RECOGNITION

Stroke is a neurological deficit of sudden onset:

with focal rather than global dysfunction
with symptoms still present (if <24 hr) or lasting >24 hr, or resulting in death before 24 hr
in which, after adequate investigation, symptoms are presumed to be of a non-traumatic vascular origin

Treat all patients with symptoms, even if minor or improving, at time of assessment as a stroke

only if symptoms have completely resolved, diagnose TIA

Symptoms and signs

Total anterior circulation syndrome (TACS)

Involving both deep and superficial middle cerebral artery (MCA) territory
New higher cerebral dysfunction (e.g. dysphasia, dyscalculia, visuospatial disorder) and homonymous visual field defect

if consciousness is impaired and higher cerebral functions or visual fields cannot be tested formally, assume a deficit present

Hemiparesis/hemisensory loss affecting at least 2 body areas (2 out of face, arm and leg)

Partial anterior circulation syndrome (PACS)

More restricted cortical infarcts in the MCA territory, including isolated infarcts in the anterior cerebral artery (ACA) territory and striatocapsular infarctions
Patients presenting with only 2 of the 3 components of the TACS or
Motor/sensory deficit restricted to face or arm or leg

Lacunar syndrome (LACS)

Small lacunar infarcts in the basal ganglia or pons
Pure motor, pure sensory or sensori-motor deficit or
Ataxic hemiparesis (with at least faciobrachial or brachiocrural involvement)

acute focal movement disorders should probably also be included in this group

Posterior circulation syndrome (POCS)

Infarcts in brainstem, cerebellum and/or occipital lobes
Ipsilateral cranial nerve palsy with contralateral motor and/or sensory deficit
Bilateral motor and/or sensory deficit
Disorder of conjugate eye movement
Cerebellar dysfunction without ipsilateral hemiparesis
Isolated homonymous visual field defect

Causes of stroke

Ischaemic

Large-artery atherosclerosis, small vessel atherosclerosis
Cardioembolism, carotid/vertebral dissection
Especially in younger patients, consider rarer causes:

drugs, vasculitis, infection
sickle cell disease, polycythaemia, haematological conditions
sarcoidosis, metabolic disorder e.g. homocystinuria

Haemorrhagic

Intracranial, subdural, and subarachnoid haemorrhage

Differential diagnosis

Acute medical problem exacerbating effects of an older established stroke
Seizures/Todd’s paralysis
Migraine
Functional
Subarachnoid haemorrhage, extradural haemorrhage, subdural haemorrhage
Space-occupying lesion
Meningitis/encephalitis
Metabolic (e.g. hypoglycaemia, hyponatraemia)
Toxic (e.g. overdose)
Anoxic encephalopathy (e.g. shock, arrhythmia)
Trauma

IMMEDIATE ASSESSMENT

Ambulance service

Pre-alert the stroke team with key patient details (name, date of birth, onset time, expected time of arrival, and contact number of ambulance crew)

Emergency department

Take a detailed history (use telephone if necessary) to accurately ascertain onset time to determine appropriate hyper-acute treatments e.g. thrombolysis and thrombectomy
Start hospital acute stroke pathway

Inpatient

If an inpatient develops symptoms or signs raising strong suspicion of an acute stroke, arrange immediate CT head scan (plain) .
Inform stroke team immediately

Urgent investigations and actions

Insert green venflon
Glucose, U&E, FBC, INR, random cholesterol, LFT, CRP

if patient on warfarin obtain INR urgently (use point of care device for immediate results)

ECG (do not delay CT for this)

Immediate CT head scan plus

If fit and independent, no contraindications to contrast, significant neurological deficit (NIHSS >7) and within 4.5 hr of onset, ask imaging:

if no signs of established infarction and no haemorrhage found on CT head scan, to perform CT angiogram (arch to Circle of Willis)

If onset >4.5 hr or no known onset, also order CT perfusion scan
If occlusion of a major intracerebral or extracerebral artery identified, discuss immediately with stroke consultant of the day

IMMEDIATE SPECIFIC MANAGEMENT

Calculate NIH Stroke scale (NIHSS)
Contact research unit

Ischaemic stroke treatment

Manage patients with antiphospholipid syndrome with an acute ischaemic stroke in the same way as patients with acute ischaemic stroke without antiphospholipid syndrome

Patient eligible for thrombolysis: within 4.5 hr of onset or small core and large penumbra

Check contra-indications to IV thrombolysis

e.g. post-operative, postpartum

Unless contraindicated, start IV thrombolysis immediately

use hospital acute stroke pathway

In patients with contraindications to IV thrombolysis or with severe stroke (i.e. proximal MCA thrombus or basilar thrombus), consider thrombectomy
In previously fit and independent patients within 4.5 hr of symptom onset or with a small core and large penumbra on the perfusion scan with occlusions in the CCA, ICA, M1, M2, ACA, basilar artery, or PCA, consider mechanical thrombectomy

alert stroke nurse
do not delay thrombolysis, mechanical thrombectomy can be arranged once treatment has been started

In thrombolysed patients, do not give antiplatelets or anticoagulants for 24 hr

Patients not eligible for thrombolysis or thrombectomy

Once CT head scan excludes haemorrhage, give aspirin 300 mg oral, rectal or via nasogastric tube immediately
Transfer patient to acute stroke unit (ASU) as soon as possible within 4 hr of arrival.
If urgent senior advice is required, call stroke consultant of the day

Intracranial haemorrhage treatment

Reverse anticoagulation

Carry out point-of-care INR, check full clotting screen and reverse immediately

even with prosthetic valves

Reverse anticoagulation with FXa inhibitors (rivaroxaban, apixaban, edoxaban, betrixaban) with adexanet alfa
Reverse anticoagulation with dabigatran with idarucizumab
Reverse anticoagulation with warfarin immediately (within 3 hr or less)

aiming for INR of 1.0 (even in patients with mechanical heart valves)
give Vitamin K₁(phytomenadione) 5 mg IV immediately as slow bolus
knowing INR and body weight, contact on-call consultant haematologist to order dried prothrombin complex (e.g. Octaplex or Beriplex) and correct INR as soon as possible within 3 hr (including patients with prosthetic valves)
in patients with prosthetic valves and disabling cerebral infarct, stop warfarin for 1 week and replace with aspirin 300 mg once daily

Other treatments

Reduce systolic BP to ≤140 mmHg within one hour

start GTN infusion at 1.5 mg/hr
reassess and adjust dose every 5 min. Follow IVH pathway

If haemorrhage is subdural or subarachnoid, the stroke consultant may refer to neurosurgeons
Call stroke nurse and start ICH Pathway

Acute venous stroke (cerebral sinus venous thrombosis)

In patients with cerebral sinus venous thrombosis including those with secondary cerebral haemorrhage, start full dose anticoagulation

initially unfractionated heparin, then warfarin aiming for target INR 2–3 unless contraindicated by other concurrent conditions

Stroke secondary to acute arterial dissection

Use either anticoagulants or antiplatelet agents

GENERAL MEASURES

Admit to Stroke Unit
Allow patient to sit up as tolerated (bed/chair) as soon as possible
Mobilise conscious patients from day 1
Ensure patients who are nil-by-mouth receive all necessary medication (use rectal, IV or nasogastric tube)
Avoid sedatives (e.g. temazepam, chlorpromazine, haloperidol)

Hypoxia

Check and clear airway. If oxygen saturation falls to <95% in spite of this, give supplemental oxygen. See Hypoxaemia guideline

Pyrexia (temperature >37.2°C)

Look for source of infection and treat as indicated
Treat pyrexia (temperature >37.5°C) with paracetamol 1 g oral or rectal 6-hrly

Hyperglycaemia

Maintain blood glucose between 4–11 mmol/L. See Control of hyperglycaemia in the ill patient guideline

Blood pressure

Correct hypotension and try to prevent BP from falling
Unless >220/120 mmHg or intracranial haemorrhage, do not lower BP acutely

in intracranial haemorrhage, use GTN infusions and/or labetalol IV to lower blood pressure rapidly (within 1 hr) to ≤140/80 and maintain this level for 7 days

Statins

If not already on a statin, start atorvastatin 80 mg/day (20 mg/day in the older frail person)
Consider switching patients on simvastatin to atorvastatin

less risk of adverse interactions

Prevention of DVT/pulmonary embolism

Mobilise (out of bed) on day of admission
Adequate hydration
As soon as CT head scan has excluded intracerebral haemorrhage, start antiplatelet therapy
For all patients not able to mobilise to the toilet independently, apply intermittent pneumatic compression (IPC) stockings day and night

stop after first of 30 days or until mobile, or until discharged from acute care
IPC may be removed temporarily during therapy, when mobilising, and while out of the ward for diagnostic tests

Do not use compression stockings
Do not use heparin/dalteparin routinely (e.g. for age and stroke related immobility or infections alone)

benefits in VTE prevention are counterbalanced by haemorrhagic complications with no evidence of an overall benefit on mortality and recovery

Check calves for evidence of DVT at every ward round
Stop VTE prevention at 30 days or at discharge, whatever comes earlier

Oral health

Check and document oral hygiene during every ward round
For patients who are nil-by-mouth, use chlorhexidine gluconate 1% dental gel or toothpaste for oral hygiene 8-hrly
Keep dentures in during the day in all patients (unless very loose and safety risk)

Fluid and nutrition management

Adequate and regular food and hydration
Patients who are nil-by-mouth, start on nasogastric feeding as soon as possible within 24 hr
In all patients receiving palliative care, given comfort feeding and oral fluids as desired and tolerated

Assess swallowing at bedside

Check patient is:

alert and co-operative
able to sit up for feeding
able to cough on demand
not drooling excessively

Sit patient up, listen to voice and give 5 mL of water on a spoon
Watch and feel swallow with fingers on larynx
Observe for 2 min, looking for:

choking or impaired breathing
delayed swallow
cough
change of voice

If 5 mL swallowed without difficulty, give 50 mL of water before giving soft diet
If there is any doubt about swallowing, recommend nil-by-mouth

give fluid IV/SC. See Fluid maintenance guideline
ask speech therapist or stroke team to assess swallowing

Fluids

Unless patient in urinary retention, do not catheterise
In patients who are nil-by-mouth, dehydrated or at risk of dehydration, follow IV Fluid maintenance guideline

Nasogastric tube feeding

In patients with severe stroke and dysphagia, start nasogastric feeding within 24 hr (unless expected to die within hours)
Prescribe metoclopramide 10 mg 8-hrly (5 mg if <50 kg body weight) via nasogastric tube for 3 weeks or until nasogastric feeding no longer required (whichever occurs earlier)
In mild strokes, where normal swallow expected to return, review after 48 hr

if dysphagia still present, pass nasogastric tube

Where a standard nasogastric tube cannot be kept in place safely and reliably, consider a nasal bridle
Refer patients with persistent dysphagia after 3 days for dietary advice

consider further investigation (e.g. video fluoroscopy)

PEG (percutaneous endoscopic gastrostomy)

If NG tube not tolerated and patient unable to take sufficient nasogastric/oral diet for 3 or more days, refer urgently for PEG
If nasogastric feeding successful but no significant recovery of swallowing occurs, consider referral for PEG within 4 weeks
If there is some recovery of swallowing and nasogastric feeding successful, PEG referral may not be necessary

continue nasogastric feeding until patient able to eat normally

Fracture prevention

If stroke patient likely to remain housebound, or discharged to a care facility, prescribe calcium and vitamin D

Nicotine withdrawal

Offer nicotine patches to all smokers, unless they do not intend to stop smoking or if they have contraindication

COMPLICATIONS

Malignant MCA syndrome

If deterioration of consciousness within first 48 hr in patients with large MCA territory infarcts (NIHSS score >15 with item 1a ≥1 (e.g. drowsy patient)), consider malignant MCA syndrome
Arrange urgent CT head scan and discuss with stroke consultant of the day

Result of CT scan

An infarct affecting at least 50% of the middle cerebral artery territory with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or with an infarct volume of >145 cm³ confirms the diagnosis

Treatment

Increase neurological observations to every 15 min
Consider referring urgently to neurosurgery (within 24 hr of stroke onset) to allow surgery within 48 hr

do not wait for midline shift on head CT scan or abnormal pupillary responses
in potential candidates for hemicraniectomy, avoid mannitol or hypertonic saline (may mask signs of deterioration and delay surgery)

Stroke progression

Treat as an emergency
Confirm by repeating NIHSS score

increase of ≥4 points indicates clinically significant deterioration

Repeat head CT scan and seek senior advice
Review differential diagnosis
Consider MR, EEG (for possible encephalitis or epilepsy), lumbar puncture

Infarct progression/further stroke

Highest risk in minor strokes/TIAs

check aspirin 300 mg oral or rectum started

Consider haemorrhagic conversion especially in large infarcts or in thrombolysed patients

Intracerebral haemorrhage progression

If deterioration in neurological signs/level of consciousness after admission, re-scan immediately

unless there are good reasons not to consider surgery, refer to neurosurgeons for advice
recheck INR and correct

Other causes

Cerebral emboli, or vasculitis
Hydrocephalus especially in cerebellar strokes or in patients with intracerebral haemorrhage

refer previously fit patients to neurosurgery

Pneumonia after starting oral fluids

Reassess swallowing, treat as Hospital-acquired pneumonia unless diagnosed on admission

Urinary retention

Relieve by in and out catheter, record drained volume
Monitor bladder volume by bladder scan

intermittent catheterisation as needed

Check for faecal impaction and treat
If retention recurrent, start tamsulosin MR 400 microgram/day

do not use in patients where BP lowering effect could be a problem
for patients with nasogastric tube in situ, use doxazosin 1 mg immediate release tablets, which may be crushed (unlicensed)

Avoid indwelling catheter

DVT/pulmonary embolism

If CT head scan has excluded haemorrhage, treat. See Deep venous thrombosis and Pulmonary embolism guidelines
In patients with haemorrhagic stroke and symptomatic DVT/PE, discuss anticoagulation or placement of a caval filter to prevent (further) PE with stroke consultant

Shoulder pain

Prevent by not pulling on the affected arm and always supporting its weight
Maintain correct position and adequate support, consult physiotherapist, consider paracetamol
For subluxation, consider functional electrical stimulation
If pain persists, consider addition of NSAIDs, supraspinal nerve block, TENS or intra-articular corticosteroids

Depression

Treat conventionally

Seizures

Treat conventionally

Pressure sores

Treat diarrhoea effectively, prevent hypotension, ensure adequate nutrition, check that pressure relief adequate. Involve tissue viability team

FURTHER INVESTIGATIONS

General

If random glucose >7.5 mmol/L, request fasting glucose and HbA1c
Lipid status (<48 hr after stroke or after 6 weeks)
Chest X-ray

For specific indications

Cardiac murmurs and/or history of rheumatic fever and/or no risk factors for atheroma

Consider echocardiography to exclude a cardiac source of embolism

Patients (age <55 yr) with no vascular risk factors nor cardiac/arterial sources of embolism

Request bubble contrast echocardiogram to exclude atrial septal defect (ASD)/patent foramen ovale (PFO)

if positive for ASD/PFO, no other cause for the stroke identified (cryptogenic), and aged <55 yr, refer to cardiology for consideration of closure

In patients with no risk factors for atheroma

Screen for arteritis (CRP, ANA, ANCA, Rh Factor)

Young patients with no atherosclerosis/risk factors

Investigate for thrombophilia

FBC: exclude polycythaemia, thrombocytosis, sickle cell disease
lupus anticoagulant, anticardiolipin antibodies
JAK-2 mutation studies: to exclude myeloproliferative disorders
fasting homocysteine levels

PFO or venous thrombosis (concurrent PE, cerebral sinus thrombosis)

Check protein C, protein S, Factor V Leiden and PT gene mutation

discuss with haematologist
send sample which will be frozen and stored in the lab (for 6 months)

Patients age <55 yr or those without vascular risk factors

Consider CT or MR angiography to exclude dissection

Patients without vascular risk factors where the diagnosis is in doubt

Consider MR (DWI) scan of brain with ADC mapping to confirm an infarct/show potential alternative pathology, or demonstrate normality

discuss with neuro-radiologists for protocol
If several repeated scans considered necessary to exclude recurrent silent ischaemic events, consider MR scan in preference to CT to reduce radiation exposure

SUBSEQUENT MANAGEMENT

Rehabilitation

Start active rehabilitation on day 1

unless consciousness impaired, sit out and mobilise from day 1

Full multidisciplinary assessment to identify rehabilitation goals

nurses, occupational therapist, physiotherapist, doctors, speech and language therapist, clinical psychologist
involve dietitian, social worker, pharmacist, other medical or surgical specialties as necessary

Quick recovery

If patient recovers rapidly and is left with no significant residual disability after a few days, arrange for urgent carotid Doppler (within 1 working day)

make sure secondary prevention (see below) is in place
12% of patients with minor strokes will extend or have a further stroke within 1 week

Secondary prevention

Advise to stop smoking
Give dietary advice
Advise to exercise regularly
Identify and treat diabetes. Keep HbA_1c below 7%

Antiplatelet treatment

Give patients with TIA or minor non-disabling stroke loading doses of aspirin and clopidogrel (300 mg each) and continued with dual therapy (75 mg each) for 3 weeks
In established stroke, once haemorrhage excluded by CT, unless contraindicated, aspirin 300 mg/day for 2 weeks or until discharge

in patients with history of dyspepsia, add proton pump inhibitor
after 2 weeks, or at discharge, change to clopidogrel 75 mg/day indefinitely

In patients allergic to, or genuinely intolerant of aspirin, use clopidogrel 300 mg stat followed by 75 mg once daily

if allergic to both aspirin and clopidogrel, give dipyridamole MR 200 mg 12-hrly

Anticoagulation

In all patients with atrial fibrillation/flutter (AF) who have no contraindications, commence anticoagulation with a direct oral anticoagulant (DOAC) or warfarin

in mild non-disabling stroke, start anticoagulation between day 2 and day 14
in severe disabling stroke, delay start of anticoagulation to 14 days or longer

Refer patients with AF, a Chads score ≥1, and contraindication to anticoagulation to cardiology for consideration of atrial appendage closure

Other medication

If non-HDL cholesterol >4.0 mmol/L, give atorvastatin 20 mg/day at night

check levels after 3 months and adjust dose to reduce LDL cholesterol by 40%
review annually

Unless there is an important reason to continue (e.g. premature ovarian failure, severe menopausal symptoms), stop contraceptive pill/hormone replacement therapy

in premenopausal women, provide advice on alternative methods of contraception

Reduce blood pressure to a target of ≤130/80 mmHg starting within 24 hr of minor stroke/TIA and within 2 weeks of moderate to severe stroke

start treatment slowly. Use indapamide 1.5 mg MR [for patients with dysphagia, use 2.5 mg plain tablets, as they can be crushed (unlicensed)] daily in morning and ACE inhibitor or a calcium channel blocker

DISCHARGE

The acute stroke unit provides information packs for patients and carers

assist in discharge planning and arrangements for continued outpatient rehabilitation
contact the stroke family support worker where needed

Use multidisciplinary stroke checklist to ensure all secondary prevention measures are in place

Follow-up

Follow-up at 6 weeks, 6 months, and annually

arrange first follow-up in a specialist hospital clinic
further follow-ups can be carried out by stroke-trained teams in the community

Referrals

Refer patients aged ≤55 yr to the young stroke clinic for follow-up
Refer all patients on anticoagulation to the anticoagulation follow-up clinic
Refer smokers to smoking cessation services
Assess functional status (Rankin), continence, pain, mood, cognition, and barriers to return to work, leisure activities and driving in clinic and refer as appropriate
Consider referral to the early supported discharge team
Consider and record whether a joint care plan with social services is required

Discharge summary

Diagnosis including OCSP class and NIHSS at admission
Thrombolysed/not thrombolysed
NIHSS on discharge, level of dependence, mobility
Risk factor assessment with instructions for secondary prevention
Driving advice
Details of any clinical trial patient taking part in

Patient and relatives

Give patient a copy of the discharge summary
Ensure patient and relatives are aware of diagnosis, discharge date, follow-up arrangements and secondary prevention measures

Driving

Check for hemianopia and hemi-inattention in all drivers

not always obvious to patient and disqualifies from driving until resolved

Give driving instructions verbally and in writing

do not drive for 1 month and inform insurance of stroke
if back to normal within 1 month and no recurrence, patient may drive again
if persistent deficit or recurrence, patient must inform DVLA and await assessment by a doctor

Acute Stroke