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Neurological Emergencies: Stroke Management

Definition

A stroke, also known as a cerebrovascular accident (CVA), is a medical emergency that occurs when the blood supply to the brain is interrupted or reduced, depriving brain cells of oxygen and nutrients. This can lead to brain damage, disability, or death.
There are two main types:

  1. Ischemic Stroke: Caused by a blockage in a blood vessel supplying the brain.
  2. Hemorrhagic Stroke: Caused by a rupture of a blood vessel in the brain.

Causes

  1. Ischemic Stroke:

  2. Hemorrhagic Stroke:

Signs and Symptoms

  1. Sudden onset of the following:

    • Weakness or numbness, especially on one side of the body.
    • Difficulty speaking or understanding speech (aphasia).
    • Vision disturbances (e.g., double vision, blindness).
    • Severe headache with no known cause.
    • Loss of balance or coordination.

  2. Use the FAST acronym:

    • Face drooping.
    • Arm weakness.
    • Speech difficulty.
    • Time to call emergency services.


Investigations

  1. Imaging:

    • CT Scan (non-contrast): To distinguish between ischemic and hemorrhagic stroke.
    • MRI: Provides detailed images of brain tissue damage.

  2. Laboratory Tests:

    • Complete blood count (CBC).
    • Coagulation profile (PT/INR, aPTT).
    • Lipid profile.
    • Blood glucose levels.

  3. Cardiac Evaluation:

    • ECG to rule out atrial fibrillation.
    • Echocardiogram for detecting cardiac emboli.

  4. Others:

    • Carotid ultrasound: To detect stenosis or blockages in carotid arteries.
    • Angiography: For vascular assessment.

Emergency Management

  1. Initial Assessment (ABCDE Approach):

    • Airway: Ensure the airway is clear and secure if necessary.
    • Breathing: Provide oxygen if SpO₂ < 94%.
    • Circulation: Establish IV access; monitor blood pressure and heart rate.

  2. Rapid Diagnosis:

    • Immediate neuroimaging (CT/MRI).
    • Blood glucose check to rule out hypoglycemia.

  3. Stroke Team Activation:

    • Notify the stroke team for further management.

Medical and Surgical Treatment

Ischemic Stroke:

  1. Thrombolytic Therapy:

    • Tissue Plasminogen Activator (tPA) (e.g., alteplase): Administered within 4.5 hours of symptom onset for eligible patients.
    • Dose: 0.9 mg/kg IV (maximum 90 mg); 10% as a bolus, remaining over 1 hour.

  2. Antiplatelet Therapy:

    • Aspirin 150–300 mg (after ruling out hemorrhage).
    • Clopidogrel for secondary prevention.

  3. Anticoagulation:

    • In cases of atrial fibrillation or embolism (e.g., warfarin, DOACs).

  4. Endovascular Procedures:

    • Mechanical thrombectomy for large vessel occlusions.

Hemorrhagic Stroke:

  1. Blood Pressure Management:

    • Lower BP cautiously with IV medications (e.g., labetalol, nicardipine).

  2. Surgical Intervention:

    • Craniotomy to relieve intracranial pressure.
    • Clipping or coiling for aneurysms.

  3. Reversal of Anticoagulation:

    • Administer fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC).

Nursing Interventions

  1. Acute Phase:

    • Monitor Neurological Status: Perform regular Glasgow Coma Scale (GCS) assessments.
    • Manage Airway and Breathing: Maintain oxygenation; suction if needed.
    • Control Blood Pressure: Monitor BP; administer antihypertensive medications as prescribed.
    • Prevent Complications:
      • Prevent aspiration by keeping the head of the bed elevated (30°).
      • Perform passive range-of-motion exercises to prevent contractures.

  2. Post-Acute Phase:

    • Nutrition: Assist with feeding or provide enteral nutrition for patients with swallowing difficulties.
    • Rehabilitation: Collaborate with physiotherapists and occupational therapists.
    • Skin Care: Prevent pressure ulcers by repositioning every 2 hours.

  3. Psychosocial Support:

    • Educate the patient and family about the disease, recovery expectations, and lifestyle modifications.
    • Address emotional and psychological needs.

  4. Medication Management:

    • Administer prescribed antiplatelets, anticoagulants, and antihypertensives.
    • Educate about adherence and side effects.

  5. Prevent Recurrence:

    • Encourage lifestyle changes such as a healthy diet, smoking cessation, and regular exercise.

Thrombolytic Therapy: Key Points

  • Strict inclusion criteria for tPA use:
    • Onset of symptoms within 4.5 hours.
    • No active bleeding or recent surgery.
    • Age >18 years.
  • Monitor for signs of bleeding post-administration.
  • Reassess neurologic status every 15 minutes during therapy.

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