STROKE

A cerebral neurological dysfunction due to a problem in blood circulation: a clot (ischaemic stroke) or bleeding (haemorrhagic stroke).

Causes

  • Clot (a thrombus in a brain vessel or an embolus from a clot sowhere else) – most common
  • Haemorrhage (from trauma or spontaneous)

Clinical features

  • Focal neurological deficits as one-sided weakness (face, arm, leg. Note that eyes are not affected) – hemiparesis or hemiplegia
  • Difficulty in speaking/swallowing
  • Severe headache (especially in haemorrhage)
  • Alteration of consciousness
  • Convulsions

Investigations

  • CT scan brain

In the absence of neuroimaging, the following clinical features may help to distinguish the stroke subtypes.

Patients
may have
reduced
alertness
and severe
headache

 

TYPE CLINICAL
COURSE
RISK FACTORS OTHER
CLUES
Intracerebral
haemorrhage
Gradual
progression
over
minutes/
hours
Hypertension,
trauma,
bleeding
disorders,
illicit drugs
Patients
may have
reduced
alertness
and severe
headache
Subarachnoid
haemorrhage
Abrupt
onset of
very severe
headache,
focal
symptoms
less common
Smoking,
hypertension,
illicit drugs,
but at times
none (due to
rupture of
congenital
aneurysms)
Patients
may have
reduced
alertness It may
happen
in young
people
Ischaemic
(thrombotic)
Gradual
development
of focal
deficits over
hours or
days
Age, smoking,
diabetes,
dyslipidemia
Symptoms
can
improve
and
worsen
in the
following
days
Ischaemic
(embolic)
Sudden
onset of
focal deficits
As above plus
valvular heart
disease and
arrhythmias
Often
improves
slowly

Management

General care

  • Ensure airways and respiration if unconscious
  • Do not give anything by mouth before assessing the ability to swallow, to avoid risk of inhalation
  • IV or NGT for hydration and nutrition if unable to swallow
  • Control blood sugar with insulin if diabetic

If ischaemic stroke

  • Aspirin 150-300 mg every 24 hours
  • In the acute phase, treat hypertension only if extreme (more than 220/120) or if there are other complications (pulmonary oedema, angina, etc),
    otherwise re-start antihypertensive 24 hours after the event and reduce blood pressure slowly
  • Consider DVT prophylaxis with enoxaparin 40 mg SC daily

If stroke clinically haemorrhagic

  • Supportive care as above
  • Refer for CT scan and neurosurgical evaluation

Chronic care of ischaemic stroke

  • Early mobilization and physiotherapy
  • Aspirin 75-100 mg once daily for life
  • Atorvastatin 40 mg daily for life
  • Control of risk factors