Management of Stroke by Amit Mistri

Urgent Brain Imaging

amitmistri — 2022-02-10 16:47:40 UTC

Urgent brain imaging is key for identification of bleeding (haemorrhage) underlying stroke.
A CT scan is the preferred modality as it is quick, inexpensive and readily available in most hospitals.
Identification of stroke type allows emergency treatment to be in initiated
Absence of acute ischaemic changes does not rule out a stroke.

IV Thrombolysis

amitmistri — 2022-02-10 17:29:32 UTC

Once bleeding is ruled out, prompt delivery of clot busting medication (thrombolysis) where appropriate is the next step.
The only licensed agent is rtPA (recombinant tissue Plasminogen Activator; reteplase), time window for treatment up to 4.5 hours from symptom onset.

Mechanical Thrombectomy

amitmistri — 2022-02-10 17:47:45 UTC

NON HAEMORRHAGIC STROKE
LARGE VESSEL OCCLUSION on CTA
MT has a dramatic effect on improving outcomes, if used in line with approval criteria (6 hour time window)
Some evidence of benefit upto 24 hours in select cases

Stroke Unit Care

amitmistri — 2022-02-10 17:49:13 UTC

Management in a dedicated Stroke Unit is associated with improved care and reduced mortality. Trusts are incentivised to ensure patients reach a stroke unit directly.
An MDT approach, and protocolised management for early identification and treatment of complications is critical.

Early Aspirin

amitmistri — 2022-02-10 17:57:03 UTC

NON HAEMORRHAGIC STROKE
NOT FOR THROMBOLYSIS
Early use of Aspirin in non-haemorrhagic stroke is associated with a small but statistically significant increase in better outcomes.
For those receiving thrombolysis, aspirin is delayed for about 24 hours (after the 24h repeat scan)

Blood pressure control

amitmistri — 2022-02-10 17:59:04 UTC

Treatment to reduce elevated blood pressure is particularly relevant in the setting of intracerebral haemorrhage, with a target BP of <140/90 advised within 1 hour of presentation. A target of <180/100 is advised prior to thrombolysis.

Nutrition

amitmistri — 2022-03-21 13:45:05 UTC

Assessment of nutrition starts at the front door with a nurse dysphagia screening. Outcomes from this include: normal food & drink, modified consistency food / drink, or nil by mouth with consideration for tube (nasogastric tube) feeding.
More detailed assessments can be undertaken by Speech & Language Therapists, with recourse to Flexible Endoscopy of Barium studies (Videofluoroscopy) in select situations.

Regular monitoring of intake charts and weight trends is an essential aspect of ongoing care.

VTE Prophylaxis

amitmistri — 2022-03-21 13:49:47 UTC

There is an increased risk of venous thrombosis post stroke, due to reduced mobility.

Intermittent pneumatic compression (IPC) stockings are used as routine to reduce venous stasis in those who are unable to mobilise independently. Contraindications include: skin breaks, significant leg swelling or severe peripheral artery disease.

There is no evidence of net benefit from routine use of low molecular weight heparin or standard TED (thrombo-embolic deterrent) stockings, in acute stroke. These can be used in select circumstances on an individualised basis where IPC are contraindicated.