Stroke is an acute neurological dysfunction with underlying ischaemic or haemorrhagic event. Patients usually present with sudden weakness or numbness; speech disturbance; confusion; memory or visual loss and severe headache. This is a neurological emergency and the initial management should be carried out in an emergency set up under expert guidance.
Initial management:
- Maintain airway, breathing and circulation
- Arrange for urgent CT scan brain and CT angiogram of circle of Willis, carotids and arch of aorta to rule out haemorrhagic or ischaemic stroke.
- Arrange for urgent transfer to secondary or tertiary care with emergency neurological and or neurosurgical facilities.
- Urgent optimisation of blood pressure – aim for target blood pressure of systolic BP less than 185 mmHg and diastolic less than 110 mmHg. See below for further details.
- Thrombolysis – if treatment can be started within 4 hours of onset of stroke (see below for further details).
Subsequent management:
This is dependent on the residual neurological function after the stroke episode has stabilised:
- Optimise blood pressure – Refer to guidelines on hypertension.
- Optimise cholesterol levels – Refer to guidelines on hyperlipidaemia.
- Control blood sugars – Refer to guidelines on type 1 or type 2 diabetes guidelines
- Thromboprophylaxis – Tab. Ecosprin 75 (Aspirin 75 mg) – once with dinner and tab. Clopikind 75 (Clopidogrel 75 mg) – once a day.
- Treat epilepsy if needed
General advice:
- Regularly assess patient’s neurology
- Advice rehabilitative physiotherapy
- Ensure adequate diet with special precautions against aspiration
- Advice good skin care and positioning since these patients are at high risk of pressure sores
Investigations:
- Repeat CT scan is not advisable unless further neurological deterioration
- MRI brain – to rule out infarct, cerebral pathology and space occupying lesions
- FBC and CRP – to rule out infection and low platelet count
- Renal function test – to rule out electrolyte disturbance. Low sodium is a likely cause of acute confusion.
- Liver function test – to rule out hepatic encephalopathy
- ECG – To rule out arrythmias (this may cause embolic stroke)
- Chest X ray – if there is clinical suspicion of aspiration
- Coagulation screen – To rule out bleeding disorders
- Blood sugars – To assess diabetic control.
Referral:
Patients with acute stroke are recommended to be managed by neurologist. Patient may need other specialist referrals depending on any other systemic problems as identified by investigations.
Urgent control of blood pressure:
- Inj. Labebet (Labetalol 5 mg/1ml) as infusion – dilute as needed and infuse at 2 mg/minute until a satisfactory response is achieved (usual dose 50–200 mg).
- If beta blockers are contraindicated, then give inj. Nitroject (Glyceryl trinitrate 50 mg/10ml) – dilute with 0.9% saline to 1mg/ml and infuse at 1 – 2 ml/hour (titrate as needed).
- Ensure good blood pressure control before and after thrombolysis.
Thrombolysis:
This is to be provided under expert care and with adequate resuscitation facilities.
Inclusion criteria:
- Onset of stroke less than 4 hours from start of treatment
- New neurological deficit
- No evidence of haemorrhage or well-defined infarct on CT scan brain
- Patient age more than 18 years and clinical evidence of stroke.
Exclusion criteria:
- Onset of stroke more than 4 hours from start of treatment
- Significant head injury
- Any evidence of coagulopathy including recent surgery which can put patient at risk of severe bleeding.
- High blood pressure – Systolic BP above 185 and/or diastolic BP above 110
Treatment:
Inj. Actilyse (Alteplase) – 900 microgram/kg (maximum dose – 90mg) – Dilute in normal saline to a concentration of 1mg/ml. Give 10% of the calculated dose as bolus and remaining 90% as infusion over 1 hour.
Post thrombolysis:
Tab. Eliquis 2.5 (Apixaban 2.5 mg) – one tablet twice a day for 5 days (start 24 hours after thrombolysis).