Stroke: management of acute ischaemic stroke

Stroke: management of acute ischaemic stroke

• blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits
• blood pressure
  • blood pressure should not be lowered in the acute phase of ischaemic stroke
    Hypertension should not be treated in the initial period following an ischaemic stroke (unless prior to thrombolysis)
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    Importance: 79
    unless there are complications e.g. Hypertensive encephalopathy or they are being considered for thrombolysis (see below)
  • blood pressure control should be considered for patients who present with an acute ischaemic stroke
    blood pressure control should be considered for patients who present with an acute ischaemic stroke
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    , if they present within 6 hours and have a systolic blood pressure > 150 mmHg
• aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
  aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
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• with regards to atrial fibrillation, the RCP state: 'anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke'
• if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation

Thrombolysis for acute ischaemic stroke

• it is administered within 4.5 hours of onset
  Stroke thrombolysis - 'standard criteria' is within 4.5 hours and haemorrhage excluded (but other patients may be eligible based on imaging)
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  Importance: 88
  of stroke symptoms
• haemorrhage has been definitively excluded
  Stroke thrombolysis - 'standard criteria' is within 4.5 hours and haemorrhage excluded (but other patients may be eligible based on imaging)
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  Importance: 88
  (i.e. Imaging has been performed)

• it recommends that patients with an acute ischaemic stroke, regardless of age or stroke severity, who were last known to be well more than 4.5 hours earlier, should be considered for thrombolysis with alteplase if
  Patients who present 4.5-9 hours after symptom onset, or with 'wake-up stroke' should still be considered for thrombolysis if they have imaging evidence of potential to salvage brain tissue
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  Importance: 55
  :
  • treatment can be started between 4.5 and 9 hours of known onset, or within 9 hours of the midpoint of sleep when they have woken with symptoms, AND
  • they have evidence from CT/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue
• this should be irrespective of whether they have a large artery occlusion and require mechanical thrombectomy.
• there are specific criteria in the guidelines that determine the imagine criteria that determine whether thrombolysis should be performed

Contraindications to thrombolysis

Thrombectomy for acute ischaemic stroke

• NICE recommend a pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS)

• confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

• confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
• if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
  For thrombectomy in acute ischaemic stroke, an extended target time of 6-24 hours may be considered if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
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  Importance: 82

• who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and
• if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Secondary prevention

• clopidogrel is now recommended
  Clopidogrel is the preferred antiplatelet for secondary prevention following stroke
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  Importance: 100
  by NICE ahead of combination use of aspirin plus modified-release (MR) dipyridamole in people who have had an ischaemic stroke
• aspirin is recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated
  aspirin is recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated
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• should only be considered if the stenosis > 50% according to North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria

• it should be performed as soon as possible within 7 days