Management Of Stroke Health Article

General Management Of Acute Stroke

Interventions in acute stroke should aim to minimize mortality and disability and to prevent complications such as deep vein thrombosis (DVT).

Admission to a stroke unit: ideally, all patients with stroke should be admitted to a specialist stroke unit. There is convincing evidence that such units reduce mortality, morbidity and dependency. ¹ For every 100 patients managed in a stroke unit, three deaths are prevented, three patients avoid long-term nursing home care and an extra six patients return home, compared with conventional care in a general medical ward. The evidence for mobile stroke teams is less convincing. Organized stroke-unit care is effective regardless of the patient’s age and sex, the severity of stroke symptoms on admission and stroke pathology or subtype. Patients with moderate-to-severe stroke appear to benefit most.

Blood pressure: optimal management of blood pressure in acute stroke is uncertain. Blood pressure is often elevated on admission, but tends to decrease spontaneously during the first few days. Existing antihypertensive therapy should be continued. Treatment may be considered in those with a sustained blood pressure of more than 220/120 mm Hg in cerebral infarction or more than 185/105 mm Hg in cerebral haemorrhage. Cerebral autoregulation is disturbed after stroke, so lower levels of hypertension should probably not be treated in the acute phase, except in patients with coexistent hypertensive encephalopathy, aortic dissection, acute myocardial infarction or severe left ventricular failure.

Oxygenation: hypoxia exacerbates cerebral ischaemia. There are no data supporting routine administration of supplementary oxygen, but oxygen should be given if hypoxia is detected (oxygen saturation <92%). Patients should be nursed sitting up or in a chair when possible, to improve pulmonary ventilation.

Control of blood glucose: hyperglycaemia in acute stroke may be associated with neurological deterioration and poor outcome in the short term. Blood sugar should be maintained within normal limits, with intravenous insulin if necessary.

Pyrexia: fever may be secondary to infection, but may also occur in patients with severe cerebral lesions. Observational data suggest that pyrexia increases infarct size. Infection should be treated promptly, but there is no evidence supporting routine use of antipyretics such as paracetamol in patients with temperatures above 37.5 °C (though they are widely used in practice). Pilot studies have suggested some benefit of induced hypothermia in severe middle cerebral artery territory infarction.

Fluid balance, swallowing and nutrition: intravenous fluid replacement should be used to correct dehydration. Patients who can swallow satisfactorily should be placed in a sitting position to eat or drink. Patients with abnormal swallow should be assessed by a speech and language therapist. Nasogastric or percutaneous endoscopic gastrostomy tube-feeding should be instituted when oral intake is not possible or is insufficient. Malnutrition is common after acute stroke and may be a risk factor for a poor outcome. Advice from a dietitian should be sought for patients needing nutritional support.

Early mobilization and rehabilitation: early mobilization may reduce the incidence of complications such as pneumonia, DVT, pulmonary embolism, orthostatic reactions, painful shoulders, contractures, pressure ulcer, depression, constipation, urinary tract infection and falls. Rehabilitation should focus on minimizing further physical deterioration, restoring function, developing strategies for coping with impairment and preventing secondary conditions, and should extend to preparing patients for independent life in the community.

DVT prophylaxis: patients without cerebral haemorrhage should receive aspirin, and dehydration should be avoided in all patients. Compression stockings should be used in immobile patients, though there are no randomized trial data.