Stroke!

I will highlight a few high yield points for a few common medical conditions throughout the series. 

These are just my opinions and are very brief for specialisation. It is just to help you grasp the gist of common and important medical problems. 

ISCHAEMIC Stroke

When you compromise the blood supply to brain tissue and some tissue DIES, you get a stroke.

There are MAINLY 2 ways you can cut the blood flow, by a cutting of blood flow inside the vessel (BLOCK) or compression from the outside (BLEED). 

How you treat an ICB and an Ischaemic stroke is totally different. ICBs will be briefly explained later on. 

Acute event QUESTION! - For thrombolysis or not for thrombolysis?

• NIHSS = 4 - 25
• CT brain (plain) = no ICB
• BP > 180/110
• Within 4.5hrs? - Last known well, Wake up stroke

• Just ask any surgeries, coagulopathies or heart problems before and explore further if they have.
• When?
• What was done
• What drugs they are on, etc

Thrombolysis - rtPa 0.9mg/kg (Usually ED folks will be giving this)

• BW x10% x 0.9 = given bolus 1min 
• BW x 90% x 0.9 = given in 1hr
• Monitor for ALLERGIES, reduced consciousness, hypotension!

Post-acute event, stroke management is pretty much like Cerebral Protection (CP). 

- NIHSS is quite useful as a quick, thorough neurological examination. Mainly used for the decision for thrombolysis in an acute stroke. Of course, other neurological physical examination methods are used to localise the lesion, in which this case, NIHSS can help you eliminate areas which are spared. 

- Blood Pressure (Targets for ICB is different!)

• 0 - 24hrs, Magic number = ~ 180/100 (Permissive hypertension)
• 180 ~= 25% reduction from SBP 220
• rtPa candidate ~< 180
• Main principle = Don't let it drop too fast!

• > 24hrs = treat as per hypertension 

• Emergency drug (KKM) : IV / IVI Labetolol 10 - 20mg every 10 minutes 
• Non-emergency: Restart antihypertensive
• Monitoring: 15 mins (2hrs) ; 30 mins (6hrs) ; 1hrly (16hrs) = total 24hrs

- Normoglycaemia 

• Give glucose if low, give insulin if high
• Regular monitoring: Aim 7 - 11 mmol/L is alright initially

- Fever = Think of it as resting the brain. The higher the temperature, the higher the metabolism, the more risk for ischaemia. Same concept to the heart!

• Paracetamol 
• Tepid sponging

- Modifiable risks

• Statins
• Hypertension
• Diabetes mellitus
• Smoking cessation
• Exercise / Rehabilitation 

- Nutrition

• I would be worried if my patient gives me some hints of dysarthria, dysphagia, vomiting, choking, dizziness. 
• If they presented at night, keep them nil by mouth with MAINTENANCE FLUIDS until their swallowing can be assessed in the morning
• Pay attention to their blood glucose and pressure - they might have missed their medications in the morning
• Fastest would be a bedside swallowing test. 

- Aspirin = Start within 48hrs of an ischaemic stroke without thrombolysis. 

• Start it 24hrs after thrombolysis

- Special causes (Brief) 

• Atrial fibrillation - CHA2DS2-VASc score & HAS-BLED score
• Prosthetic Valve / Valvular Heart Disease - anticoagulation
• Carotid stenosis - Endarterectomy in 70 - 99% stenosis at symptomatic side
• Hypercoagulable state (APLS) - anticoagulation

Long Term

The journey of a stroke patient is arduous. Patients and their families need to be aware of WHAT A STROKE COULD MEAN (INSIGHT). 

A stroke could mean just be a scary event in your life, assuming it scares you. For others, it could mean that the patient can NEVER walk again, be completely reliant on others for hygiene and food. Most people fall in between a spectrum of these extremes. 

Whichever it is, try your best to explain the importance of lifestyle changes (to those who still can), exercise/physiotherapy, and family support. 

Special issues to deal with will require very strong caregiver support. Therefore, you will need a session or two with the family members. 

• Dementia (stepwise decline)
• Depression
• Cerebellar stroke

It can be heartbreaking to deal with those with a bad stroke and poor social support. Similarly, frustrating if you meet those who walk away scot-free and continue to smoke like a chimney. Life has its way of dealing with people like that, your job is to keep them well informed. 

Pictures & Tables

Click here for a standardised Swallowing test form.

Reference Links  

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530420/pdf/10.1177_1941874415578532.pdf

2. https://www.moh.gov.my/moh/resources/Penerbitan/CPG/CARDIOVASCULAR/10a.pdf

3. https://www.mdcalc.com/tpa-contraindications-ischemic-stroke

4. UpToDate

See Also

• Monroe-Kelly doctrine 
• Transient Ischaemic Event (TIA) - no tissue death
• ABCD2