ischaemic stroke management Flashcards
(26 cards)
What is the time frame for administering intravenous alteplase for acute ischaemic stroke?
Within 4.5 hours of onset of symptoms
Earlier treatment has better outcomes
What is the main adverse effect of intravenous alteplase?
Bleeding, including symptomatic intracranial haemorrhage
also angiodema which may compromise airway and extracranial haemorrhage
This is a critical consideration when administering thrombolysis
What should be done if a patient has raised blood pressure before starting thrombolysis?
Treat the blood pressure to 185/110 mmHg or lower
Possible drugs include glyceryl trinitrate and labetalol
What is the recommended monitoring period after administering intravenous alteplase?
24 hours
Blood pressure and neurological status should be monitored during this time
What should be done if blood pressure exceeds 185/110 mmHg after alteplase infusion?
Treat promptly, aiming to maintain it below this level
How long should aspirin be withheld after administering alteplase?
24 hours
This is to minimize the risk of haemorrhage
What is endovascular thrombectomy used for?
Occlusion of a large vessel
ie distal internal carotid artery, proximal middle cerebral artery [M1 segment], basilar artery
What is the time frame for performing endovascular thrombectomy after symptom onset?
Within 6 hours
It can also be effective for patients presenting 6 to 24 hours after onset with salvageable brain tissue
When is endovascular thrombectomy appropriate?
Usually a subset of patients receiving alteplase, and they can have both. Also indicated when intravenous alteplase is contraindicated or when patients present too late for alteplase therapy
when should you prescribe aspirin in acute ischaemic stroke
modest benefit if given within 48 hours
do not give aspirin until brain imaging has excluded haemorrhage
in patients who have received alteplase, withold for 24 hours and do not give until follow up imaging has excluded haemorrhage
What should be done before administering aspirin to a stroke patient?
Exclude intracranial haemorrhage via brain imaging
What is the initial dose of aspirin to be administered on the first day after ischaemic stroke?
300 mg orally or via nasogastric tube or rectally
What should the aspirin dosage be on the second day following ischaemic stroke?
100 mg daily and continue indefinitely
What is a reasonable alternative to aspirin for patients who are allergic?
Another standard antiplatelet drug, such as clopidogrel
should you use intravenous fluids containing glucose
avoid these
hyperglycaemia is associated with worse outcome in stroke
treat hypoglycaemia if BGL is <60
What is a potential complication of IV thrombolytic therapy that can compromise the airway?
Angioedema
Angioedema can occur as a reaction to thrombolytic therapy, necessitating immediate intervention.
What should be done if angioedema occurs during IV thrombolytic therapy?
Stop tPA infusion and any ACE inhibitors
secure airway
administer methylprednisolone, diphenhydramine, famotidine
What is the management protocol for angioedema during IV thrombolytic therapy?
Administer medication in rapid sequence
Methylprednisolone, Diphenhydramine, Famotidine
What complication should be suspected in case of sudden neurological deterioration or headache after IV thrombolytic therapy?
Intracranial hemorrhage
What is the first step if intracranial hemorrhage is suspected?
Stop tPA infusion and obtain immediate noncontrast head CT
order CBC, coagulation panel, fibrinogen level, blood type and screen, crossmatching
consult neuro and haematology
administer cryoprecipitate and TXA
additional measures after thrombolysis
check neurological status frequently
obtain follow up head CT non-con or MRI 24 hours after thrombolysis, prior to starting anticoagulants or anti platelet drugs
neuroprotective measures
targeted temperature management, treat any temperature >38
avoid neurogenic fever
hypothermia is not recommended for acute stroke
treat hypoglycaemia <60
supportive care post acute stroke
keep patient NPO until risk of aspiration is assessed
VTE prophylaxis: mechanical preferred
early rehabilitation and mobilisation
screen for depression
antiplatelet therapy
aspirin or clopidogrel if aspirin allergy
consider DAPT for minor strokes
