Stroke

Question 1

Definition

Answer 1

Stroke is defined as an acute neuronoligal deficit lasting more than 24 hours and caused by lack of oxygen by blockage of blood flow (ischaemic stroke) or vascular rupture (haemorrhagic stroke) in the brain

Question 2

Transient ischaemic attack

Answer 2

Defined as an acute neurological deficit that fully resolves within 24 hours
- if suspected within the last week aspirin 300mg

Question 3

Clinical features

Answer 3

Limb weakness or numbness
Speech disturbance
Visual loss
Disturbance of balance

With haemorrhagic stroke there may be a preceding headache and vomiting

Question 4

Acute management of ischaemic stroke

Answer 4

IV thrombolysis
- Alteplase
- Within 4.5hrs of onset

Antiplatelet medicine
- Aspirin 300mg ASAP
- Aspirin 300mg for 14 days thereafter
- If aspirin not tolerated, clopidogrel 300mg stat then 75mg daily

Statin therapy:
- Start 48 hours after onset and continue in those already on statins

Question 5

Treatment and monitoring for all patients

Answer 5

Swallowing assessment
- Excessive salivation (hyoscine)
- Dry mouth (artificial saliva)

Fluid replacement
Blood glucose maintained between 5-15mmol/L
Temperature >37.5C requires paracetamol however, check for sepsis and start antibiotics if needed
VTE - start mobilisation and early hydration

For neuropathic pain - Amitryptiline 10mg / Gabapentin 300mg BD/Pregablin 150mg

Question 6

Blood pressure in ischaemia

Answer 6

Lower BP to below 185/110mmHg
- If raised apply 5mg GTN patch
- If remains high, administer 10mg IV labetalol over 1-2 mins. Can be repeated after 10mins if needed.
- If labetalol is contraindicated, consider GTN infusion at a rate of 0.6-12mL/hr.

Question 7

Secondary prevention of stroke

Answer 7

1. Antiplatelet therapy
   First line: Clopidogrel 75mg OD
   If contraindicated Aspirin 75mg OD + MR Dipyridamole 200mg BD
   If both contraindicated then Dipyridamole on its own
   Started 14 days after the acute event and continued life long
2. Anticoagulation only needed if patient has AF
3. Cholesterol reduction
   Atorvastatin 80mg OD
   If contraindicated, offer a lower dose or alternative

Question 8

Pre-menopausal women

Answer 8

Not to be offered combined oral contraceptive pill
- Use non hormonal or progesterone only pill