MANAGEMENT OF STROKE
Stroke: Definition
Stroke is clinically defined as a neurologic
syndrome characterized by acute disruption of
blood flow to an area of the brain and
corresponding onset of neurologic deficits
related to the concerned area of the brain
Nurs Clin N Am 2002;37:35-57
The Burden of Stroke
Most common life-threatening neurologic disease
Third most common cause of death globally
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
Stroke 1998;29:1730-36
Neurol India 2002;50:279-81
Stroke: Classification
Ischemic stroke: Account for 80%. Results from
occlusion in the blood vessel supplying the brain
Thrombotic: Occlusion due to atherothrombosis
of small/large vessels supplying the brain
Embolic: Occlusion due to embolus arising
either from heart (e.g. atrial fibrillation, valvular
disease) or blood vessel
Classification (contd.)
Hemorrhagic stroke: Account for 20%. Results from
rupture of blood vessels leading to bleeding in brain
Intracerebral: Bleeding within the brain due to
rupture of small blood vessels. Occurs mainly
due to high blood pressure
Subarachnoid: Bleeding around the brain;
commonest cause is rupture of aneurysm.Other
causes: Head injury
Stroke: Predisposing factors
Age (risk doubles for every decade after age 55)
Gender (males>females)
Family history of stroke/TIA
Hypertension
Diabetes
Hyperlipidemia
Hyperhomocysteinemia
Obesity
Smoking
Atrial fibrillation
Sedentary lifestyle
Drug abuse (e.g. cocaine use)
Hormone replacement therapy
Oral contraceptive
Stroke: Symptoms
Onset of stroke symptoms varies as per type of
stroke
Thrombotic stroke: Develop more gradually
Embolic stroke: Hits suddenly
Hemorrhagic stroke: Hits suddenly and
continues to worsen
Stroke: Symptoms (contd.)
Dizziness
Confusion
Loss of balance/coordination
Nausea/vomiting
Numbness/weakness on one side of the body
Seizure
Severe headache
Movement disorder/speech disorder/blindness etc (depending on the area of brain
affected)
Additional symptoms for hemorrhagic stroke
Pain upon looking at or into light
Painful stiff neck
People may also experience “silent
strokes” with no symptoms
A silent stroke is a stroke which causes brain damage,
but does not exhibit classic symptoms of stroke.
They are detected only when a person undergoes a
brain scan.
Transient Ischemic Attack (TIA)
“Mini stroke”
Stroke symptoms last for less than 24 hours (usually
10 to 15 mins)
Result as a brief interruption in blood flow to brain
Every TIA is an emergency
TIA may be a warning sign of a larger stroke
Patients with possible TIA should be evaluated by a
physician
Diagnosis of acute ischemic stroke
Physical examination: For carotid bruits
Brain imaging (cranial CT and/or MRI): Detect small
vessel disease. Helps to effectively discriminate
between ischemic and hemorrhagic stroke, and
stroke from brain tumours
Doppler ultrasonography/Angiography: Detect large
vessel atherosclerosis
ECG/Echocardiography: Detect cardiac embolism
Exclusion of conditions mimicking stroke
(hypoglycemia, migraine, seizure)
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
Lacunar syndrome
Cortical
syndrome Doppler MRI Vasculopathy CRYPTOGENIC
MRA CT Coagulopathy STROKE
ECG Angiogram
Echo
CARDIAC LARGE ARTERY SMALL OTHER DETERMINED
EMBOLISM ATHEROSCLEROSIS VESSEL DISEASE CAUSE
Emergency Medical Care for Neurologic
Emergencies
• Provide reassurance.
• Ensure proper airway and breathing.
• Place the patient in a position of comfort.
• If you suspect stroke, transport immediately and
notify hospital.
• Assess and care for any injuries if you suspect any
type of trauma.
Management of acute ischemic stroke
Systemic thrombolysis: Intravenous recombinant
tissue plasminogen activator (rt-PA): Within 3 hrs of
onset of stroke. Dose 0.9 mg/kg, max 90 mg.
Antiplatelet agents: Aspirin 160-300 mg within 24-
48 hrs (not during first 24 hrs following thrombolytic
therapy). Clopidogrel a potential alternative.
Combination of clopidogrel and aspirin currently
being evaluated
Management of acute ischemic stroke
(CONTD)
Anticoagulants: Heparin/LMWH are not
recommended in acute treatment of ischemic
stroke. Recommended in setting of atrial
fibrillation, acute MI risk, prosthetic valves,
coagulopathies and for prevention of DVT.
Intra-arterial thrombolytics: An option for
treatment of selected patients with major
stroke of < 6 hrs duration due to large vessel
occlusion.
Management of acute ischemic stroke
(CONTD)
BP management: Should be kept within higher
normal limits since low BP could precipitate perfusion
failure. Markedly elevated BP (>220/110mmHg)
managed with nitroglycerin, clonidine, labetalol,
sodium nitroprusside. More aggressive approach is
taken if thrombolytic therapy is instituted
Blood glucose management: Should be kept within
physiological levels using oral or IV glucose (in case
of hypoglycemia)/insulin (in case of hyperglycemia)
Elevated body temperature management:
Antipyretics and use of cooling device can improve
the prognosis
Management of Acute hemorrhagic stroke
Analgesics/Antianxiety agents: To relieve headache.
Analgesics having sedative properties are beneficial for
patients having sustained trauma (e.g. morphine sulphate)
Antihypertensives:(e.g. sodium nitroprusside, labetolol)
Hyperosmotic agents (e.g. mannitol, glycerol,
furosemide): To reduce cerebral edema, and raised
intracranial pressure.
Adequate hydration is necessary
Surgical intervention may occasionally be life saving
Management of TIA
Evaluation within hours after onset of
symptoms
CT scan is necessary in all patients
Antiplatelet therapy with aspirin (50-325 mg/d),
consider use of clopidogrel, ticlopidine, or
aspirin-dipyridamole in patients who are
intolerant to aspirin or those who experience
TIA despite aspirin use
Secondary prevention of stroke
Recurrence: Annual risk is 4.5 to 6%. Five year recurrence rates range
from 24 to 42%; one-third occur within first 30 days, hence high priority
should be given to secondary prevention.
Patients with TIA or stroke have an increased risk of MI or vascular event.
Management of hypertension (goal <140/85 mm Hg)
Diabetes control (goal<126 mg/dL)
Lipid management: Statins (goal cholesterol<200 mg/dL, LDL<100 mg/dL)
Antiplatelet agents: Aspirin (50-325 mg), clopidogrel (75 mg). A fixed dose
combination of the two drug may also be used
Anticoagulants: Warfarin (target INR 2 to 3); esp. recommended in
patients with cardioembolic stroke
Appropriate life style modification (cessation of smoking, exercise, diet etc)
Surgical interventions
Balloon angioplasty/stenting
Carotid endarterectomy/Bypass
Decompressive surgery
