stroke management Flashcards
blood pressure management in acute stroke
should NOT be lowered in acute phase of ischaemic stroke
- unless prior to thrombolysis
bp control should be considered for patients who present with an acute ischaemic stroke if;
- present within 6hrs
- systolic bp >150
how and when should aspirin be given in acute ischaemic stroke
aspirin 300mg orally or rectally should be given ASAP if haemorrhagic stroke has been excluded
how should anticoagulation be managed in those with AF having an acute ischaemic stroke
anticoags should not be started until imaging has excluded haemorrhage
+ not until 14days has passed since onset of stroke
when should a patient presenting with stroke be started on a statin
if cholesterol >3.5
- delay tx until after at least 48hrs due to risk of haemorrhagic transformation
criteria for thrombolysis with alteplase or tenecteplase
- administer within 4.5hrs of onset of stroke sx
- haemorrhage has been defo excluded (imaging done)
extended inclusion criteria for thrombolysis
cute ischaemic stroke, regardless of age or stroke severity, who were last known to be well more than 4.5 hours earlier, should be considered for thrombolysis with alteplase if:
- tx can be started between 4.5 - 9hrs of know onset
AND - have evidence from CR/MRperffusion or MRI of potential to salvage brain tissue
blood pressure management prior to thrombolysis
lowered to 185/110 before thrombolysis
absolute contraindication to thrombolysis
- previous intracranial bleed
- seizure at onset of stroke
- intracranial neoplasm
- suspected SAH
- stroke or trauma brain injury in last 3 months
- lumbar puncire in prev 7 days
- GI bleed in prev 3 weeks
- active bleeding
oesophageal varices
uncontrolled hypertension >200/120
relative contraindication to thrombolysis
- pregnancy
- concurrent anticoag (INR>1.7)
- haemorrhagic diathesis (prone to bleeding)
- active diabetic haemorrhagic retinopathy
- suspected intrcardiac thrombus
- major surg/trauma in preceding 2 wks
when to offer thrombectomy AND thrombolysis together
ASAP + within 6 hrs + 4.5hrs of sx onset if;
- confirmed occlusion of the proximal anterior circulation demostrated by CTA OR MRA
when to offer thrombectomy
ASAP to those last known to be well between 6hrs + 24hrs prev;
- confirmed occlusion of proximal anterior circulation shown on CTA or MRA
AND
- theres potential to slavage brain tissue, as show by imaging such as CT perfusion or diffusion weighted MRI sequence showing limited inferct core volume
secondary prevention mx of stroke
clopidogrel
- aspirin recommended after an ischaemic stroke ONLY if clopidofrel is contraindicated or not tolerated
carotid endarterectomy
recommended if patient has suffered stroke or TIA in carotid territory + is not severely disabled
- only consider if stenosis >50%
should be performed ASAP within 7 days
ROSIER score
exclude hypoglycaemia first
-1 point for;
- loss of conscious/syncope
- seizure activity
+1point for new acute onset of;
- asymmetric facial weakness
- asym arm weakness
- asym leg weekness
- speach disturbance
- visual field defect
stroke likely if score >0
first line radiologicl ix for suspected stroke
non-contrast CT head
signs of ischaemic stroke on non-contrast CT
low density in grey + white matter of territory - may take time to devlop
hyperdense artery, corresponds with responsible arterial clot –> visible immediately
signs of haemorrhagic stroke on non-contrast CT
hyperdense material (blood) surrounded by low density (oedema)
age and further investigations for “young” strokes
<55 yrs with no obvious cause of stroke
–> thrombophilia + autoimmune (ANA etc) screening
