6.12 Stroke + Thrombolysis

Question 1

a) What imaging modalities are
recommended by NICE in acute
stroke?

Answer 1

● Non-contrast CT scan.

● CT angiogram.

● Diffusion-weighted MRI,
MR angiography.

● Carotid angiogram.

Question 2

b) What specific treatments can be considered for acute
thrombotic ischaemic strokes?

Answer 2

Non-surgical treatment:
● Aspirin.

● Thrombolysis with alteplase within
4.5 hours of symptom onset.

● Intra-arterial thrombolysis and thrombectomy.

● Full-dose anticoagulation with heparin and later warfarin — acute venous stroke.

Surgical treatment:
● Decompressive hemicraniectomy.

Question 3

c) What are the other general and supportive treatment
measures that you would implement in the treatment of an
acute stroke?

Answer 3

● Supplemental oxygen if the SpO2 is below 95%.

● Maintain blood glucose between 4-11mmol/L.

● Control of BP.

● Adequate nutrition and hydration.

● Early mobilisation.

● Prevent aspiration pneumonia.

Question 4

d) In these patients, what is the potential consequence of severe
hypertension?

Answer 4

Severe hypertension causes haemorrhagic transformation and cerebral oedema.

Question 5

e) What level of hypertension (systolic and diastolic) is regarded
as severe after an ischaemic stroke?

Answer 5

Severe hypertension after a stroke >220/110mmHg.

Question 6

f) What is the recommendation for arterial BP values in patients
for thrombolysis?

Answer 6

Arterial BP should be lowered below 185/110mmHg.

Question 7

g) A patient has had a large hemispheric infarction following a
stroke. Outline your management of this patient following
admission to critical care

Answer 7

● Nurse at 30° head up.

● Ventilation:

• intubate if there are signs of respiratory insufficiency
  or neurological deterioration;
• aim for normocapnia (PaCO2 4.5-5.0kPa).

● Sedation:
- the use of barbiturates is discouraged;

• sedation holds should be guided by ICP
  monitoring and clinical condition;
• blanket daily wake-up trials are not recommended.

● Thrombolysis:
- still of benefit in this population if commenced within 4.5 hours;

• the impact on future plans for
  surgical decompression should be considered.

● Arterial pressure control:
- MAP should be maintained >85mmHg;

• systolic BP should be maintained at less than 220mmHg.

● Nutrition — SALT assessments are mandated
before oral feeding is recommenced.

● Glycaemic control — maintain blood glucose at 7.8-10mmol/L.

● A transfusion threshold of 70g/L is recommended.

● DVT prophylaxis:
- use intermittent pneumatic compression rather than stockings;
- prophylactic LMWH;
- early mobilisation for haemodynamically stable patients.

● Osmotherapy for cerebral oedema —
mannitol and hypertonic saline.

● Prophylactic antibiotics, steroids and seizure
prophylaxis are not recommended