Management of Acute Stroke 2

General management and drug therapy

• Do not prescribe antihypertensive drugs, warfarin or other anticoagulant, heparin or steroids except after discussion with a consultant. There is no evidence of harm from temporarily withholding antihypertensive drugs in patients early after stroke. Early blood pressure lowering may benefit patients with intracranial haemorrhage or who receive thrombolytic therapy. This should only be commenced after discussion with a stroke specialist.
• Blood glucose:
  • If low – correct. See GGC guideline "Diabetes, Algorithm for Treatment of Hypoglycaemia in Adults with Diabetes" for more information.
  • If high – may require insulin but important to avoid hypoglycaemia. See GGC guideline "Diabetes, Inpatient Prescribing FAQs for Junior Doctors" for more information.
• All patients should receive fluids. Prescribe intravenous fluids as clinically indicated and adjust infusion volume as clinically necessary.
• Oxygen saturation: Target O₂ saturation is 95% – if <95%, change posture, clear upper airway, start oxygen supplements as clinically appropriate.
• After CT brain - see below for information.
• Temperature >37.5ºC and evidence of infection:

  If aspiration probable, commence appropriate antibiotic therapy while awaiting culture results and give paracetamol (oral or per rectum) 1g every four to six hours as required (maximum dose 4g/day). N.B. Consider dose reduction in patients with low body weight (<50kg), renal impairment, glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15mg/kg/dose up to four times daily (max 60mg/kg/day). An example is: paracetamol oral 500mg four times daily. Patients with chronic liver failure may require a further dose adjustment (7.5mg/kg/dose, max 30mg/kg/day).

• Atrial fibrillation: for management, see here.
• DVT prophylaxis: for management, see here and also protocols in stroke units regarding intermittent pneumatic compression (IPC) stocking use.

After CT brain

If CT scan shows no haemorrhage, prescribe a 'one-off' dose of aspirin oral 300mg (or PR if swallow impaired). Ensure aspirin is given immediately, i.e. do not leave for administration at the next morning's drug round. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel can be used in people with non-cardioembolic minor ischaemic stroke (NIHSS score of 3 or less) or high-risk TIA (ABCD score of 4 or more) in the past 24 hours, if diagnosis is confirmed by a stroke specialist and brain imaging has excluded intracranial haemorrhage (ICH). DAPT is usually used for 21 days then the patient is continued on clopidogrel oral 75mg daily for long-term treatment.

If patient has had thrombolysis, delay aspirin initiation for 24 hours and ensure a follow up CT brain scan is done before aspirin is administered. After the initial stat dose of aspirin, further antiplatelet therapy should be prescribed as per guidance in Secondary Prevention of Stroke and TIA.

If CT scan shows haemorrhage:

• Consider Neurosurgical referral.
• Check urgent coagulation screen and discuss treatment of coagulopathies with consultant.
• Stop all antithrombotics or anticoagulants the patient may have been on previously, and consider anticoagulant reversal – should be discussed with consultant.

If CT scan shows an alternative pathology (e.g. tumour, subdural haematoma), discuss with consultant.

Patient deterioration after admission

In the event of deterioration after admission, re-examine and specifically:

• Check oxygenation and correct hypoxaemia with oxygen supplementation and postural change.
• Check BP: treat as outlined at the start of this guideline.
• Check temperature: if pyrexial, check for signs of infection and treat. Also administer antipyretic (paracetamol dose as above).
• Check blood sugar and correct hypoglycaemia, consider insulin for hyperglycaemia (blood glucose >9mmol/L). See above for links to GGC guidelines. 
• Consider repeat ECG and treat as appropriate.
• Reconsider potential indications for urgent CT or discuss repeat CT with stroke consultant.
• Proximal occlusion of the middle cerebral artery can lead to a large cerebral infarct which may go on to develop cerebral oedema, causing raised intracranial pressure, deteriorating consciousness level, loss of consciousness and eventual death. This syndrome is more common in younger stroke patients. If any clinical suspicion of Malignant Middle Artery Syndrome, request immediate CT brain scanning and refer to Neurosurgery for possible hemicraniectomy to relieve the intracranial pressure.