Acute Management of Stroke

Dr Amri Masri June 2011

Race against time

 Treatment and stabilisation of patient. Specific therapy:

Recanalisation Neuroprotection

Acute complications:
Secondary haemorrhage, oedema, seizures, aspiration, infections, ulcers, DVTs, PE.

Early secondary prevention. Early rehabilitation.

Penumbra

Emergency diagnostic tests in acute stroke.

Brain imaging CT or MRI. ECG. FBC, Clotting profile. Serum electrolytes. Blood glucose. Hepatic and renal parameters. CRP or ESR.

The decision: To thrombolyse or not

Ischaemic Stroke Thrombolysis

Inclusion:
Clinical diagnosis of ischaemic stroke with recognisable neurological deficits. *Within 4.5hrs. *Seizures at stroke onset but must be clear the seizure is due to cerebral ischaemia. *Age 18-80 yrs. *Haemorrhage excluded by CT. Consent to treat.

Ischaemic Stroke Thrombolysis

Exclusion:
Beyond 4.5hrs. Severe neurological deficit NIHSS > 25. Stroke within last 3 mths. Traumatic brain injury last 3 mths. MI last 3 mths. GI/GU bleeding last 3 weeks. Larger surgical interventions last 2 weeks. Symptoms suggestive of SAH even if CT is normal. Arterial puncture in non-compressible site.

Ischaemic Stroke Thrombolysis

Exclusion(cont):
Large stroke in CT >1/3 of hemisphere. Intracerebral bleeding in history. Diabetes and stroke in history. On oral anticoagulation, INR must be <1.5. Heparin in the last 48hrs, aPTT <40s, Platelets >100 Uncontrolled BP, must be <185/110 Dysglycaemia <3 or >22 mmol/L Acute pancreatitis. Endocarditis.

rtPA- Actilyse
0.9mg/kg, maximum dose of 90mg. Give 10% of dose as bolus then the remaining as infusion over 1hr.

Thrombolysis SOP
2 large bore cannulas both antecubital veins before thrombolysis. Catheterise before thrombolysis. No invasive procedures, IM injections after thrombolysis. No FH, LMWH, antiplatelets 24hrs after thrombolysis. Beware of anaphylaxis, bleeding. If headache, nausea, vomiting, acute BP increase stop thrombolysis and repeat CT. 24hrs bed rest. Repeat CT 24-48hrs after thrombolysis.

Monitoring parameters: Airway and Respiratory

Airway protection. Risk of aspiration. Maintain adequate oxygenation for preservation of penumbra. Continuous SpO2 monitoring at least 24-48hrs.

Monitoring parameters: Cardiovascular

Continuous heart rate monitoring. Prior HTN 180/100-105. Without prior HTN 160-180/90-100. Thrombolysed patient BP <185/110. Avoid nifedipine SL and drastic BP reduction. Immediate antihypertensive therapy in concomittant medical problems e.g. ICH, cardiac failure, ACS, aortic dissection, hypertensive encephalopathy. Avoid and treat hypotension: fluids, volume expanders, catecholamines.

Monitoring Parameters: Blood glucose

Keep blood glucose <10mmol/L. Avoid hypo or hyperglycaemia- associated with poor functional outcomes. Hypoglycaemia may mimic stroke.

Monitoring parameters: Body temperature

Hyperthermia associated with larger infarcts and poor outcome. Could be centrally driven or exogenous. Search for infection and treat. Temperature <37.5 degrees C.

Monitoring parameters: Fluid and electrolytes

Balanced electrolyte and fluid status important to avoid:
Hypo/hypervolaemia. Plasma volume contraction. Raised haematocrit.

Avoid hypotonic fluids.

Anticoagulation
For DVT prophylaxis. No benefit on stroke outcome. However, selected indications for full dose heparin e.g. cardiac sources with high risk of re-embolism, high grade arterial stenosis.

THE END