Simon Howard Medical Management of Acute Stroke

Fast Recognition of Stroke With sudden onset neurological symptoms: 'FAST' should be used to screen for Stroke / TIA Hypoglycaemia should be rapidly excluded In A&E, ROSIER score should be used to establish the diagnosis quickly Brain imaging

Managing TIAs If no remaining neurological deficit at presentation: o Start 300mg aspirin immediately o Measure risk of further stroke with ABCD2 score o High Risk (ABCD2 ≥ 4, Crescendo TIAs)  Specialist assessment within 24hrs o Low Risk (ABCD2 ≤ 3, presenting over a week afterwards)  Specialist assessment within 1 week Otherwise, proceed to brain imaging

Brain Imaging Should be completed within the hour if any of the following... Potential for thrombolysis or early anticoagulation Patient is on anticoagulation therapy Patient has known bleeding tendency Patient's GCS < 13 Symptoms are unexplained, fluctuating, or progressive Papiloedema, neck stiffness, or fever present Severe headache at onset of stroke symptoms Otherwise, should be completed within 24hrs

Thrombolysis Indicated if... Ischaemic stroke, with ICH excluded by imaging Within 3 hours of symptom onset Specialist physician present and within a specialist centre Level 1 & 2 specialist nursing care available Immediate re-imaging available Contraindicated if... Seizure at onset of stroke Clinical suspicion of SAH Current anticoagulation (INR > 1.7) Stroke or head injury in last 3 months Major surgery within last 2 weeks Previous ICH IC Neoplasm Atriovenous malformation or aneurysm GI or urinary tract haemorrhage in last 3 weeks Lumbar puncture in last 3 weeks

Admission to Specialist Unit Unit should consider: Pharmacological factors Nutrition Getting back to normal - eg mobilising ASAP

Aspirin and Anticoagulation Acute Ischaemic Stroke (No ICH) 300mg Aspirin ASAP, continued for two weeks or until discharge 75mg aspirin longterm thereafter PPI with aspirin if known to be dyspepsic with it No anticoagulation Primary Haemorrhagic Stroke Reverse any anticoagulation with Vit K and PT complex concentrate

Aspirin and Anticoagulation Acute Venous Stroke Full dose heparin followed by warfarin Maintain INR at 2-3 Acute Arterial dissection Enter RCT Receive either anticoagulants or antiplatelets

Aspirin and Anticoagulation Disabling Ischaemic Stroke and AF Give 300mg aspirin for 2 weeks, then consider anticoagulation Disabling Ischaemic Stroke and Prosthetic Valves Swap anticoagulants for 300mg aspirin for 1 week Ischaemic Stroke and DVT / PE Anticoagulate Haemorrhagic Stroke and DVT / PE Anticoagulate, or use caval filter

Statins Don't start them immediately after a stroke Don't stop them immediately after a stroke

Nutrition Specialist swallow assessment should be within 24 hours NG Feeding should be commenced within 24hrs if deemed necessary Any NG Feeding or Specialist diet should be reviewed by a specialist at least every three days Regularly assess hydration status Only give nutrition supplements where indicated

Restoring Homeostasis Maintain Sats above 95% Maintain Blood Gluocse between 4 and 11 Blood Pressure o Only give antihypertensives if:  Hypertensive encephalopathy / neuropathy  Hypertensive cardiac failure / MI  Aortic Dissection  Pre-eclampsia / Eclampsia  ICH with systolic bp > 200 o Reduce bp to < 185/110 if thrombolysing

Neurosurgery Some people should be surgically managed rather than medically managed: Previously fit people with ICH and hydocephalus Decompressive hemicraniotomies necessary if MCA infarction present and... Patient 60 years old or younger Level of conciousness decreased CT shows infarct of at least 50% in MCA territory Able to perform surgery within 48hrs of onset

Carotid Endarterectomy Those with a TIA or non-disabling stroke should be referred for carotid dopplers within 1 wk of symptom onset (provided carotid endarterectomy may be an option for them) If stenosis great enough (>50% using criteria at FRH), then endarterectomy should be completed with 2 wks of onset.

Before discharge The following should be considered.. Cholesterol lowering BP control Dietary advice Antiplatelet treatment Lifestyle advice