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International Journal of Caring Sciences January-April 2015 Volume 8 Issue 1 Page 201

REVIEW PAPER

Management of Acute Stroke: A Debate Paper on Clinical Priorities.


A Literature Review

Dimitrios Theofanidis, RGN, MSc, PhD


Clinical Lecturer, Nursing Department, Alexander Technological Educational Institute of
Thessaloniki, Greece

Correspondence: Ierosolimon 21 str., Kalamaria, 55134, Thessaloniki, Greece


E-mail: dimitrisnoni@yahoo.gr

Abstract:
Stroke is a leading cause of death and disability globally. Also, it is expected that the burden of stroke will
increase due to the rise of the elderly population within societal age structures. The aim of this literature
review is to present in detail the important issues regarding contemporary management of stroke. For this
reason, a thorough search was undertaken via Medline, CINHAL and ELIN from 2004 to 2014. Analysis
of the search results led to the corresponding domains as presented below, namely: nursing implications for
stroke, interventions in the acute phase, investigations/other treatment options and cost implications. In this
context, a number of goals for more efficient care of stroke patients are now set, using advanced,
integrated care plans and critical pathways. From the above, it can be concluded that stroke has a major
impact on society and hospital resources and its high incidence and frequency of prolonged survival
requires a heavy investment in human and financial recourses for provision of care. On the other hand, the
rising hospital costs coupled with a growing elderly population are limiting the financial resources of the
health care system, and therefore, an improved development of the long-term care continuum is required.
Key words: stroke, management, interventions and cost

Background and thus cannot be ascribed to medical care.


This trend has not continued in the latter part
Stroke is the third leading cause of death and
of the century.
an important cause of hospital admission and
long-term disability in all industrialised In the U.K the link between incidence,
populations (Paul et al. 2007; Brown et al. outcome and socioeconomic status has been
2007). The global incidence of stroke is documented whereby unskilled manual
300/100,000 in the general population workers had a 60% higher risk of stroke
(Brainin et al, 2000). According to the World compared to blue collar workers. In addition,
Health Organisation, despite recent advances there was a 50% higher age-adjusted mortality
in medical treatment for stroke, more than rate. While age-specific death rates for stroke
30% of all stroke patients die within the first have declined during the 20th century,
year of onset (WHO, 2004). currently they remain greater for women than
men. In the U.S, the projected increase is from
Stroke mortality rates declined for several
approximately 700,000 in 2002 to 1,136,000
populations during the twentieth century. In
in 2025 (Broderick and Wiliam, 2004).
the first two decades of the last century, this
was 0.5% per year in the U.S., and rose to It has been over 20 years since the logarithmic
approximately 1.5% per year from 1950 to relationship between stroke mortality and age
1970 (Feigin et al., 2009). All age groups were was first described. Consequently, it is
affected, suggesting that this was a period expected that the burden of stroke will
effect rather than a cohort effect. Yet, this increase due to the rise in median age and the
decrease began long before effective therapies alteration of the population age structure,
for stroke prevention treatment were available,

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International Journal of Caring Sciences January-April 2015 Volume 8 Issue 1 Page 202

despite stable or falling age-adjusted incidence investigations/other treatment options and cost
rates (Brice et al., 2002). implications.
It is well documented that the risk factors for Nursing implications for stroke
stroke overlap significantly with those for
Acute stroke poses a challenge for nursing as it
ischaemic heart disease. Following age, the
is a demanding condition within the spectrum
most important risk factor is blood pressure.
of neurological disorders. Staff nurses need to
The risk of stroke increases across both
correct not only for obvious neurological
elevated systolic and diastolic blood pressure.
deficits such as reduced mobility and other
The relative risk of stroke increases by a factor
degrees of limb paresis bit also for systematic
of 2.3 for each 10 mm Hg increase in systolic
implications such as respiratory problems to
blood pressure or 5 mm Hg increase in
give one major example (Theofanidis, 2003).
diastolic pressure (Weiner et al., 2007). Yet,
significant reductions of risk for first and According to Ali et al., (2007) hypoxia is a
subsequent stroke can result from effective serious clinical problem after stroke, and may
anti-hypertensive treatments (Chapman et al., lead to serious complications and slower
2004). recovery. At present, supplemental oxygen is
Diabetes and smoking each increase the commonly administered in the acute stroke
relative risk by a factor of 2.35 while hyper- phase as some current guidelines and standard
homocysteinaemia is another significant risk nursing practice suggest that oxygen saturation
factor with a relative risk of 5 to 7 between the after acute stroke should be maintained at 95%
highest and lowest quartiles of serum or higher and at a dose of 2 to 4 L/minute via
homocysteine concentration (Myint et al., nasal cannulae.
2010). Heart arrhythmias such as atrial Yet, not all abnormal findings should be
fibrillation also hold a relative risk of 5 for treated spontaneously as in some cases
stroke (Engstrm et al., 2010). Serum evidence is conflicting and some
cholesterol is somewhat more complex for recommendations are not based on controlled
stroke than for coronary artery disease as some clinical studies (Ali et al., 2005). Patients with
observational studies show that elevated milder strokes may experience worse
cholesterol levels do not necessarily increase outcomes with oxygen treatment. Although
risk. It is notable that low cholesterol may hypoxia has been well associated with
result in an increased risk of hemorrhagic aggravation of damage to the ischaemic parts
stroke. Yet a major therapeutic trial of lipid of the brain after stroke, early in vitro evidence
lowering therapy has demonstrated reduced in experimental animals suggest that
ischaemic stroke incidence without any administration of pure O2 may aggravate the
increase in hemorrhagic stroke, but in a sub- situation even more by enhancement of free
group within this trial, patients with prior radical formation and lipid peroxidation.
ischaemic stroke placed on statin therapy Singhal, (2006) in a small randomised
showed no reduced incidence of stroke controlled trial found mean NIHSS scores at
(Goldstein, 2011). 24 hours to be significantly lower in patients
Literature review receiving high flow oxygen therapy for eight
hours via face mask, in comparison to
The aim of this review is to cover the receiving room air. Moreover, Sjberg and
important management issues related to stroke Singer, (2013) caution that hyperoxia on
both from a medical and a nursing aspect. For normal vasculature may have a vasoconstrictor
this reason, a thorough literature search was effect and, consequently, significant reduce
undertaken via Medline, CINHAL and ELIN blood flow to the tissue at-risk.
from 2004 to 2014 using the following key
words: stroke, management, interventions and Overall, there is a lack of clear consensus
cost. Analysis of the search results led to the among stroke physicians whether O2 should be
corresponding domains as presented below, administered after acute stroke, and if so how
namely: nursing implications for stroke, much, and which route should be selected
interventions in the acute phase, (Poli and Veltkamp, 2009). However, Singhal

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(2007) suggests that an alternative benefit of acute stroke care was seen as a key role of
early administration of O2 in acute stroke is the these centres (Goldstein and Amarenco, 2004).
'buy time' effect, whereby the window for
The core rational behind this process was that
administration of thrombolytic or neuro-
effective delivery of acute stroke therapy
protective drugs can be expanded. Yet,
involves a pre-hospital phase and a Casualty
Summers et al., (2009) emphasised that
phase. The latter requires a rapid and intense
supplemental oxygen should be administered
application of clinical, radiological (Computed
to patients with O2 saturation <90% and
Tomography / Magnetic Resonance
decreased level of consciousness.
Investigation), and biochemical analyses of the
Despite controversies over benefits and risks patient who is eligible for thrombolysis. These
of oxygen therapy, strong emphasis has been evaluations serve to interpret compliance with
placed on routine, accurate monitoring of O2 eligibility criteria, thereby maximising the
saturation, coupled with correct positioning of probability of positive outcomes (Marks et al.,
the patient in order to achieve higher O2 2008).
saturation levels; patents should be placed up-
Yet, the main determinant of eligibility
right where appropriate, preferably in a chair
remains the time since onset and earlier
with care to avoid slumping (Jones et al.,
treatment is associated with improved
2007).
outcomes (Lansberg et al., 2009: Hacke et al.,
Thrombolytic therapy in current practice 2004). Thus, attention should be focused on
the pre-hospital phase. In order to reduce delay
Thrombolytic therapy for acute stroke has
times in the pre-hospital phase, public
received widespread, though not universal,
awareness of the urgency for treatment is
support as it is a complex intervention which
essential. This requires good recognition of
requires intensive use of resources and
symptoms, action to contact emergency
personnel in order to meet its narrow
services and rapid transportation to a facility
therapeutic window, which is 3-hour from
capable of delivering specialised stroke care
symptom onset (Lee et al., 2004). Current
(Goldstein and Simel, 2005).
clinical protocols advocated by the Brain
Attack Coalition (BAC) in the U.S. and the A successful public awareness campaign was
Heart and Stroke Foundation of Canada launched in the UK in 2009, i.e. Act F.A.S.T.
(HSFC) indicate multilevel system change to (Face, Arm, Speech, Time), aiming at
increase the number of patients eligible for improving public knowledge on the signs of
increased therapeutic time window, increased stroke and the need for rapid admission to
age limits, and increased administration of hospital which improves chances of patient
thrombolytic therapy including improved in- outcomes. Despite criticisms, this simple test
hospital infrastructure ranging from acute is helping people to recognise the signs of
stroke wards to a minimum of specialised units stroke and understand the importance of
(Barber et al., 2004). emergency treatment (Mellon et al., 2013;
Dombrowski et al., 2013; Bietzk et al., 2012).
Some western countries have undergone major
system changes in stroke care (Donnan et al., Although many educational strategies have
2008). This process is unique among large been shown to increase the publics awareness
jurisdictions and forms an important of stroke urgency, the problem in many
framework for initiating and evaluating such countries is poor infrastructure and limitations
strategies. Over a decade ago, the Heart and in the hospital settings where thrombolysis for
Stroke Foundation of Ontario, Canada, stroke and other treatments are severely
introduced a coordinated system of stroke care limited as specialised stroke care is not readily
locally (Schneider et al., 2003). Over the next available (Rudolf et al., 2011).
years, the Ministry of Health funded a
Patient Selection for Thrombolysis
coordinated province-wide stroke strategy and
a total of nine regional stroke centres were Thrombolytics restore cerebral blood flow in
designated as the development of integrated some patients with acute ischaemic stroke and
may lead to improvement or resolution of

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neurologic deficits. Thrombolytic therapy is of potentially disabling deficits and large artery
proven and substantial benefit for these cerebral thrombotic occlusions (Wahlgren et
selected patients. The current treatment al., 2008; Graham, 2003).
protocols rely on the entry criteria used for the
Thus, rt-PA treatment should remain a priority
National Institute of Neurological Disorders
as this has proven to be a highly effective
and Stroke (NINDS) Trial and are as follows:
treatment within the tight time-window and
a prompt diagnosis of acute ischaemic stroke
other constrains imposed.
of less than 3 hours from onset, absence of
haemorrhage on CT scan, good blood pressure Investigations and other treatments for
control, a National Institute of Health Stroke stroke
Scale Score of greater than 4 along with Investigations like Computed Tomography
exclusion of those at high risk for bleeding
(CT scanning), Magnetic Resonance
with therapy (Hacke et al., 2008; Adams et al., Imaging (MRI), diffusion and perfusion
2007). weighted MRI which may help to
Reanalysis of the results from the original trial differentiate between infarcted tissue and
suggest a better outcome if treated within 0 to tissue at risk, are used most commonly in
90 minutes compared to 91 to 180 minutes defining a stroke with CT being the most
(Saver and Levine, 2010). Yet, the 3-hour widely used, as access to MRI can be more
window has been challenged by some authors limited (Fiebach et al., 2001). A CT is highly
claiming that clinical benefits can be seen up reliable in distinguishing between
to 4.5- hours from onset (Del Zoppo et al., hemorrhagic and ischaemic stroke and early
2009). The counter challenge to this is that signs of ischaemia can be detected as early as
when the time-window is extended the number 2 hours after the onset of stroke and thus is
of patients eligible for thrombolytic therapy considered to be the gold standard
increases only marginally. Therefore, prompt diagnostic measure (Adams et al., 2007). It
transfer to hospitals that are properly prepared also identifies haemorrhages almost
for rt-PA therapy remains a priority (Mihout et immediately and detects sub-arachnoid
al., 2012; Macleod et al., 2005). haemorrhages in the majority of cases (Lin et
al., 2008).
Data from these trials are congruent in
supporting the following conclusions: Other investigations which can provide a
baseline for management of the stroke patient
Intravenous fibrinolytic therapy at the
are: chest radiography, urea and electrolytes,
cerebral circulation dose within the first 3
full blood count, urinalysis, random blood
hours of ischaemic stroke onset offers
sugar, electrocardiogram, and serum
substantial net benefits for virtually all patients
cholesterol and triglycerides (Andre et al.,
with potentially disabling deficits (Huang et
2008). These tests are far cheaper than CT and
al., 2011).
MRI, and they are regarded as the minimum
Intravenous fibrinolytic therapy at the series of investigations that a new stroke
cerebral circulation dose within 3-4.5 hours patient should have. These investigations and
offers moderate net benefits when applied to tests assist clinicians to subcategorise patients
all patients with potentially disabling deficits at three specific levels: to separate strokes
(Huang et al., 2011) from non-strokes (for example, cerebral
tumours), to distinguish haemorrhage from
MRI of the extent of the infarct core
infarction and to identify specific
(already irreversibly injured tissue) and the
pathophysiological subtypes of cerebral
penumbra (tissue at risk but still salvageable)
infarction which influence decisions
can likely increase the therapeutic yield of
concerning therapy and prognosis. However,
lytic therapy, especially in the 3- to 9-hour
it is mainly neuroimaging that can help
window (Diedler et al., 2010)
clinical decision making and subsequent
Intra-arterial fibrinolytic therapy in treatment options (Kane et al., 2008; Kane et
the 3- to 6-hour window offers moderate net al., 2007).
benefits when applied to all patients with

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Globally, there are two main types of medical (Jauch et al., 2013; Boatright, 2003).
treatment that are prescribed for patients with Currently, thrombolysis for stroke with the
stroke (Rothwell et al., 2011; Sakai et al., innovation of Recombinant Tissue
2008). Plasminogen Activator (rt-PA) is a major
breakthrough in the treatment of acute stroke
a) Basic medical treatment which
although the therapeutic window for such a
includes standard medical treatment, routine
treatment is narrow, that is 3 hours from
nursing care and simple dietary
onset (Butcher et al., 2003). Furthermore
recommendations that is often given with little
there are certain inclusion criteria that have
or no monitoring to virtually all patients and
to be met before a patient is offered this
usually delivered in conventional medical
option but in any case stroke should be
wards and,
treated as a very urgent condition where
b) Interventional treatments which are every minute counts (Wardlaw et al., 2003).
complex and are more invasive, costly and
Along these lines, the American Stroke
technically challenging to administer and
Association proposed an alternative term for
monitor, usually delivered in specialised
stroke, which is: Brain Attack, in order to
neurology or stroke-specific dedicated wards.
underline the message: time is brain and
The first type of treatment consists of just as a myocardial infarction is conceived
administrating aspirin, fixed-dose as an urgent medical condition by the health
subcutaneous heparin, oral calcium antagonists care personnel and the wider public,
and corticosteroids (Georgiadis et al., 2013; likewise, the brains version of heart attack
Hills and Johnston 2008). should be treated as a medical emergency
accordingly (Dhamija and Donnan, 2007;
The complex ones are fibrinolytic drugs,
isorolalmic haemodilution, intravenous Alberts et al., 2005).
naftidrofuryl, hyperbaric oxygen, intravenous Cost implications of stroke
inhibitors of excitatory amino acids and the
The above mentioned interventions are
administration of thrombolytic agents
measures for acute stroke management and
(Nutescu et al., 2004). Yet, in the recent years,
should be carefully budgeted. This is
highly sophisticated devices came in use,
especially relevant to date due to the heavy
designed to stabilise an intracranial aneurysm,
burden of austerity that most national health
thus avoiding a haemorrhagic stroke.
care systems are facing in combination with
Moreover, in patients beyond the systemic
the rising numbers of elderly at risk of stroke.
thrombolysis therapeutic window, other
devices have been used more often, to perform Stroke currently consumes significant
mechanical embolectomy. These are also resources through healthcare costs and
known as clot retrievals such as the Stentriever disability. The cost of stroke to the British
or the Merci Retriever device. Overall, these NHS is estimated to be 2.8 billion and the
have shown higher recanalisation rates and financial burden extended to the wider
better outcomes for embolic stroke (Mokin et economy is summed up to 1.8 billion (Lee et
al., 2014; Murthy et al., 2014; Hassan et al., al., 2011). These costs are mainly due to the
2013; Alshekhlee A., et al., 2012). complexity of nursing stroke patients as their
care requires a multi-disciplinary approach.
For many years stroke was believed to be a
low-urgency medical situation. Yet, today A recent study shows that stroke units could
the recognition for urgency of treatment is of reduce costs by $ 240 million in Canada
paramount importance as the most important (Gladstone et al., 2009). It is also worth noting
aim in treating stroke is maintenance of that at the turn of the millennium, 28% of total
perfusion of the ischaemic penumbra, which stroke incidence occurs in individuals under
is the area of the brain where blood supply is the age of 65 and accounts for 20% of all
restricted due to the thrombus or emboli but acute, and 25% of all chronic care beds. There
these nerve cells have a good chance of has also been a significant increase in the
survival if the occlusion is removed soon absolute figure of hospitalisations for acute

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stroke over the last 20 years with a projected 2,300 on average. Overall, the highest costs
increase of 10% in 1996 to a projected 15% in are associated with stroke patients who died in
2016 (Matchar and Samsa, 2000). hospital as compared to survivors with similar
length of stay. Independent predictors of cost
Hospitalisation makes up 87% of the total
included the stroke type, stroke severity on
direct cost of stroke care, which was estimated
admission, type of admission ward and status
by the Heart and Stroke Foundation of Canada
on discharge.
to be 2.8 billion dollars in 1996. However, this
cost does not include costs related to either Approximately half of all individuals who
short- or long-term disability. Such costs may survive a stroke are disabled to some degree
be considerable since, in the case of ischaemic because of a persisting neurological
stroke, only 25% of people make a full impairment. The cost of treatment is expensive
recovery (Goeree et al., 2005). More recent as it accounts for approximately 10% bed-day
costs are available for the U.S., where the costs. Therefore, the rehabilitation process
estimated direct cost for stroke in 2004 is 33 must either improve functional ability in
billion dollars - 41% of this is due to hospital patients or must reduce long-term cost. In this
costs reflecting the expense of acute care light, acute stroke unit care is more cost-
(Luengo-Fernandez et al., 2009). Indirect costs effective than medical ward care when it
due to loss of productivity are estimated at reduces disability within a relatively short
53.6 billion dollars (van Exel et al., 2003). length of stay (Sheppard and Ko, 2009).
Given the trends observed in stroke worldwide Conclusions
over the last three decades and the associated
Stroke has a major impact on society and yet
steep rise in costs, stroke is, and will remain a
there is notable room for improvement even in
significant problem for North American and
countries with sophisticated health care
other societies, especially in the western world
systems. Its high incidence and frequency of
although considerable savings can be made
prolonged survival requires a heavy
with prompt and readily available
investment in human and financial resources
comprehensive services for stroke patients.
for provision of care. On the other hand, the
Acute stroke care on a neurological ward is rising hospital costs coupled with a growing
less costly than care on a stroke unit but the elderly population limit the financial resources
latter is known to have better outcomes. The of the health care system, and therefore, a
higher costs of stroke unit care are due to better analysis and development of the long-
diagnostic procedures and personnel. term care continuum is required.
However, intensive non-medical costs tend to
Overall, stroke patients necessitate a higher
decrease. Thus, stroke unit care seems to be
acuity medical setting with specialised
more outcomes oriented but selection bias of
personnel providing complex diagnostic and
patients could lead to underestimation of cost
treatment modalities. Although these services
differences. As cost-effective medical care for
are expensive in the acute phase, the benefits
stroke is important, future studies are needed
ensuing from them lead to notable savings and
to assess this plus the cost-benefit ratio of
improved patient outcomes during the
different stroke care concepts (Epifanov et al,
rehabilitation phase. Therefore, stroke units
2007).
and swift medical and nursing interventions
A study in Greece by Gioldasis et al., (2008) not only save lives but can also improve the
calculated the in-hospital cost of stroke based quality of life for stroke survivors.
on real costs for the resources used, showing
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