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Stroke Management

The Royal College of Physicians (RCP) published guidelines on the diagnosis and management of patients following a stroke in 2004. NICE updated their stroke guidelines in 2019.

Selected points relating to the management of acute stroke include:

  • blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits
  • blood pressure should not be lowered in the acute phase unless there are complications e.g. Hypertensive encephalopathy*
  • aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
  • with regards to atrial fibrillation, the RCP state: 'anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke'
  • if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation

Thrombolysis for acute ischaemic stroke

Thrombolysis with alteplase should only be given if:
- it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial) - haemorrhage has been definitively excluded (i.e. Imaging has been performed)

Contraindications to thrombolysis:

Absolute
  • Previous intracranial haemorrhage
  • Seizure at onset of stroke
  • Intracranial neoplasm
  • Suspected subarachnoid haemorrhage
  • Stroke or traumatic brain injury in preceding 3 months
  • Lumbar puncture in preceding 7 days
  • Gastrointestinal haemorrhage in preceding 3 weeks
  • Active bleeding
    - Pregnancy
  • Oesophageal varices
  • Uncontrolled hypertension >200/120mmHg
Relative
  • Concurrent anticoagulation (INR >1.7)
  • Haemorrhagic diathesis
  • Active diabetic haemorrhagic retinopathy
  • Suspected intracardiac thrombus
  • Major surgery / trauma in the preceding 2 weeks

Thrombectomy for acute ischaemic stroke

Mechanical thrombectomy is an exciting new treatment option for patients with an acute ischaemic stroke. NICE incorporated recommendations into their 2019 guidelines. It is important to remember the significant resources and senior personnel to provide such a service 24 hours a day. NICE recommend that all decisions about thrombectomy take into account a patient's overall clinical status:
- NICE recommend a pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS)

Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
- confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
- confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and - if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Consider thrombectomy together with intravenous thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes):
- who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and - if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Secondary prevention

NICE also published a technology appraisal in 2010 on the use of clopidogrel and dipyridamole

Recommendations from NICE include:
- clopidogrel is now recommended by NICE ahead of combination use of aspirin plus modified-release (MR) dipyridamole in people who have had an ischaemic stroke - aspirin plus MR dipyridamole is now recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated, but treatment is no longer limited to 2 years' duration - MR dipyridamole alone is recommended after an ischaemic stroke only if aspirin or clopidogrel are contraindicated or not tolerated, again with no limit on duration of treatment

With regards to carotid artery endarterectomy:
- recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled - should only be considered if carotid stenosis > 70% according ECST criteria or > 50% according to NASCET* criteria

Questions

  1. A 62-year-old man is admitted to the Emergency Department with a left hemiplegia. His symptoms started around 5 hours but he initially thought he had slept in an awkward position. He has no past medical history of note but on examination is found to have and irregular pulse of 150 / min. The ECG confirms atrial fibrillation. A CT head is immediately arranged and reported as normal. What is the most appropriate initial management?
    Asprin Asprin + dipyridamole Atleplase Warfarin Asprin + warfarin