Acute Stroke

Whilst on call or in A&E you may be asked to assess somebody who is suspected to have had a stroke. This is a very brief overview that gives you an approach to managing a patient in this setting.

A stroke is a serious life-threatening medical condition that occurs when the blood supply to part of the brain is cut off.<span class="su-quote-cite">NHS website </span>

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Classification

Before considering treatment options, it is important to remember that there are two causes of stroke:

  • Haemorrhagic; i.e. subarachnoid haemorrhage/intracerebral haemorrhage
  • Ischaemic; i.e. occlusion of one of the cerebral arteries secondary to thromboembolic event. May or may not be transient (TIA).

Assessment

Asked to see patient….
“Doctor, this patient is more confused/drowsy than normal.”
“Mr Smith has had a fall. Could you please come and assess?”
“Doctor, Mrs Andrews seems to be slumping to one side”
“The patient is saying he’s lost some of his vision”
“Mr Potter sounds a bit slurred, can you please urgently come and assess?”
“Doctor this patient’s blood pressure is really high!”

All of the above are different things that you might get bleeped about where you need to consider stroke! Whilst you’re on the way to the ward, you can ask the nurses to do some very basic tasks to help speed up your assessment:

  • Full set of observations, including neuro obs
  • ECG – very important, don’t forget this!
  • Find a tendon hammer to use!

When you get to the patient, don’t forget your basics – DR ABCDE:

  1. Danger – If you’re called because the patient had a fall, was it secondary to something on the floor? Water/urine/wires?
  2. Response – Where on the AVPU scale is the patient?
  3. Airway  
  4. Breathing – Is the breathing regular, or is it irregular/shallow/apnoeic (Cushing response of raised ICP)?
  5. Circulation – Is the heart rate irregular (consider AF for the cause of an ischaemic CVA – this is why you need the ECG)? Are they hypertensive (Cushing response of raised ICP)?
  6. Disability – What is the GCS (see below)? If less than 12 – consider calling a senior/critical care outreach for help. Is there extensor or flexor posturing? What are the pupils like? Neuro exam findings? Although not related to assessment for CVA, don’t forget glucose!
  7. Exposure 

When taking a history, don’t forget to include the following:

  • Onset of symptoms, was it gradual or sudden? Sudden onset makes CVA more likely.
  • Duration – if less than 24 hours, consider TIA instead of CVA.
  • Headache – where? Nature of onset?
  • Medical background – AF/Previous strokes/recent valve replacements or IVDU (risk of infective endocarditis, therefore a risk of emboli)/smoker/diabetic/hypertension/family history of stroke
Examination findings you might see in CVA:
  • FAS +ve? – Facial droop, arm weakness, slurred speech
  • Hypertonia +/- hyperreflexia +/- motor weakness – Tends to be one-sided
  • Decreased sensation
  • Babinski positive (plantars upgoing)
  • Visual deficits – pattern depends on the location of the stroke
  • Unequal pupils which may or may not be reactive
  • Confusion/decreased GCS
  • Abnormal posturing

The key to assessing stroke is more in the exam than in the history! Make sure your neuro exam is thorough – the stroke registrar will ask for everything.

Management

  • A stroke is always something you should involve your seniors with for management!
  • You will need to know if this was haemorrhagic or ischaemic in nature before doing anything. Discuss with a senior if a CT head needs to be done urgently. It is useful to ask the radiology department to forward scans to tertiary centres as soon as they are done. This is usually done by calling the PACS team.
  • Stop all anticoagulants to prevent haemorrhagic transformation/further bleed if a haemorrhagic stroke
  • Discuss with stroke SpR/Stroke centre/HASU for consideration of thrombolysis if within the window (within 4 hours, although may change with local guidelines).
  • If CT head shows SAH/ICH – discuss with neurosurgeons
  • Ensure the patient is haemodynamically stable. Remember that there is an element of permissive hypertension in acute stroke
  • Ask the nursing staff to do regular neuro obs. Ensure ECG is done if not already done.
  • If symptoms have resolved – refer to TIA clinic/Stroke registrar after discussion with senior
  • It is helpful to download MDCalc or other apps to quickly score this

Evidence for Inpatient Management – Blood Pressure in Acute Stroke Patients

  • It’s pretty common to get called about blood pressure management in acute ischaemic stroke patients when on-call and having oversight for a stroke unit
  • If the patient has received thrombolysis, hospitals will have local policies to manage this as high blood pressure is associated with an increased risk of haemorrhagic transformation; ignore the next bit if your question is about thrombolysed patients
  • However, if there is an ischaemic stroke and there has been no thrombolysis, meta-analyses of sufficient quality have failed to demonstrate a benefit to antihypertensive in the acute phase of stroke.
  • A 2014 Cochrane review found initiating new BP control in an attempt to drop blood pressure had no clear effect on outcomes including death if treatment is started more than 6h after stroke symptom onset (1)
  • A subsequent 2020 meta-analysis that ticks all the boxes for a good review but importantly is not peer-reviewed also failed to demonstrate any benefit of acute blood pressure treatment within 72h (2)
  • An individual patient data meta-analysis (3), as well as the Cochrane review (1) have failed to show that continuing prior antihypertensive treatment after a stroke affects patient outcomes. There is no evidence that this is an urgent consideration.

References

  1. Bath PMW, Krishnan K. Interventions for deliberately altering blood pressure in acute stroke. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD000039. DOI: 10.1002/14651858.CD000039.pub3. Accessed 26 September 2023.
  2. Li Z, Ma Y, Huang G, Zhang G. Effects of effective acute anti-hypertensive therapy on ischemic stroke prognosis: a meta-analysis of randomized controlled trials. Research Square; 2020. DOI: 10.21203/rs.3.rs-35888/v1.
  3. Woodhouse LJ, Manning L, Potter JF, Berge E, Sprigg N, Wardlaw J, et al. Continuing or Temporarily Stopping Prestroke Antihypertensive Medication in Acute Stroke. Hypertension. 2017;69(5):933-41.
Appendix – Assessment of GCS

Eyes
Open spontaneously (4)
Opens on command (3)
Opens to pain (2)
No opening (1)

Voice
Oriented (5)
Confused (4)
Inappropriate words (3)
Incomprehensible sounds (2)
No response (1)

Motor
Obeys commands (6)
Localising pain (5)
Withdrawing from pain (4)
Flexion to pain (3)
Extension to pain (2)
No response (1)

By Dr Gwenllian Evans (SHO)

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