Management of stroke

Question 1

Patients suspected of having a transient ischaemic attack should immediately receive what treatment?

Answer 1

1) Aspirin 300 mg once daily until diagnosis established 2) If aspirin is contraindicated clopidogrel [unlicensed]

Question 2

Outline the initial pharmacological management of an ischemic stroke

Answer 2

1) Alteplase for acute ischaemic stroke if it can be administered within 4.5 hours of symptom onset
2) Aspirin 300mg daily as soon as possible after the onset of symptoms and continued for 14 days.
↳ If a patient has received thrombolysis, antiplatelet
therapy should be not be started until 24 hours have passed

Question 3

True or False:

warfarin should not be commenced in the acute phase of ischaemic stroke

Answer 3

True

Question 4

Treatment of hypertension in the acute phase of ischaemic stroke can result in what?

Answer 4

Reduced cerebral perfusion- so only initiate in the event of a hypertensive emergency, or in those patients considered for thrombolysis

Question 5

Following a TIA or an ischaemic stroke (not associated with AF) what long term treatments are recommended in patients?

Answer 5

1) Clopidogrel- long term
2) A statin - 48 hours after stroke,regardless of serum-cholesterol concentration
3) Antihypertensive if necessary
4) (warfarin/anticoagulant if stroke associated with AF)

Question 6

If clopidogrel is contra-indicated or not tolerated in the long term management of stroke, what other options are available?

Answer 6

1) M/R dipyridamole in combination with aspirin
→If both aspirin and clopidogrel are contra-indicated
2) M/R dipyridamole alone is recommended
→if both M/R dipyridamole and clopidogrel are C/I
3) aspirin alone

Question 7

Patients with stroke associated with atrial fibrillation should be reviewed for long term treatment for which drug?

Answer 7

warfarin or an alternative anticoagulant

Question 8

Are anticoagulants recommended in the long-term prevention of recurrent stroke?

Answer 8

not routinely recommended- except in patients with atrial fibrillation

Question 9

Following the acute phase of ischaemic stroke, blood pressure should be measured and treatment initiated to achieve a target blood pressure of what ?

Answer 9

<130/80 mmHg

Question 10

Can Beta-blockers be used in the management of hypertension following a stroke?

Answer 10

should not be used unless they are indicated for a co-existing condition

Question 11

what non-pharmacological advice should be provided to all patients following a stroke?

Answer 11

make lifestyle modifications that include beneficial changes to diet, exercise, weight, alcohol intake, and Smoking cessation

Question 12

outline the initial management of an Intracerebral haemorrhage

Answer 12

1) surgery may be required to remove the haematoma and relieve intracranial pressure
2) Patients taking anticoagulants should have this treatment stopped and reversed

Question 13

Anticoagulant therapy has been used in patients with intracerebral haemorrhage who are symptomatic of deep vein thrombosis or pulmonary embolism. This can be risky, what can be considered instead?

Answer 13

placement of a caval filter

Question 14

outline the long term management of patients following an intracerebral haemorrhage

Answer 14

1) Aspirin- only to patients at a high risk of a cardiac ischaemic event.
2) Anticoagulant therapy is not recommended following an intracerebral haemorrhage, even in those with AF, unless patient is very high risk
3) BP measured and treatment initiated where appropriate, taking care to avoid hypoperfusion.
4) Statins - avoidfollowing intracerebral haemorrhage

Question 15

Statins should be avoided following an intracerebral haemorrhage, however which patients might still be able to use them?

Answer 15

can be used with caution when the risk of a vascular event outweighs the risk of further haemorrhage.