Acute Stroke and Transient Ischaemic Attack (TIA) Management - Inpatient

General management and drug therapy

Before CT brain:

• Suspend antiplatelets / anticoagulants / heparin until a CT brain scan is completed. The decision to resume anticoagulants will be at the discretion of the stroke specialist.

Blood glucose (aim 4-11mmol/L):

• In the context of acute stroke, hypoglycaemia is more dangerous than hyperglycaemia.
• If low – correct as per the Management of Hypoglycaemia guideline.
• If high or for the management of patients with diabetes who are NBM – refer to the Variable Rate Intravenous Insulin Infusion (VRIII) guideline.

Fluid management:

• In stroke patients, adequate fluid intake and hydration are important for recovery. Many patients are also nil by mouth due to unsafe swallow due to stroke. 
• If IV fluids are required, this should be administered via the unaffected upper limb if appropriate.
• Prescribe either IV sodium chloride 0.9% with appropriate potassium supplementation, or Hartmann's (compound sodium lactate).
• Avoid IV glucose fluids in acute stroke as this can worsen intracranial oedema secondary to ischaemia, unless required as part of the VRIII regime to control blood sugars while nil by mouth.
• Continue IV fluids until oral fluid intake is adequate to meet fluid maintenance goals / enteral feeding regime has been established, or after a decision has been taken to discontinue their use.
• N.B. New acute stroke patients are excluded from NHS A&A IV fluid prescription regime for the first 7 days following stroke.

Oxygen saturation:

• If <95%, prescribe oxygen therapy unless contraindicated. Refer to Guidelines on Oxygen and Oximetry.

After CT brain:

• If CT scan shows no haemorrhage, prescribe a loading dose of antiplatelet agent as per Secondary Prevention of Stroke and Transient Ischaemic Attack (TIA) guideline.
• Ensure antiplatelet is given immediately i.e. do not leave for administration at next morning's drug round.
• If the patient has had thrombolysis, delay antiplatelet loading for 24 hours and ensure a follow-up CT brain scan is completed first.
• If CT scan shows haemorrhage:
  • Discuss with the neurosurgical team at Queen Elizabeth University Hospital (QEUH) unless palliative and not for any potential surgical option (contact via QEUH switchboard on 0141 201 1100 and ask to page neurosurgical registrar, or phone 0141 451 8929).
  • Check urgent coagulation screen.
  • Stop all antiplatelets or anticoagulants patient may have been on previously and discuss with stroke consultant (or on call geriatrician consultant out of hours) and haematology consultant as reversal agents may be required.
• If CT scan shows an alternative pathology (e.g. tumour, subdural haematoma), discuss with stroke consultant.

Repeat CT scan is indicated after the initial scan in the following circumstances:

• If the patient’s conscious level deteriorates or neurological impairment deteriorates
• 24 hours after thrombolysis scan
• If clinically indicated

Other investigations

Chest X-Ray should be carried out in the following instances:

• Unsafe swallow
• Long term smoker
• Any findings on auscultation
• Oxygen requirement
• Cough or pyrexia

Consider the following at the discretion of the stroke consultant: MRI imaging, CT carotid angiogram, carotid duplex, 72-hour ECG monitoring and transthoracic echocardiogram. If Patent Forearm Ovale (PFO) identified the patient should be referred to the PFO multidisciplinary team for PFO closure, if deemed appropriate.

Blood pressure management

• In general, all pre-admission antihypertensive agents should continue.
• If <100/60mmHg seek cause and consider commencing IV fluids (see Fluid management section above for details).
• If >200/120mmHg seek evidence of malignant hypertension and consider treatment only after discussion with consultant.
• See advice on BP management in haemorrhagic stroke in table below.

Table 1 – Blood pressure control in acute intracerebral haemorrhage (refer to exceptions below)

Exceptions to rapid blood pressure lowering listed below:

• Have an underlying structural cause (for example tumour, arteriovenous malformation or aneurysm)
• Have a GCS of below 6
• Are going to have early neurosurgery to evacuate the haematoma
• Have a massive haematoma with a poor expected prognosis.

Temperature >37ºC and/or evidence of infection:

• Commence antimicrobials at the earliest opportunity for suspected infection while awaiting culture results as per the infection management guidelines and give Paracetamol (oral/IV/per rectum) 1g every four to six hours as required (maximum dose 4g/day) N.B. Consider dose reduction in patients with low body weight (<50kg), renal impairment, glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15mg/kg/dose up to four times daily (max 60mg/kg/day). An example is: paracetamol oral 500mg four times daily. Patients with chronic liver failure may require a further dose adjustment (7.5mg/kg/dose, max 30mg/kg/day).

Seizures:

• Following an acute stroke, seizure activity increases oxygen utilisation of the ischaemic area and is likely to contribute to further neuronal death and extension of the infarcted area.
• For the treatment of seizures, see the Management of Status Epilepticus guideline.
• Correct any metabolic disturbances that may aggravate seizure activity.
• Levetiracetam is a suitable agent for post-stroke epilepsy particularly in the elderly.
• Patients should be referred to the seizure clinic for specialist assessment.

Atrial fibrillation (AF):

• For rate control management, see AF guideline via AthenA / Guidelines - Prescribing.
• Timing of initiation or re-introduction of anticoagulants in patients with AF will be at the discretion of the stroke consultant. More information is detailed within the Secondary Prevention of Stroke and TIA Management guideline.

Venous thromboembolism (VTE):

• Intermittent pneumatic compression (IPC) stocking should be considered for immobile stroke patients as soon as possible on admission (ideally within 3 days) to reduce DVT risk.
• Early mobilisation should be encouraged.
• Avoid prophylactic low molecular weight heparin within the first two weeks of a stroke due to the risk of haemorrhagic transformation.
• For treatment of venous thromboembolism, refer to VTE treatment guideline via AthenA / Guidelines - Prescribing.

Further specialist assessment:

• Patients may require referral for further specialist assessment, if clinically indicated. This may include input from: physiotherapy, occupational therapy, speech and language therapy, stroke specialist nurse, pharmacy, dietetics, orthoptics, clinical psychology.