Teaching session - Stroke
I have made a guideline on stroke and its management in the NHS based on my experience.
This is only for educational purposes and if in doubt, kindly refer to your local guidelines and ask your seniors. Please remember that these guidelines vary from trust to trust which you will be introduced to during your induction and your first few days in your trust.
This is only for educational purposes and if in doubt, kindly refer to your local guidelines and ask your seniors. Please remember that these guidelines vary from trust to trust which you will be introduced to during your induction and your first few days in your trust.
THE BASICS
There are 2 types of stroke:
1. Hemorrhagic stroke - which is bleed in the brain
2. Ischemic stroke - when there is a clot in one of the arteries supplying the brain which results in an ischemic infarct.
Hemorrhagic stroke is classified into:
1. Intracerebral hemorrhage
Bleeding within the brain tissue
2. Subarachanoid hemorrhage
Bleeding outside the brain tissue but within in the skull
Ischemic strokes have different classifications. Each trust may use its own classification. The most commonly used classification is known as the Bamford/Oxford Classification.
http://www.medquarterly.com/mq88/MQPDF/MM/OxfordStrokeClassification.pdf
The management of these 2 different types of stroke is very different therefore it is very important to do appropriate investigations.
ISCHEMIC STROKE
What are the symptoms of stroke?
The main stroke symptoms can be remembered with the word F.A.S.T.:
Face – the face may have dropped on one side, the person may not be able to smile, or their mouth or eye may have drooped.
Arms – the person with suspected stroke may not be able to lift both arms and keep them there because of weakness or numbness in one arm.
Speech – their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake.
Time – it's time to dial 999 immediately if you notice any of these signs or symptoms.
https://www.nhs.uk/conditions/stroke/symptoms/
What if the patient fails the sip test?
The patient should have PR aspirin and then get assessed by the speech and language therapists.
What do the speech and language therapists do?
They assess the swallow of the patient by trying different consistencies of food which the patient can tolerate and then advise a particular diet.
What if the patient cannot tolerate any sort of diet?
A NG tube is passed. The dieticians will then review him/her and start a NG based feeding regime.
What sort of blood tests do we need to monitor?
When a patient has been nil by mouth for some time, (s)he may develop refeeding syndrome due to deficiency of certain electrolytes. These include magnesium, phosphate, calcium, albumin.
Therefore it is important to check these bloods along with routine bloods at least twice a week (or as advised by the dietician).
How long does the patient continue on aspirin 300 mg for?
2 weeks - then the patient is switched to clopidogrel 75 mg. However if the patient is discharged before the 2 weeks, then (s)he is started on 75 mg clopidogrel upon discharge.
What about VTE prophylaxis?
LMWH/enoxaparin/heparin are contraindicated in the first 2 weeks of an acute ischemic stroke. Instead of these, intermittent pneumatic compression stockings should be worn by the patient which inflate and deflate intermittently thus acting like muscles of the leg. This prevents DVT formation.
When can the patient have LMWH/enoxaparin/heparin ?
After 2 weeks. The intermittent pneumatic compression stockings are no longer required when LMWH/enoxaparin/heparin is started.
How long does the patient have the NG tube in for?
The patient will be assessed on the regular basis by the dieticians. If they continue to fail the swallow assessment, then a PEG (Percutaneous endoscopic gastrostomy) tube is considered in 4 weeks.
What is a PEG tube?
This is inserted by the endoscopists- a small hole is made in the abdomen and stomach and a tube is inserted. This way, the patient does not have a NG tube which can be very irritating. You can read more about it here:
https://patient.info/doctor/peg-feeding-tubes-indications-and-management
What other assessments does the patient with a stroke have?
1.The patient will be seen by the stroke nurse/doctor carrying the stroke bleep on admission
2. The patient is seen by a stroke consultant if (s)he is admitted during hospital hours and discussed with the stroke consultant on call if the patient is admitted during out of hours.
3. Assessed by the speech and language therapists
4. Assessed by the physiotherapists
5. Assessed by the occupational therapists.
TIME OF ONSET < 4.5 HOURS
1. History, examination, bloods
2. CT head to rule out bleed.
3. Transfer to monitored bed
4. Do thrombolysis
5. Do sip test and get a speech and language therapist review
6. Prescribe aspirin 300 mg and statin from the following day- PO if (s)he passes the sip test, PR if (s)he fails the sip test.
7. Prescribe IV fluids if the patient fails the sip test
TIME OF ONSET>4.5 HOURS
1. History, examination, bloods
2. CT head to rule out bleed.
3. Transfer to monitored bed
4. Do sip test and get a speech and language therapist review
5. Prescribe aspirin 300 mg STAT- PO if (s)he passes the sip test, PR if (s)he fails the sip test.
6. Prescribe IV fluids if the patient fails the sip test.
There are strict rules on this:
https://www.gov.uk/stroke-and-driving
These are the basic rules:
https://www.gpnotebook.co.uk/simplepage.cfm?ID=1268383807
Some top tips:
1. New onset confusion in a patient on anticoagulation - rule out bleed ASAP.
2. Think about differentials. An elderly patient who is confused may have sepsis. However do a CT head if in doubt.
3. Always discuss these cases with your seniors! Stroke is serious and the registrar must know about it.
4. When answering the stroke bleep, always ask these questions
- Time of onset
- Whether the patient is on any anticoagulants
- What features of stroke does the patient have
5. Acute strokes need monitored beds unless your trust has a different protocol
6. You cannot diagnose a patient with TIA unless the symptoms have resolved completely.
7. A normal CT head does not rule out ischemic stroke
8. Follow your trusts protocol.
There are 2 types of stroke:
1. Hemorrhagic stroke - which is bleed in the brain
2. Ischemic stroke - when there is a clot in one of the arteries supplying the brain which results in an ischemic infarct.
Hemorrhagic stroke is classified into:
1. Intracerebral hemorrhage
Bleeding within the brain tissue
2. Subarachanoid hemorrhage
Bleeding outside the brain tissue but within in the skull
Ischemic strokes have different classifications. Each trust may use its own classification. The most commonly used classification is known as the Bamford/Oxford Classification.
http://www.medquarterly.com/mq88/MQPDF/MM/OxfordStrokeClassification.pdf
The management of these 2 different types of stroke is very different therefore it is very important to do appropriate investigations.
ISCHEMIC STROKE
What are the symptoms of stroke?
The main stroke symptoms can be remembered with the word F.A.S.T.:
Face – the face may have dropped on one side, the person may not be able to smile, or their mouth or eye may have drooped.
Arms – the person with suspected stroke may not be able to lift both arms and keep them there because of weakness or numbness in one arm.
Speech – their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake.
Time – it's time to dial 999 immediately if you notice any of these signs or symptoms.
https://www.nhs.uk/conditions/stroke/symptoms/
Other than this the patient may have cerebellar features (loss of balance thus falls, ataxia, nausea, vomiting)
The patient may also have visual symptoms.
What is a transient ischemic attack?
This is a stroke which completely resolves completely within 24 hours.
How should I investigate stroke?
If you suspect a stroke, book a CT head immediately.
You need to rule out a bleed.
The CT head is normal. Does this rule out ischemic stroke?
A normal CT does not exclude an ischemic stroke.
You can see the changes in the CT head of an ischemic stroke over a few hours to weeks here:
https://radiopaedia.org/articles/ischaemic-stroke
So a patient with features of a stroke but with a normal CT head is an ischemic stroke then?
Yes.Or it could be a transient ischemic attack (which will be confirmed if the symptoms resolve within 24 hours).
What else should I do?
History, detailed examination, send the following bloods when you cannulate the patient:
FBC, CRP, U and E's, clotting, liver profile, lipid profile, plasma glucose.
Do a 12 lead ECG
Why is time of onset so important?
Ischemic strokes can be treated with thrombolysis if the presentation is less than 4 hours, 30 minutes. This is known as the "window period"
What if the patient woke up with features of stroke and has presented within this window period?
If the patient woke up with these symptoms, then you cannot accurately calculate the time of onset.
What is thrombolysis?
This is a clot busting medication (known as alteplase) which is given intravenously. This is given on a monitored bed such as an acute stroke unit/HDU etc.
https://www.stroke.org.uk/what-is-stroke/diagnosis-to-discharge/treatment
The patient may also have visual symptoms.
What is a transient ischemic attack?
This is a stroke which completely resolves completely within 24 hours.
How should I investigate stroke?
If you suspect a stroke, book a CT head immediately.
You need to rule out a bleed.
The CT head is normal. Does this rule out ischemic stroke?
A normal CT does not exclude an ischemic stroke.
You can see the changes in the CT head of an ischemic stroke over a few hours to weeks here:
https://radiopaedia.org/articles/ischaemic-stroke
So a patient with features of a stroke but with a normal CT head is an ischemic stroke then?
Yes.Or it could be a transient ischemic attack (which will be confirmed if the symptoms resolve within 24 hours).
What else should I do?
History, detailed examination, send the following bloods when you cannulate the patient:
FBC, CRP, U and E's, clotting, liver profile, lipid profile, plasma glucose.
Do a 12 lead ECG
Why is time of onset so important?
Ischemic strokes can be treated with thrombolysis if the presentation is less than 4 hours, 30 minutes. This is known as the "window period"
What if the patient woke up with features of stroke and has presented within this window period?
If the patient woke up with these symptoms, then you cannot accurately calculate the time of onset.
What is thrombolysis?
This is a clot busting medication (known as alteplase) which is given intravenously. This is given on a monitored bed such as an acute stroke unit/HDU etc.
https://www.stroke.org.uk/what-is-stroke/diagnosis-to-discharge/treatment
This link also mentions thrombectomy as another treatment option.
This service is not available in every trust and your stroke consultant will advise whether this is indicated or not.
What is the risk of thrombolysis?
This may cause a bleed in the brain however the risk is less if it done within the window period.
Other risks may include drug reactions, etc.
What are the contraindications to this?
If the patient is outside the window period and there are some contraindications to this which are mentioned here:
https://www.stroke.org.uk/what-is-stroke/diagnosis-to-discharge/treatment
What is the management after thrombolysis?
The patient should have aspirin 300 mg from the following day along with a PPI (especially if there history of gastritis)
The patient should have a repeat CT head 24 hours after the thrombolysis to ensure there is no bleed.
This service is not available in every trust and your stroke consultant will advise whether this is indicated or not.
What is the risk of thrombolysis?
This may cause a bleed in the brain however the risk is less if it done within the window period.
Other risks may include drug reactions, etc.
What are the contraindications to this?
If the patient is outside the window period and there are some contraindications to this which are mentioned here:
https://www.stroke.org.uk/what-is-stroke/diagnosis-to-discharge/treatment
What is the management after thrombolysis?
The patient should have aspirin 300 mg from the following day along with a PPI (especially if there history of gastritis)
The patient should have a repeat CT head 24 hours after the thrombolysis to ensure there is no bleed.
What other medications is this patient started on?
Statin
Nicotine patch- if the patient smokes and has agreed to quit.
What if the patient has presented outside the window period and has features of stroke?
Take a history, examine the patient and send investigations mentioned above.
Once the CT head is ruled out a bleed, give aspirin (PR- per rectal/PO- per oral) 300 mg STAT
What do you mean by PR or PO?
When a patient presents with a stroke, (s)he is transferred to the acute stroke unit after a CT head (which has ruled out a bleed) and the stroke nurses/ doctor carrying the stroke bleep does a sip test. The patient is asked to sip some water and if the patient passes it (ie does not cough or regurgitate ), you can give PO aspirin. If (s)he fails, give PR aspirin.
Why is the patient transferred to a stroke unit/monitored bed?
The blood pressure of the patient needs to be monitored. Studies have shown that a very low blood pressure can can hypoperfusion of the brain and exacerbate the symptoms or if it is very high (ie higher than 180mmhg systolic), it can cause a bleed.
Plus the stroke nurses can do a sip test as well as they are trained to do this.
Stroke patients can become unstable therefore it is important to monitor them for at least 24 hours in such a unit.
What if the blood pressure is above 180mmHg systolic?
If the patient is post-thrombolysis or has had a bleed, then you give IV labetolol to bring it down. As it can also cause a low heart rate, the patient needs to be on monitored bed.
Some trusts may have different protocols for managing high blood pressure in stroke patients so check your local guidelines.
Usually IV labetolol is effective till 24 hours and then an alternate medication should be considered - This is upto the stroke consultant to decide.
Nicotine patch- if the patient smokes and has agreed to quit.
What if the patient has presented outside the window period and has features of stroke?
Take a history, examine the patient and send investigations mentioned above.
Once the CT head is ruled out a bleed, give aspirin (PR- per rectal/PO- per oral) 300 mg STAT
What do you mean by PR or PO?
When a patient presents with a stroke, (s)he is transferred to the acute stroke unit after a CT head (which has ruled out a bleed) and the stroke nurses/ doctor carrying the stroke bleep does a sip test. The patient is asked to sip some water and if the patient passes it (ie does not cough or regurgitate ), you can give PO aspirin. If (s)he fails, give PR aspirin.
Why is the patient transferred to a stroke unit/monitored bed?
The blood pressure of the patient needs to be monitored. Studies have shown that a very low blood pressure can can hypoperfusion of the brain and exacerbate the symptoms or if it is very high (ie higher than 180mmhg systolic), it can cause a bleed.
Plus the stroke nurses can do a sip test as well as they are trained to do this.
Stroke patients can become unstable therefore it is important to monitor them for at least 24 hours in such a unit.
What if the blood pressure is above 180mmHg systolic?
If the patient is post-thrombolysis or has had a bleed, then you give IV labetolol to bring it down. As it can also cause a low heart rate, the patient needs to be on monitored bed.
Some trusts may have different protocols for managing high blood pressure in stroke patients so check your local guidelines.
Usually IV labetolol is effective till 24 hours and then an alternate medication should be considered - This is upto the stroke consultant to decide.
What if the patient has had an ischemic stroke and has not been thrombolysed but the blood pressure is above 180 mmHg systolic?
This is usually left to the stroke consultant to decide. It is advised NOT to bring the blood pressure down rapidly as it can cause hypoperfusion of the area of infarct and make it worse.
What other investigations does a patient need?
A carotid doppler to rule out significant carotid artery stenosis.This is usually done the same day if the patient presents within hospital hours or the following day if the patient presents out of hours.
What if the carotid doppler shows significant stenosis?
The stroke consultant may then transfer the patient to the vascular surgeons for a carotid endarterectomy. Read about it here:
https://www.nhs.uk/conditions/carotid-endarterectomy/
This is usually left to the stroke consultant to decide. It is advised NOT to bring the blood pressure down rapidly as it can cause hypoperfusion of the area of infarct and make it worse.
What other investigations does a patient need?
A carotid doppler to rule out significant carotid artery stenosis.This is usually done the same day if the patient presents within hospital hours or the following day if the patient presents out of hours.
What if the carotid doppler shows significant stenosis?
The stroke consultant may then transfer the patient to the vascular surgeons for a carotid endarterectomy. Read about it here:
https://www.nhs.uk/conditions/carotid-endarterectomy/
The patient might be repatriated back to the trust after the procedure (which takes a day or 2 if there are no complications)
What if the patient fails the sip test?
The patient should have PR aspirin and then get assessed by the speech and language therapists.
What do the speech and language therapists do?
They assess the swallow of the patient by trying different consistencies of food which the patient can tolerate and then advise a particular diet.
What if the patient cannot tolerate any sort of diet?
A NG tube is passed. The dieticians will then review him/her and start a NG based feeding regime.
What sort of blood tests do we need to monitor?
When a patient has been nil by mouth for some time, (s)he may develop refeeding syndrome due to deficiency of certain electrolytes. These include magnesium, phosphate, calcium, albumin.
Therefore it is important to check these bloods along with routine bloods at least twice a week (or as advised by the dietician).
How long does the patient continue on aspirin 300 mg for?
2 weeks - then the patient is switched to clopidogrel 75 mg. However if the patient is discharged before the 2 weeks, then (s)he is started on 75 mg clopidogrel upon discharge.
What about VTE prophylaxis?
LMWH/enoxaparin/heparin are contraindicated in the first 2 weeks of an acute ischemic stroke. Instead of these, intermittent pneumatic compression stockings should be worn by the patient which inflate and deflate intermittently thus acting like muscles of the leg. This prevents DVT formation.
When can the patient have LMWH/enoxaparin/heparin ?
After 2 weeks. The intermittent pneumatic compression stockings are no longer required when LMWH/enoxaparin/heparin is started.
How long does the patient have the NG tube in for?
The patient will be assessed on the regular basis by the dieticians. If they continue to fail the swallow assessment, then a PEG (Percutaneous endoscopic gastrostomy) tube is considered in 4 weeks.
What is a PEG tube?
This is inserted by the endoscopists- a small hole is made in the abdomen and stomach and a tube is inserted. This way, the patient does not have a NG tube which can be very irritating. You can read more about it here:
https://patient.info/doctor/peg-feeding-tubes-indications-and-management
What other assessments does the patient with a stroke have?
1.The patient will be seen by the stroke nurse/doctor carrying the stroke bleep on admission
2. The patient is seen by a stroke consultant if (s)he is admitted during hospital hours and discussed with the stroke consultant on call if the patient is admitted during out of hours.
3. Assessed by the speech and language therapists
4. Assessed by the physiotherapists
5. Assessed by the occupational therapists.
What are the other investigations required for ischemic stroke?
1. 24 HR ECG - to rule out paroxysmal AF which may have caused the stroke. The patient can be started on anticoagulation as advised by the stroke consultant (usually it is at least 2 weeks after the acute stroke)
2. ECHO - To rule out cardiac embolus and to assess the hearts structure in general.
Is there any follow up?
The patient is usually followed up in the stroke clinic in 2 months and is seen by the stroke team in the community.
So to summarize, what is the management of an ischemic stroke?
1. 24 HR ECG - to rule out paroxysmal AF which may have caused the stroke. The patient can be started on anticoagulation as advised by the stroke consultant (usually it is at least 2 weeks after the acute stroke)
2. ECHO - To rule out cardiac embolus and to assess the hearts structure in general.
Is there any follow up?
The patient is usually followed up in the stroke clinic in 2 months and is seen by the stroke team in the community.
So to summarize, what is the management of an ischemic stroke?
TIME OF ONSET < 4.5 HOURS
1. History, examination, bloods
2. CT head to rule out bleed.
3. Transfer to monitored bed
4. Do thrombolysis
5. Do sip test and get a speech and language therapist review
6. Prescribe aspirin 300 mg and statin from the following day- PO if (s)he passes the sip test, PR if (s)he fails the sip test.
7. Prescribe IV fluids if the patient fails the sip test
8. Carotid doppler
9. Continue aspirin 300 mg and intermittent pneumatic compression stockings for 2 weeks
10. Switch to clopidogrel 75 mg and LMWH/enoxaparin/heparin after 2 weeks. Switch to clopidogrel is the patient is discharged earlier than that.
11. Pass a NG tube if the patient fails a swallow assessment
12. Consider PEG tube if the patient still needs a NG tube in 4 weeks.
13. Regular assessment by SLT, OT, PT.
9. Continue aspirin 300 mg and intermittent pneumatic compression stockings for 2 weeks
10. Switch to clopidogrel 75 mg and LMWH/enoxaparin/heparin after 2 weeks. Switch to clopidogrel is the patient is discharged earlier than that.
11. Pass a NG tube if the patient fails a swallow assessment
12. Consider PEG tube if the patient still needs a NG tube in 4 weeks.
13. Regular assessment by SLT, OT, PT.
14. 24 HR ECG and ECHO (may be done as an outpatient)
15. Follow up by stroke team in the community
16. Follow up in the stroke clinic in 2 months
15. Follow up by stroke team in the community
16. Follow up in the stroke clinic in 2 months
TIME OF ONSET>4.5 HOURS
1. History, examination, bloods
2. CT head to rule out bleed.
3. Transfer to monitored bed
4. Do sip test and get a speech and language therapist review
5. Prescribe aspirin 300 mg STAT- PO if (s)he passes the sip test, PR if (s)he fails the sip test.
6. Prescribe IV fluids if the patient fails the sip test.
7.Carotid doppler
8. Start on statin
9. Continue aspirin 300 mg for 2 weeks.
10. Switch to clopidogrel 75 mg and LMWH/enoxaparin/heparin after 2 weeks. Switch to clopidogrel is the patient is discharged earlier than that.
11. Pass a NG tube if the patient fails a swallow assessment
12. Consider PEG tube if the patient still needs a NG tube in 4 weeks.
13. Regular assessment by SLT, OT, PT
8. Start on statin
9. Continue aspirin 300 mg for 2 weeks.
10. Switch to clopidogrel 75 mg and LMWH/enoxaparin/heparin after 2 weeks. Switch to clopidogrel is the patient is discharged earlier than that.
11. Pass a NG tube if the patient fails a swallow assessment
12. Consider PEG tube if the patient still needs a NG tube in 4 weeks.
13. Regular assessment by SLT, OT, PT
14. Follow up by stroke team in the community
15. Follow up in the stroke clinic in 2 months
What if the patient in another ward has stroke like features?
Stop all blood thinning medications, quickly do a CT head and discuss this with your seniors. The patient might be moved to the stroke unit and may be considered for thrombolysis if the time of onset is within the window period.
What are conditions which mimic strokes?
Sepsis in elderly can also mimic stroke. However you should never ever delay doing a CT head. Always ask your seniors if in doubt.
TRANSIENT ISCHEMIC ATTACKS.
How can we differentiate TIA from ischemic stroke on admission (ie less than 24 hours).
It is very difficult to. You cannot be sure till 24 hours have passed or if the symptoms have completely resolved before that.
So what is the treatment?
Same as ischemic stroke - aspirin 300 mg STAT given that you are unsure if the patient has had a TIA or ischemic stroke.
Then start on clopidogrel 75 mg OD the following day if the symptoms resolve completely by/before 24 hours.
Is there any other investigation?
Like ischemic stroke, you need to rule out causes which can be potentially reversible. The investigations depend on the stroke consultant. Some prefer doing carotid dopplers as inpatient and then follow them up in the clinic.
What is the TIA pathway?
This is a trust based guideline. If the patient is stable, (s)he can be discharged on clopidogrel 75 mg OD with a TIA clinic follow up. Such cases do not need to be admitted and can be discharged from ED after a senior review.
HEMORRHAGIC STROKE
What are the symptoms?
Similar to ischemic stroke or the patient may just be confused.
What are the investigations?
The same as for ischemic stroke - CT head is very important.Make sure you do clotting (an INR if the patient is on warfarin)
The CT head confirms a bleed. What should I do?
Contact the neurosurgeons immediately. Find out what medications the patient is taking.
The patient is on an anticoagulant. What should I do?
Stop it. Be it aspirin, clopidogrel, LMWH/enoxaparin/heparin , warfarin, dabigatran, rivaroxaban or apixaban.
Discuss reversal of warfarin/dabigatran with the hematology consultant on call.
How do I refer such cases to neurosurgeons?
Some trusts have neurosurgeons on site. Some do not and use an online portal. Consult your seniors and find out what your trusts protocol is. Make sure the images are transferred to the neurosurgeons if they are based in another trust (usually the CT department does this anyway and mentions this in the CT report)
The neurosurgeons do not want to operate. What should I do next?
Ensure the anticoagulants have been stopped and if possible, reversed. Then transfer the patient to a stroke unit where (s)he will have the following:
1. Have a sip test and get a speech and language therapist review
2. Prescribe IV fluids if the patient fails the sip test.
3. Consider starting LMWH/enoxaparin/heparin after 4 weeks. This is the stroke consultants decision.
4. Pass a NG tube if the patient fails a swallow assessment
5. Consider PEG tube if the patient still needs a NG tube in 4 weeks.
6. Regular assessment by SLT, OT, PT
7. Monitor neuro obs - repeat CT head if the GCS worsens.
Sometimes the neurosurgeons want further investigations. What are these for?
They may want a CT angiogram to check for aneurysms which can be treated by "clipping" the aneurysm - which is a neurosurgical procedure.
They may want to do a MRI head in a few weeks time if they think that the bleed is secondary to an underlying malignancy. This interval is important so that the bleed is resorbed and an underlying lesion can be visualized properly.
What happens if the neurosurgical team is willing to do surgery?
If the team is based in another trust, you must ensure that all of the patients admission notes, drug charts are photocopied. Ensure that you have done a transfer letter and the nurses have informed the clinical site manager who can liaise with the bed manager in the other trust to ensure that there is a bed available in the appropriate unit for the patient. The patient is then transferred via "blue light ambulance".
15. Follow up in the stroke clinic in 2 months
What if the patient in another ward has stroke like features?
Stop all blood thinning medications, quickly do a CT head and discuss this with your seniors. The patient might be moved to the stroke unit and may be considered for thrombolysis if the time of onset is within the window period.
What are conditions which mimic strokes?
Sepsis in elderly can also mimic stroke. However you should never ever delay doing a CT head. Always ask your seniors if in doubt.
TRANSIENT ISCHEMIC ATTACKS.
How can we differentiate TIA from ischemic stroke on admission (ie less than 24 hours).
It is very difficult to. You cannot be sure till 24 hours have passed or if the symptoms have completely resolved before that.
So what is the treatment?
Same as ischemic stroke - aspirin 300 mg STAT given that you are unsure if the patient has had a TIA or ischemic stroke.
Then start on clopidogrel 75 mg OD the following day if the symptoms resolve completely by/before 24 hours.
Is there any other investigation?
Like ischemic stroke, you need to rule out causes which can be potentially reversible. The investigations depend on the stroke consultant. Some prefer doing carotid dopplers as inpatient and then follow them up in the clinic.
What is the TIA pathway?
This is a trust based guideline. If the patient is stable, (s)he can be discharged on clopidogrel 75 mg OD with a TIA clinic follow up. Such cases do not need to be admitted and can be discharged from ED after a senior review.
HEMORRHAGIC STROKE
What are the symptoms?
Similar to ischemic stroke or the patient may just be confused.
What are the investigations?
The same as for ischemic stroke - CT head is very important.Make sure you do clotting (an INR if the patient is on warfarin)
The CT head confirms a bleed. What should I do?
Contact the neurosurgeons immediately. Find out what medications the patient is taking.
The patient is on an anticoagulant. What should I do?
Stop it. Be it aspirin, clopidogrel, LMWH/enoxaparin/heparin , warfarin, dabigatran, rivaroxaban or apixaban.
Discuss reversal of warfarin/dabigatran with the hematology consultant on call.
How do I refer such cases to neurosurgeons?
Some trusts have neurosurgeons on site. Some do not and use an online portal. Consult your seniors and find out what your trusts protocol is. Make sure the images are transferred to the neurosurgeons if they are based in another trust (usually the CT department does this anyway and mentions this in the CT report)
The neurosurgeons do not want to operate. What should I do next?
Ensure the anticoagulants have been stopped and if possible, reversed. Then transfer the patient to a stroke unit where (s)he will have the following:
1. Have a sip test and get a speech and language therapist review
2. Prescribe IV fluids if the patient fails the sip test.
3. Consider starting LMWH/enoxaparin/heparin after 4 weeks. This is the stroke consultants decision.
4. Pass a NG tube if the patient fails a swallow assessment
5. Consider PEG tube if the patient still needs a NG tube in 4 weeks.
6. Regular assessment by SLT, OT, PT
7. Monitor neuro obs - repeat CT head if the GCS worsens.
Sometimes the neurosurgeons want further investigations. What are these for?
They may want a CT angiogram to check for aneurysms which can be treated by "clipping" the aneurysm - which is a neurosurgical procedure.
They may want to do a MRI head in a few weeks time if they think that the bleed is secondary to an underlying malignancy. This interval is important so that the bleed is resorbed and an underlying lesion can be visualized properly.
What happens if the neurosurgical team is willing to do surgery?
If the team is based in another trust, you must ensure that all of the patients admission notes, drug charts are photocopied. Ensure that you have done a transfer letter and the nurses have informed the clinical site manager who can liaise with the bed manager in the other trust to ensure that there is a bed available in the appropriate unit for the patient. The patient is then transferred via "blue light ambulance".
DVLA AND STROKES
There are strict rules on this:
https://www.gov.uk/stroke-and-driving
These are the basic rules:
https://www.gpnotebook.co.uk/simplepage.cfm?ID=1268383807
Some top tips:
1. New onset confusion in a patient on anticoagulation - rule out bleed ASAP.
2. Think about differentials. An elderly patient who is confused may have sepsis. However do a CT head if in doubt.
3. Always discuss these cases with your seniors! Stroke is serious and the registrar must know about it.
4. When answering the stroke bleep, always ask these questions
- Time of onset
- Whether the patient is on any anticoagulants
- What features of stroke does the patient have
5. Acute strokes need monitored beds unless your trust has a different protocol
6. You cannot diagnose a patient with TIA unless the symptoms have resolved completely.
7. A normal CT head does not rule out ischemic stroke
8. Follow your trusts protocol.
Useful resources:
https://www.stroke.org.uk
https://www.nice.org.uk/guidance/cg68
https://www.stroke.org.uk
https://www.nice.org.uk/guidance/cg68
https://pathways.nice.org.uk/pathways/stroke
As mentioned above, this is only for educational purposes and if in doubt, kindly refer to your local guidelines and ask your seniors. Please remember that these guidelines vary from trust to trust which you will be introduced to during your induction and your first few days in your trust.
As mentioned above, this is only for educational purposes and if in doubt, kindly refer to your local guidelines and ask your seniors. Please remember that these guidelines vary from trust to trust which you will be introduced to during your induction and your first few days in your trust.
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