization, good hydration, a diet rich in complex polysaccharides, and the use of commodes or toilets rather than bedpans.

Establishing the Cause of the Stroke!!navigator!!

Investigations needed are summarized in Table 65.8.

Preventing Another Stroke (Secondary Prevention)!!navigator!!

All patients

  • Give advice and support for smoking cessation if indicated.
  • Give advice on diet and exercise.
  • Blood pressure management. Probably the lower the blood pressure the better, so most patients will benefit from antihypertensive treatment.
  • Patients should be started on a statin if fasting total cholesterol is >3.5 mmol/L.

Following cerebral infarction due to arterial atherothromboembolism

  • Give aspirin 300 mg daily for 2 weeks, followed by clopidogrel 75 mg thereafter.
  • If the patient cannot tolerate clopidogrel, give the combination of aspirin 75 mg daily and dipyridamole MR 200 mg 12-hourly.
  • Patients should be considered for carotid endarterectomy if they have between 50 and 99% carotid stenosis (measured using the NASCET method) on the symptomatic side. The earlier the surgery is performed after TIA or minor stroke the better, as the risk of recurrence is highest in the first few days. There is rarely an indication for operating on asymptomatic stenosis.

Following cerebral infarction related to atrial fibrillation

  • Give aspirin 300 mg daily for 2 weeks, followed by anticoagulation with warfarin or a direct-acting anticoagulant (Chapter 103).
  • If the stroke is small and the patient is being discharged from hospital, then earlier commencement of anticoagulation is appropriate as the risk of haemorrhagic transformation of the infarct is low.

Further Reading ⬆

Fernandes PM, Whiteley WN, Hart SR, Salman RA-S . (2013) Stroke: mimics and chameleons. Pract Neurol 13, 21–28.

Hankey GJ. (2017) Stroke. Lancet 389, 641–654.

Intercollegiate Stroke Working Party (2016) National clinical guideline for stroke 5th edn. http://guideline.ssnap.org/2016StrokeGuideline/index.html