GUIDELINES FOR MANAGEMENT OF STROKE

STROKE MANAGEMENT GUIDELINE

SUSPECTED STROKE
REFER O
T A HOSPIT
AL RAPIDL
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IDEALL
Y TREAT INA STROKEUNIT

Initial assessment
General assessment
Airway breathing,
circulation
Blood sugar- keep at RBS
50-200mg/dL
Good hydration
Normal temperature
Blood pressurecautiously lower if
>220/120
Treat hypertension after 7
days
Treat of hypertensive

Urgent CT if,
Thrombolysis or early
anticoagulation
Already on anticoagulation
Known bleeding tendency
Altered level of consciousness
Fluctuating symptoms
Fever, neck stiffness, papilloedema
severe headache at onset
Infarction

Neurological assessment

Level of consciousness
Severity of stroke
Time of onset
Swallowing- 50ml water swallow test
NBM until swallowing assessed
Bladder/ bowel care

TIA should be assessed a specialist

clinic within 7 days
Aspirin 300mg/day or alternative
antiplatelet agent stat
More than 1 TIAwithin a week
admit
CEA or stenting within 2 weeks
in suitable candidates
A statin if total cholestrol
>135mg/dL
Secondary prevention same as
for ischaemic stroke

Thrombolysis with rTP A- if NINDS

guidelines satisfied
Aspirin 300mg stat
Continue Aspirin 50-300mg indefinitely
Statin 20-80mg/day in all with a total
cholestrol >3.5mmol/L
Mannitol 250ml tds for 48 hours
DO NOT GIVE STEROIDS
Avoid anxiolytics, tranquilizers
Anticonvulsants- if epilepsy develops
Monitor- BP, pulse, temperature, blood
sugar , hydration, oxygen saturation

Surgical interventions

Other investigations

A SPECIALIST PHYSICIAN SHOULD REVIEW THE DIAGNOSIS

Carotid endartectomy (CEA)

Consider in all carotid artery territory strokes
without severe disability
Preferably done within 2 weeks of stroke/ TIA
70-99% stenosis-definite benefit
50-69% stenosis- potential benefit
Do carotid doppler/ MRA to screen for stenosis

Secondary prevention

Should be individualized
Implement soon after stroke / TIA
Antiplatelet-Aspirin 50-300mg/day
Aspirin+Dipyradamole MR superior to aspirin alone
Clopidogrel if aspirin contraindicated
Aspirin+Clopidogrel- not recommended
Anticoagulation- start after 14 days if indicated
Stop smoking/ reduce alcohol
Weight reduction/ dietary modification
Target BP
non diabetic<140/85
diabetic<130/80
ACEI+thiazide diuretic best combination
Lipid lowering- treat all if total cholestrol>135mg/dL

CT scan brain within 24 hours

ICH
Withdraw antiplatelets and
anticoagulants
Reverse anticoagulation
Maintain mean BP at 130mmHg
DO NOT USE STEROIDS
Routine surgical evacuation
is not recommended
Vascular imaging in
young patients (<45 years)
Non HT ICH
Lobar or IVH
Surgery may be indicated in
cerebellar or posterior fossa ICH,
supratentorial ICH with mass
effect
Aneurysm
AVM

SAH
Urgent CT scan brain and if there is
evidence SAH contact and transfer to NSU
urgently
If no CT available and with deteriorating
level of consciousness- contact and
transfer to a NSU
If no CT available and condition is stable LP
If CT negative- do LP
Analgesia- avoid Pethidine/ morphine
Nimodipine 60mg 4 hourly for 21 days
Monitor- hydrocephalus, ischaemia,
rebleed, electrolytes. Hypotension

Rehabilitation
Should start ASAP
Multidisciplinary assessment
Physiotherapy- start within 24 hours,
atleast twice/day
Nutrition
Speech therapy
Occupational therapy
Pain assessment
DVT prevention
Bladder bowel care
Spasticity management
Psychiatric assessment
Neuropsychological assessment

Other diagnosis
T reat accordingly

Basic tests
FBC, ESR, CRP, LFT, renal profile, lipid
profile, CXR, ECG
Special tests

Carotid doppler/ MRA/ DSA

Echocardiogram- TTE/ TOE
Thromobophilia screen
Homocysteine level
Vasculitis screen

Discharge Plan
Involve patient, carer, MOH/ primary
care team, social service
Nominate key worker
Detailed discharge summary/card
Plan long-term rehabilitation (Home/
community/ institution)
Take patients domestic situation into