Stroke
- Treatment

General principles

Early recognition of symtpoms

Emergency transport to hospital

Rapid triage in A&E

Urgent investigations

Management in a specialised stroke unit

• Adequate hydration
• Optimal oxygenation
• Avoidance of glucose-containing solutions (?)
• Prevention of complications (e.g. DVT)

Hypertension

• BP is often elevated as a result of stroke
• Usually settles spontaneously
• Aggressive treatment of hypertension should be avoided because it can cause stroke extension (unless there is malignant hypertension or renal impairment)

 

50% dextrose injection to any patients with neurologic deficit and hypoglycemia

 

 

 

Ischaemic stroke

Aspirin

Aspirin should be used routinely (after CT scan is taken and cerebral haemorrhage is excluded), unless thrombolysis or anticoagulation are used, or if there is contraindication to aspirin.

Heparin

Not used routinely

Consider in patients with AF and mild ischaemic stroke

Tissue plasminogen activator

Improve outcome if given within 3 hours of onset of acute ischaemic stroke

But also associated with increased risk of symptomatic intracerebral haemorrhage

(Streptokinase is NOT used because of increased mortality.)

Use only if:

• An ischaemic stroke confirmed to be <3hours duration
• No major changes of early ischaemia on CT
• No contraindication for thrombolytic therapy (e.g. bleeding disorder, recent peptic ulceration, serious medical condition, recent surgery)

Contraindication include:

• Prior intracranial haemorrhage
• Seizure at onset of stroke
• Recent MI
• GIT bleeding in the past 3 weeks
• Severe hypertension
• Previous stroke within the preceding 90 days
• Previous head injury within preceding 90 days
• Current use of oral anticoagulant or INR >1.7
• Proliferative diabetic retinopathy

Neurosurgery

Consider for young patients with space-occupying infarcts in nondominant hemisphere or cerebellum.

Others

Corticosteroid is of no use and may be harmful

 

Intracerebral haemorrhage

Neurosurgery to decompress haematomas of the posterior fossa, drain cerebral hemispheric haematoma or insert shunts.

 

Subarachnoid haemorrhage

Vasospasm and re-bleeding are the main causes of morbidity and mortality.

Risk highest in the first 24 hours.

Maintain blood pressure at pre-stroke level.

Early surgery

Give nimodipine

• dihydropyridine calcium channel blocker, cerebral vasodilator

 

Post-stroke treatment

Post-stroke rehabilitation (different models including home-based care, inpatient, outpatient)

Treatment of associated psychiatric condition, especially depression

Secondary prevention