Hub teaching

Management of stroke
Dr Solomon Oladele
 Outline
• Case presentation
• General overview of stroke
• Assessment
• Management of stroke
• Conclusion
 Case presentation
• 54yr old man
• 6 days history of headache, slurred speech, left facial weakness and
general unwell
• 7 TIA episodes and 2 major strokes
• Hypertensive, DM, hypercholesterolemia, smoking, alcohol
• Observation stable
• GCS-15, L. facioparesis, subtle weakness on the right.
 Case presentation
• Stroke was diagnosed
• Discussion with Acute stroke unit
• Agreed on hospital admission
• Events at hospital
• Post discharge update
 Overview of stroke
• Stroke is a clinical syndrome of presumed vascular origin characterized by
rapidly developing signs of focal or global disturbance of cerebral
functions which lasts longer than 24 hours or leads to death.[TIA <24hrs]
• About 85% of strokes are ischaemic and 15% of strokes are haemorrhagic.
• There are around 100,000 strokes every year in the UK
 Overview of stroke
• Risk factors for stroke and TIA
• Lifestyle factors- Smoking, EtOH misuse, physical inactivity
• Established CVD- HTN, VHDx, IHDx, AF
• Other medical conditions- DM, TGL,
• Social factors-Age,
 Management of stroke
• Management from primary care perspective
• First contact- UCC/GPS
• Follow up after discharge from hospital
 Management of stroke
• History
• Examination
• Initial care/first aid
• Emergency admission/Urgent referral as appropriate
 Assessment for suspected stroke
• History- Neurological deficit-Onset, time, and duration. Other associated
symptoms
• Risk factors for CVD
• Rapid ABCDE assessment for deteriorating patient
• Specific neurological examination- FAST
• Emergency hospital admission/urgent referral as appropriate
 Time-sequence
of event in stroke
• Umbra change
• Penumbra
 NICE Guidance for suspected stroke
• How should I manage a person with suspected acute stroke?
• Arrange immediate emergency admission to an acute stroke facility for anyone with suspected acute
stroke or emergent transient ischaemic attack (TIA).
• Ensure the hospital receives advanced notification of arrival — this should include details of time of
onset, symptom evolution, current condition, and medications (especially anticoagulants).
• Do not start anticoagulation (for example in people with atrial fibrillation) or antiplatelet treatment in
people following ischaemic stroke until intracerebral haemorrhage has been excluded by brain imaging.
• While awaiting transfer:
• Monitor and manage any deterioration in clinical condition (airway, breathing, and circulation [ABCs]).
• Give supplemental oxygen to people with acute stroke if oxygen saturations are less than 95% and there are no
contraindications.
 NICE Guidance for Suspected TIA
• How should I manage a person with suspected TIA?
• For people who have had a suspected TIA within the last week:
• Offer aspirin 300 mg immediately- If aspirin is contraindicated discuss management urgently with the specialist
team. If already taking low dose aspirin regularly to continue — do not offer them aspirin 300 mg.
• Refer the person for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms.
• Urgent CT scan to exclude haemorrhage, if history of bleeding disorder.
• For people who have had a suspected TIA more than 7 days ago:
• Refer for specialist assessment as soon as possible within 7 days.
• Give patients and their family/carers information on the recognition of stroke and TIA + appropriate advice
 Conclusion
• Stroke and TIA is an actual emergency
• Time is of utmost importance in the management
• Prompt admission and timely intervention improve outcome and
prognosis
 Reference
• NICE clinical knowledge summary: Stroke and transient ischaemic
attacks; https://cks.nice.org.uk/topics/stroke-tia/
• ACLS Suspected stroke algorithms;
https://www.vascularsociety.org.uk/_userfiles/pages/files/Resources/ACL
S%20Suspected%20Stroke%20Algorithm.pdf
• Stroke: What you need to know;
https://myheart.net/articles/stroke-what-you-need-to-know/