MANAGEMENT OF

ACUTE STROKE
DR. BABAKURA AUDU GUBIO
DEPT. OF INTERNAL MEDICINE, FMC GUSAU.
18TH JANUARY, 2022

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OUTLINE
• INTRODUCTION
• Definition, epidemiology, classification, risk factors
• DIAGNOSIS
• HISTORY
• EXAMINATION
• INVESTIGATION
• TREATMENT AND PATIENT STABILISATION
• Specific therapy
• Acute complications
• Early secondary prevention.
• Early rehabilitation.

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INTRODUCTION: Definition
Stroke is defined as rapid onset of global or focal neurological deficit,
lasting >24 hours and/or leading to death, which is the result of a
vascular lesion and associated with infarction of central nervous tissue.
Others related terms:
stroke in evolution – signs and symptoms worsening
minor stroke – without significant neurological deficit, usually within 1
week
TIA – transient episode of neurological dysfunction caused by focal
brain, spinal cord or retinal ischaemia without acute infarction.

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INTRODUCTION: Epidemiology
• Most common life-threatening neurologic disease
• Third most common cause of death globally, 2nd most common cause
of dementia, epilepsy in elderly and depression.
• Incidence in India: 73/1,00,000 per year
• Burden is likely to increase with risk factors like aging, smoking,
adverse dietary patterns
• Most common cause of disability and dependence, with more than
70% of stroke survivors remaining vocationally impaired and more
than 30% requiring assistance with daily activities

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 INTRODUCTION:
Classification
Ischaemic stroke accounts
for about 85%, while
haemorrhagic accounts for
15% (ICH 10% and SAH 5%).
Mortality is about 13% in
ishaemic and 70% in
haemorrhagic stroke

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Risk Factors for Stroke
Although some strokes occur without warning, most stroke victims
have prior risk factors.

Major strokes can be prevented in many cases, but only if early signs
and symptoms are heeded.

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Well-Documented

Modifiable Risk Factors

• Hypertension • Atrial Fibrillation

• Smoking • Hyperlipidemia
• Diabetes • Sickle Cell Disease
• Asymptomatic Carotid • Other cardiac diseases
Stenosis

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Less Well Documented

Potentially Modifiable Risk Factors

• Obesity • Hypercoagulability
• Physical Inactivity • Hormone Replacement
• Poor Diet/Nutrition Therapy
• Alcohol Abuse • Oral Contraceptive Use
• Drug Abuse • Inflammatory Process

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Non-modifiable Risk Factors
• Age
• Sex
• Race/Ethnicity
• Family History

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 TIME LOST
IS
BRAIN LOST
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Mainstay in Management of Acute Stroke
• Confirm diagnosis to provide therapeutic decisions
• Treatment of general conditions that influence lont-term functional
outcome (BP, body temp, glucose level, fluid balance, etc)
• Specific therapy directed against particular aspects of stroke
pathogenesis.
• Prevention and treatment of complications either medical or
neurosurgical
• Early secondary prevention, to reduce incidence of early recurrence
• Early rehabilitation to maximise independence

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DIANOSIS: History
Signs and symptoms
SUDDEN:
• numbness or weakness of face, arm, or leg, especially on one side of the
body
• confusion, trouble speaking or understanding,
• trouble seeing in one or both eyes

• trouble walking, dizziness, loss of balance or coordination

• severe headache with no known cause

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TIME TARGET
Door to doctor 10 minutes

Door to CT† completion 25 minutes

Door to CT read 45 minutes
Door to treatment 60 minutes
Access to neurological expertise‡ 15 minutes

Access to neurosurgical expertise‡ 2 hours

Admit to monitored bed 3 hours

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DIANOSIS: History
Distinguishing Features:
• Appear more seriously ill
• Deteriorate more rapidly
• Severe headache
• Alteration in consciousness
• Nausea and/or vomiting
• Neck pain
• Intolerance of noise or light

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History
• Comorbid condition-DM, HTN, HF, SCA, Ca, Atrial fibrillation, prev.
stroke, epilepsy, psychiatric disorders
• Current medications if any including HRT, anticoagulants.
• History of recent major surgery
• History of alcohol, smoking
• History of trauma
• History of bleeding disorders

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DIANOSIS: Examination
Common signs of stroke include the following:
• Acute hemiparesis or hemiplegia
• Complete or partial hemianopia, monocular or binocular visual loss,
or diplopia
• Dysarthria or aphasia
• Ataxia, vertigo, or nystagmus
• Sudden alteration in consciousness

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DIANOSIS: Investigations
• Brain imaging CT or MRI (posterior fossa ischaemic lesions).
• ECG, ECHO.
• FBC, Clotting profile.
• Serum electrolytes.
• Blood glucose.
• Hepatic and renal parameters.
• CRP or ESR.
• PT

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The rationale of early neuro-imaging is to
• Identify the lesion
• Determine the type of stroke
• Localise the stroke
• Quantify the lesion
• Determine the age of the lesion
• If haemorrhagic, what is the possible etiology?

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 Ischemic stroke diagnostic algorithm

Acute focal brain deficit Excluded hypoglycemia, migraine

with aura, post-seizure deficit

< 1 hour TIA (if CT/MR brain imaging

Head CT without ischemic lesion)

Ischemic Stroke

Cortical Lacunar syndrome

syndrome
Doppler MRI Vasculopathy CRYPTOGENIC
MRA CT Coagulopathy STROKE
ECG Angiogram
Echo

CARDIAC LARGE ARTERY SMALL OTHER DETERMINED

EMBOLISM ATHEROSCLEROSIS VESSEL DISEASE CAUSE

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Stroke
Algorithm

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Severity Assessment
NIHSS (Nat. Inst. Of Health Stroke Scale) is the standardized method used
by health care professionals to measure the level of impairment caused
by a stroke.
Purpose is to determine whether a tPA is required or not based on the
severity.
13 item scorring system, 7 minutes examination. Integrates visual, motor,
sensory, cerebellar, inattention, language, LOC.
Maximum of 42, minimum of 0
0 no stroke, 1-4 minor, 5-15 moderate, 16-20 moderate-severe, and 21-
42 severe stroke.
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GENERAL STROKE TREATMENT
• Monitoring
• Pulmonary and airway care
• Fluid balance
• Blood pressure
• Glucose metabolism
• Body temperature

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monitoring
• Continuous monitoring >24hrs
• HR
• RR
• SaO2
• Intermittent monitoring
• BP
• Blood glucose
• Vigilance (GCS), pupils
• Neurological status (e.g. NIHSS)

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Pulmonary and airway care
• Adequate O2 is important to maintain saturation at >94%
• Mechanical airway protection in comatose patients

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Fluid balance
• The fluid of choice is N/saline administered at 50-100ml/hr except
otherwise contraindicated.
• Avoid use of dextrose containing fluid except when indicated
• If patient is hypovolaemic, resuscitate adequately with volume
expanders or crystalloids.

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Blood pressure
• Elevated in most patients with acute stroke either as a cause of stroke
or reflex.
• It spontaneously drops during the first 24hrs in most patients
• Blood flow in the critical penumbra is passively dependent on the
MAP
• Avoid and treat hypotention, either with fluid or vasopressors
depending on the patients hydration status
• DOC is labetolol max of 300mg, others such as amlodipine,
nicardipine can also be used.

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 NOTHING UNDER THE
TONGUE (SUBLINGUAL
NIFEDIPINE)

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Hypertension in AIS
Decreasing BP in certain conditions
• Acute ischemic stroke: SBP >220 ; DBP > 120
• Acute Ischemic Stroke with hypertension :
• Hypertensive encephalopathy; Aortic dissection; Acute MCI; Acute lung
edema; ARF
• Goal is to lower blood pressure by 15% during the first 24 hours after
onset of stroke.

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Hypertension in HS
Decreasing BP in certain conditions
• SBP >200 mmHg or MAP >150 mmHg - aggressive reduction of BP with
cont. i.v., BP monitoring every 5’.
•  SBP >180 mmHg or MAP >130 mmHg and elevated ICP - monitoring ICP
and reducing BP using intermittent or cont. i.v. to keep CPP > 60 - 80 mmHg.
• SBP >180 mmHg or MAP >130 mmHg and no elevated ICP àmodest
reduction of BP (eg, MAP of 110 mmHg or target BP of 160/90 mmHg) using
intermittent or cont. i.v. medications to control BP, and clinically reexamine
the patient every 15’.
• For ICH patients with SBP between 150 and 220 mm Hg who lack
contraindications to BP lowering, decreasing SBP to <140 mm Hg is safe and
can improve functional outcome.
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Glucose Metabolism
• If <3mmol/l, resuscitate as per any other case using dextrose fluid
• If >10 mmol/l, use insulin to achieve euglycaemia
• Both conditions lead to poor outcome, leading to poor tissue
recovery.
• Hypoglycaemia can also mimic acute ischaemic infarction
• In patients on NPO, maintain with dextrose or NG tube feeding.

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Body temperature
• Fever is associated with poorer neurological outcome after stroke
• Fever increases infarct size in experimental stroke
• Many patients with acute stroke develop a febrile infection
• It is common practice treat fever (and its cause) when the
temperature reaches 38°C
• However, it is important to look for other causes of fever and treat
appropriately, as it may co-exist with stroke

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SPECIFIC STROKE TREATMENT
Stroke can be both a medical and surgical emergency
• Thrombolytic therapy
• Early Antithrombotic treatment
• Treatment of elevated ICP
• Prevention and management of complications

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Thrombolytic therapy
• IV rtPA (0.9mg/kg max 90mg over 1 hour) given within 3-4.5 hrs of
stroke onset, significantly improves outcome in patients with AIS
• Exclusion criteria
• age (<18 or >80)
• Oral anticoagulant, heparin 48hrs prior to stroke. INR =< 1.7
• Coexisting DM, major surgery within the last 3weeks, CHF, severe stroke
• Repeat CT after 24hrs and stop if ICH suspected.

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Antiplatelet therapy
• Aspirin 50-150mg daily alone or in combination with dipyridamole or
clopidogrel in patients intolerant to Aspirin.

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Anticoagulation
Anticoagulants are not recommended except in the setting of AF, MI
risk, prevention of DVT, prosthetic valves, coagulopathies.
• UFH
• LMWH
• Heparinoid

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Elevated ICP
• Basic management
• HOB 30o
• Pain relief and sedation esp. in haemorrhagic due to severe headache and to
reduce agitation.
• Osmotic agents (Mannitol, hypertonic saline)
• Ventilatory support
• Normothermia
• Barbiturates ( to induce coma (rare))
• Surgical decompressive therapy

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Surgical intervention
• Surgical decompressive therapy in patients unresponsive to medical
management of raised ICP
• Carotid endarterectomy is critical carotid artery stenosis
• Baloon embolisation , clipping of aneurysm neck in aneurysm.

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Management of Complications
• Aspiration and pneumonia
• Preventive strategies: withhold oral feeding until dysphagia ruled out, NG
tube or PEG, freq. change of patient’s position in bed and pulmonary physical
therapy
• UTI
• Freq. change of catheter forth nightly
• Detect and treat promptly
• DVT and PE
• Good hydration and early mobilisation
• Use of Low dose LMWH (without any significant risk of ICH or ECH).

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Management of complications
• Pressure ulcers
• Use of support surfaces, freq. repositioning, nutritional optimization,
moisturizing sacral skin care.
• When developed, proper dressing.
• Seizures
• Prophylaxis not routinely advocated
• Agitation
• Casual treatment must precede any type of sedation or antipsychotic treatment
• Falls
• Dysphagia and feeding: NG or PEG feeding.
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Early rehabilitation
• Active rehabilitation as early as possible once patient is stable
• If patient is unconscious and paralyzed, passive rehabilitation
• Rehabilitation is continued as long as perceptible recovery is taking
place
• Involvement of social workers
• Occupational therapy should also be offered
• Detect and treat depression and anxiety which are common.

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Prevention of stroke and recurrence
• Treatment of underlying conditions
• Use of lipid lowering statins
• Diet and lifestyle modification e.g. cessation of smoking, low salt diet,
low fat intake, increase exercise, decrease alcohol intake, reduce
weight, etc.
• Control DM, dyslipidaemia, BP.
• Address and promptly treat TIA

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THANK YOU
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