Management of Stroke Patients
The treatment modalities for stroke patients depend on the type of stroke they have had. It is therefore very important to get a CT scan of the head as soon as possible to rule out a bleed in the case of Hemorrhagic stroke. Once a bleed is ruled out, the following treatment options are available for ischaemic strokes :
Thrombolysis
… this is the intravenous administration of a clot bursting drug, alteplase within the thrombolysis window of 4.5 hours from onset of symptoms as per current NICE guideline.
Thrombectomy
… is a process where interventional radiologists mechanically extracts blood clots (Thombus) from within the affected artery. Thrombectomy is ideally performed within 6 hours from time of onset (window range is within 6-24 hours) for patients that meet the criteria.
Antiplatelet Therapy
platelets are blood cells that play a very significant role in blood clot formation.
… platelets are blood cells that play a very significant role in blood clot formation. Anti-platelets are used in treating ischaemic stroke patients. High dose aspirin 300mg daily should be started once a CT scan of the head rules out a bleed, for patients that do not meet the criteria for thrombolysis/Thrombectomy. For those that meet the criteria, a repeat CT scan of the head should be done 24 hours post thrombolysis/thrombectomy to rule out Hemorrhagic transformation/complication of the procedure. Once ruled out, 300mg daily of aspirin is given for 2 weeks and then stepped down to clopidogrel 75mg od lifelong.
Statins – given to mitigate hypercholesterolaemia risk factor. Those intolerant to statins can be put on ezetimibe as an alternative. Haemorrhagic Stroke is treated primarily by treating the cause eg optimising bp control in the case of hypertensive aetiology.
STROKE REHABILITATION :
This is a very important aspect of stroke management and is my personal area of interest.
Mismanagement post stroke could lead to avoidable morbidity and mortality. This aspect of stroke management is multidisciplinary, involving a team of doctors, nurses, physiotherapists, speech and language therapists, Dieticians, neuropsychologists / neuropsychiatrists, occupational therapists and healthcare assistants. Everyone in the team (T-together, E-everyone, A-achieves, M-more) is important and all work together to achieve the common goal of best clinical outcome for the patients. Below are some of the complications post stroke that could result in fatalities if not addressed :
Aspiration Pneumonia
depending on the part of brain affected by the stroke, the patient’s ability to swallow safely can be impaired, a condition known as dysphagia. This predisposes him/her to aspiration pneumonia (some of the food/water go into the lungs instead of the food pipe and cause pneumonia). Their management should be guided by the speech and language team after a swallow assessment. They are initially fed via NG (Nasogastric) tube.
Majority of stroke patients will recover the ability for safe swallow. A minority may need a longer term feeding route such as PEG (Percutaneous Endoscopic Gastrostomy), where a PEG tube is inserted into the patients stomach through the abdominal wall. Patients at risk of aspiration pneumonia should be monitored very closely and doctors should have low threshold to start antibiotics if they spike temperature of their inflammatory markers significantly trending up.
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
Because most stroke patients are immobile following disability from stroke, they are
quite prone to developing DVT(blood clot in the limbs) and PE (Blood clot in the lungs) -To prevent this from happening it is very important for every stroke patient to be on an intermittent Pneumatic Compression (IPC) device which can be switched to prophylactic blood thinners when appropriate.