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ALL / Neurology

Stroke management: other issues

Stroke management: other issues

This background note focuses on other issues in acute stroke management, particularly management of fluids, glycaemic control, blood pressure management, feeding assessment/management and disability scales.

Fluid management
  • As in all patients in hospital, regular assessment for fluid status must be undertaken to ensure patients remain normovolaemic
  • The NICE guidelines recommend assessing the hydration of all patients with acute stroke on admission, with regular review during their stay
  • Greater than 80% of patients who cannot swallow post stroke will recover within 2-4 weeks
  • However, it is important to manage fluids in this immediate post-event period as hypovolaemia can worsen the ischaemic penumbra, as well as increase risk of other complications such as infection, deep vein thrombosis, constipation and delirium
  • Conversely, over-hydration can also complicate matters by leading to cerebral oedema, cardiac failure and hyponatraemia, therefore it is important to regularly review fluid status in these patients
  • Recommendations for management:
    • Oral hydration is preferable in all patients who are able to safely swallow
    • Intravenous hydration may be necessary otherwise, and although studies have remained contentious regarding choice of intravenous fluid, UptoDate currently recommend isotonic saline without dextrose as the agent of choice in most patients
    • Other factors to take into consideration when choosing fluid agent include electrolyte disturbances and/or cardiovascular status

Glycaemic control
  • It is important to closely monitor and control blood sugar, particularly if they are nil by mouth due to concerns regarding swallowing safety post stroke, and/or in diabetics
  • Post stroke, patients with hyperglycaemia have increased mortality independent from their age and the severity of stroke
    • This is likely due to increased tissue acidosis from anaerobic metabolism, free radical generation, and increased blood brain barrier permeability post injury
  • The NICE guidelines recommend maintaining a blood sugar level between 4 and 11 mmol/L in people with acute stroke
  • Diabetic patients
    • It is important to provide intensive management for diabetics post acute stroke
    • The NICE guidelines suggest optimising insulin treatment using intravenous insulin and glucose infusions
    • Hypoglycaemia also needs to be managed appropriately, as alone it can cause neuronal injury as well as mimic stroke-related neurological deficits

Blood pressure management
  • Use of anti-hypertensive medications should only be used for blood pressure control in patients post ischaemic stroke if there is a hypertensive emergency with one or more of the following serious concomitant medical issues (according to the NICE guidelines):
    • Hypertensive encephalopathy
    • Hypertensive nephropathy
    • Hypertensive cardiac failure/myocardial infarction
    • Aortic dissection
    • Pre-eclampsia/eclampsia
  • This is because lowering blood pressure too much can potentially compromise collateral blood flow to the affected region, and possibly hasten the time to complete and irreversible tissue infarction
  • If if treatment is indicated, UptoDate recommend cautious lowering of blood pressure by approximately 15% in the first 24-hours after stroke onset
  • UptoDate suggest using intravenous labetalol, nicardipine and clevidipine as first-line agents, due to the possibility for rapid and safe titration to control blood pressure

  • However, in patients who are candidates for thrombolytic therapy for acute stroke, blood pressure should be reduced to 185/110mmHg or lower
    • Elevated BP can affect thrombolytic eligibility and delay treatment
    • Timely management of elevated BP is crucial when patients are otherwise eligible for intravenous thrombolysis
    • After thrombolytic therapy, UptoDate recommend ensuring that the blood pressure is stabilised and maintained at or below 180/105mmHg for at least 24 hours after treatment

Feeding assessment and management
  • All patients presenting with acute stroke must be screened for safe swallowing function prior to further oral intake, as dysphagia is common after stroke
    • This is to reduce the risk of aspiration and subsequent complications
    • This includes prior to any oral intake of food, fluids, and/or medications
  • If there are any concerns regarding swallowing, the NICE guidelines recommend specialist assessment of swallowing
    • This should preferably within 24 hours of admission and not greater than 72 hours after
    • Prior to assessment is undertaken, a patient should remain nil by mouth to prevent complications
  • Recommendations for patients deemed unsafe for oral intake:
    • Patients should receive nasogastric tube feeding, ideally within 24 hours of admission, unless they have had thrombolytic therapy
    • If nasogastric tube feeding is not tolerated, patients should be considered for a nasal bridle tube/gastrostomy instead
    • Medications need to be assessed to determine if formulations are available for nasogastric feeding, or if conversion to subcutaneous or intravenous forms are required
  • Nutritional support may be required for patients at risk of malnutrition post stroke, whether a result from dysphagia, poor oral health or reduced ability to self-feed due to weakness or paralysis

Disability scales
  • Stroke can result in a number of complications and subsequent disability, therefore disability scales are often used as a measure of functional decline post event and subsequent improvement after medical intervention
  • Disability, often measured in terms of functional status (notably, basic activities of daily living), is often the leading cause of morbidity after stroke
  • After a patient is medically stabilised after a stroke, they may require transfer to a rehabilitation team for ongoing treatment depending on their level of disability
  • Disability is most commonly measured using the Barthel index (BI), an outcome measure for stroke
    • Describes 10 tasks, and is scored according to amount of time or assistance required by the patient for each given task
    • Tasks: feeding, moving from wheelchair to bed, personal toileting, getting on/off toilet, bathing, walking on level surface, ascending/descending stairs, dressing, controlling bowels and controlling bladder
    • The total score is from 0 to 100, with 0 being completely dependent, and 100 being completely independent
  • This index should be used to assess the functional status of a patient post stroke, and to monitor their improvement with ongoing rehabilitation to regain independence after the event
+PassMedicine Notes

This background note focuses on other issues in acute stroke management, particularly management of fluids, glycaemic control, blood pressure management, feeding assessment/management and disability scales.

Fluid management
  • As in all patients in hospital, regular assessment for fluid status must be undertaken to ensure patients remain normovolaemic
  • The NICE guidelines recommend assessing the hydration of all patients with acute stroke on admission, with regular review during their stay
  • Greater than 80% of patients who cannot swallow post stroke will recover within 2-4 weeks
  • However, it is important to manage fluids in this immediate post-event period as hypovolaemia can worsen the ischaemic penumbra, as well as increase risk of other complications such as infection, deep vein thrombosis, constipation and delirium
  • Conversely, over-hydration can also complicate matters by leading to cerebral oedema, cardiac failure and hyponatraemia, therefore it is important to regularly review fluid status in these patients
  • Recommendations for management:
    • Oral hydration is preferable in all patients who are able to safely swallow
    • Intravenous hydration may be necessary otherwise, and although studies have remained contentious regarding choice of intravenous fluid, UptoDate currently recommend isotonic saline without dextrose as the agent of choice in most patients
    • Other factors to take into consideration when choosing fluid agent include electrolyte disturbances and/or cardiovascular status
Glycaemic control
  • It is important to closely monitor and control blood sugar, particularly if they are nil by mouth due to concerns regarding swallowing safety post stroke, and/or in diabetics
  • Post stroke, patients with hyperglycaemia have increased mortality independent from their age and the severity of stroke
    • This is likely due to increased tissue acidosis from anaerobic metabolism, free radical generation, and increased blood brain barrier permeability post injury
  • The NICE guidelines recommend maintaining a blood sugar level between 4 and 11 mmol/L in people with acute stroke
  • Diabetic patients
    • It is important to provide intensive management for diabetics post acute stroke
    • The NICE guidelines suggest optimising insulin treatment using intravenous insulin and glucose infusions
    • Hypoglycaemia also needs to be managed appropriately, as alone it can cause neuronal injury as well as mimic stroke-related neurological deficits
Blood pressure management
  • Use of anti-hypertensive medications should only be used for blood pressure control in patients post ischaemic stroke if there is a hypertensive emergency with one or more of the following serious concomitant medical issues (according to the NICE guidelines):
    • Hypertensive encephalopathy
    • Hypertensive nephropathy
    • Hypertensive cardiac failure/myocardial infarction
    • Aortic dissection
    • Pre-eclampsia/eclampsia
  • This is because lowering blood pressure too much can potentially compromise collateral blood flow to the affected region, and possibly hasten the time to complete and irreversible tissue infarction
  • If if treatment is indicated, UptoDate recommend cautious lowering of blood pressure by approximately 15% in the first 24-hours after stroke onset
  • UptoDate suggest using intravenous labetalol, nicardipine and clevidipine as first-line agents, due to the possibility for rapid and safe titration to control blood pressure
  • However, in patients who are candidates for thrombolytic therapy for acute stroke, blood pressure should be reduced to 185/110mmHg or lower
    • Elevated BP can affect thrombolytic eligibility and delay treatment
    • Timely management of elevated BP is crucial when patients are otherwise eligible for intravenous thrombolysis
    • After thrombolytic therapy, UptoDate recommend ensuring that the blood pressure is stabilised and maintained at or below 180/105mmHg for at least 24 hours after treatment
Feeding assessment and management
  • All patients presenting with acute stroke must be screened for safe swallowing function prior to further oral intake, as dysphagia is common after stroke
    • This is to reduce the risk of aspiration and subsequent complications
    • This includes prior to any oral intake of food, fluids, and/or medications
  • If there are any concerns regarding swallowing, the NICE guidelines recommend specialist assessment of swallowing
    • This should preferably within 24 hours of admission and not greater than 72 hours after
    • Prior to assessment is undertaken, a patient should remain nil by mouth to prevent complications
  • Recommendations for patients deemed unsafe for oral intake:
    • Patients should receive nasogastric tube feeding, ideally within 24 hours of admission, unless they have had thrombolytic therapy
    • If nasogastric tube feeding is not tolerated, patients should be considered for a nasal bridle tube/gastrostomy instead
    • Medications need to be assessed to determine if formulations are available for nasogastric feeding, or if conversion to subcutaneous or intravenous forms are required
  • Nutritional support may be required for patients at risk of malnutrition post stroke, whether a result from dysphagia, poor oral health or reduced ability to self-feed due to weakness or paralysis
Disability scales
  • Stroke can result in a number of complications and subsequent disability, therefore disability scales are often used as a measure of functional decline post event and subsequent improvement after medical intervention
  • Disability, often measured in terms of functional status (notably, basic activities of daily living), is often the leading cause of morbidity after stroke
  • After a patient is medically stabilised after a stroke, they may require transfer to a rehabilitation team for ongoing treatment depending on their level of disability
  • Disability is most commonly measured using the Barthel index (BI), an outcome measure for stroke
    • Describes 10 tasks, and is scored according to amount of time or assistance required by the patient for each given task
    • Tasks: feeding, moving from wheelchair to bed, personal toileting, getting on/off toilet, bathing, walking on level surface, ascending/descending stairs, dressing, controlling bowels and controlling bladder
    • The total score is from 0 to 100, with 0 being completely dependent, and 100 being completely independent
  • This index should be used to assess the functional status of a patient post stroke, and to monitor their improvement with ongoing rehabilitation to regain independence after the event


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