This document provides an overview of acute stroke, including: 1) It defines stroke as a sudden loss of neurological function lasting more than 30 minutes caused by a blockage or rupture of blood vessels in the brain. During a stroke, 2 million brain cells die per minute, making it a medical emergency. 2) It outlines the assessment and workup of acute stroke patients, including using the ROSIER and NIH stroke scales to evaluate severity, performing a CT scan to identify blockages or bleeding, and collecting blood tests. 3) It describes the management of ischemic and hemorrhagic strokes, including the criteria for providing tissue plasminogen activator to dissolve clots or controlling blood pressure to stop

1. Acute Stroke
Dr Anoja Rajapakse
MBBS,MD,FRCP,FRCPE,FACP,FCCP
Consultant Physician
Geriatric & Stroke Medicine
13th July 2020

2. Definition
• World Health Organization defined stroke as ‘rapidly developed
clinical signs of focal (or global) disturbance of cerebral function,
lasting more than 24 hours or leading to death, with no apparent
cause other than of vascular origin’.
• Sudden focal loss of neurology lasting more than 30 minutes is
considered a stroke and considered for TL
• During acute Stroke, 2 million brains cells die per minute. MEDICAL
EMERGENCY.

5. ROSIER score

6. ROSIER score interpretation
• Blood glucose should be normal
• If the score is 1 or more suggest a stroke
• If the score is 0 or less stroke is unlikely but not excluded

7. History
• Time of onset
• Chronologically what happened
• Drug history – OAC
• Risk factors
• Hypertension
• Diabetes
• High cholesterol
• Smoking
• Atrial fibrillation
• Modified Rankin Score (mRS)

8. EXAMINATION
• Vital signs – LOC, HR, RR, Temperature, SaO2, BP
• Trauma – bleeding, fractures
• NIH Stroke Scale
• Blood pressure
• Lung signs
• Abdomen examination
• Skin rashes
• Body weight

9. NIH Stroke Scale training
• http://www.nihstrokescale.org/
• https://learn.heart.org/lms/activity?@curriculum.id=-
1&@activity.id=2695217&@activity.bundleActivityId=-1
• Do the NIH Stroke Scale in the given order
• Take the first effort

11. INVESTIGATIONS
• Non-contrast CT scan of Brain
• Random Blood Sugar
• Full Blood Count
• Clotting Profile
• ESR
• Renal Function
• Lipid Profile
• HbA1c
• ECG

12. Flow chart for Acute Stroke
Nurse: – Doctor : -
Set of observation* Confirm onset time
Capillary blood sugar Confirm stroke
Insert 18 G Canula Exclude trauma
Blood test ** Request CTB non-cE
¯
Resident Physician/Stroke Physician***
NIHSS
mRS
Stroke checklist
Inform Radiologist
Take patient to CT Scan
¯
Stroke Physician***
Review CTB scan
Review Checklist
Obtain verbal consent
Bolus dose Alteplase
CT angio if indicated with discussion with radiologist
Start Alteplase infusion
Decide on MT
Transfer to ICU/Cathlab
*Observation include Blood pressure, Heart rate, Respiratory rate, Oxygen Saturation, and
ECG monitor
**Blood should include FBC, renal function, Clotting profile, Lipid profile, ESR, HbA1c
***Stroke Physician – any Neurologist, Geriatrician, Internal Medicine Physician maintaining
skill mix to manage Acute Stroke

13. Types of stroke
• Ischemic stroke
• TIA
• Haemorrhagic stroke

14. Flow chart for BEL-FAST positive patients
Acute Stroke
CT brain
(Non-Contrast)
st
Ischemic Stroke Haemorrhagic Stroke
Symptoms <4.5 hours
Candidate for TL
Give i.v Alteplase
Admit for management
(ICU/ward)
Candidate for Mechanical Thrombectomy?
CT angiogram aortic arch &above
ASPECTS score >6, NIHSS>6
MT (ICA/M1/M2/BA)
*Control BP
*Stop and reverse OAC
*Refer to Neurosurgeon
Yes
No
Yes
No
Yes
Yes
Transfer to cath lab

15. Acute management of Ischemic Stroke
• Fulfil criteria for TL  TL
• If not for TL but suitable for MT  CT angiogram  refer for MT
• If not for TL or MT.
• Aspirin 300mg stat and daily for 2 weeks. Then Clopidogrel 75mg daily
• PPI cover to reduce gastric erosions

16. Inclusion criteria for TL
• Symptoms of acute stroke on going for at least 30 minutes
• Clear onset time
• Can TL be given within 4.5 hours since the onset of the stroke
• Haemorrhage excluded on CTB
• If the patient has taken warfarin today INR <1.7
• If the patient on DOAC last dose > 24 hours
• NIHSS >5 or disabling speech or vision

17. Exclusion criteria
• Rapidly improving NIHSS
• Stroke or head injury within 3 months
• Major surgery within 14 days
• GI or GU haemorrhage within 21 days
• History of intracranial haemorrhage
• Symptoms suggestive of SAH
• Blood pressure >185/110
• No clotting disorders, thrombocytopenia, IDA
• Hypoglycaemia <3 mmol/l
• No evidence/suspicion of bacterial endocarditis/pericarditis
• Seizure at the onset of stroke
• Child birth within 10 days
• Arterial puncture in a non-compressible site within 7days
• Acute pancreatitis, oesophageal varies, ulcerative GI disease within 3/12, aortic aneurysm, active hepatitis, cirrhosis

18. ALTEPLASE
• Fibrinolytic drug
• Activates plasminogen to form plasmin
• Plasmin degrades fibrin and break the thrombus

19. Alteplase indications
• Acute ischemic stroke within 4.5 hours
• Acute Myocardial infarction
• Pulmonary embolism
• Acute Respiratory Distress Syndrome ???
• Occluded central venous access devices (including those used for
haemodialysis)

21. Dose for acute ischemic stroke
• 0.9mg/kg body weight (max 90mg )
• 10% of the dose given as a intravenous bolus dose over 2 minutes
• 90% of the dose in N/S 100 ml over 1 hour
• During the infusion look for bleeding, allergic reaction, worsening
neurology

22. Observation – post-TL
• NIHSS in 1 hour post-TL
• NIHSS in 24 hours
• NIHSS if clinical deterioration noted
• Observations
• Every 15 minutes for 2 hours
• Every 30 minutes for 6 hours
• Every 60 minutes for 16 hours

23. Observations post-TL
• Why observe so frequently?
• Recognise bleeding from any site – intraabdominal/intracranial
• What to do if deteriorating?
• During thrombolysis any evidence of bleeding stop infusion
• Inform stroke consultant and investigate and recognise the cause of bleeding
• May need haematologist input/neurosurgical input/other experts
• NO INTERVENTIONS for 24hrs – catheters, NG tubes, IM injections

24. Other interventions in ischemic stroke
• NBM until swallow assessed
• Antiplatelets
• After 24 hours for patients who have had TL
• As soon as possible after excluding bleed on the CTB
• Aspirin 300mg orally, Rectally, NG (2 weeks)
• PPI cover to reduce gastric erosions.
• Continue antihypertensives/OHG
• Atorvastatin 80mg noct
• Intermittent Pneumonic Compression stockings for prevention of DVT

28. Haemorrhagic Stroke

29. Haemorrhagic Stroke
• More likely when rapidly deteriorating LOC
• Patients on OAC
• High Blood pressure

30. Haemorrhagic Stroke
• Assess swallow and NG tube if unsafe.
• Reduce Systolic Blood pressure to 130-140 mmHg within 1 hours
• Reverse Oral anticoagulant
• Recombinant Prothrombin Complex (Octoplex)
• Intravenous vitamin K 10 mg stat
• FFP if Octoplex not available
• Refer to neurosurgeon
• Intermittent Pneumonic Compression stocking for DVT prevention

31. feeding
• If swallow safe continue oral feeds and medication
• If swallow unsafe
• Intravenous fluids for 24 hours
• NG tube for nutrition and medication
• Refer to SALT and reassess with therapy
• NG feeds – dietician guided
• Modified diets and fluids

32. Diet for patients with swallowing difficulty

33. Positioning for Left hemispheric Stroke

34. Post-Stroke Rehabilitation
• Using neuroplasticity principle
• Physiotherapy (PT)
• Occupational Therapy (OT)
• Speech And Language Therapy (SALT)
• Continence
• Orthoptic
• Dietician
• Pharmacy

36. The Stroke Aphasia Depression Questionnaire
-10

37. Modified Rankin Score (mRS)

38. Thank you