STROKE MANAGEMENT (Beaumont Hospital)

On Admission:
1) Focused history and examination
2) Immediate urgent non-contrast CT + CT angiogram immediately after non-
contrast CT* (usually done straight away in Beaumont!)
3) Calculate the NIHSS score (this is done really while you are escorting the
patient for CT, as everything is done simultaneously as time is BRAIN!)

*The rational behind CT angiogram is to visualize the circulation for

thrombectomy if thrombolysis is CI and also to visualize for any carotid artery
dissection.

THROMBOLYSIS window of 4.5 hours dose of 0.9mg/kg up to 90mg,

10% of total dose given as bolus over 1-2minutes while the rest given in the next
hour.

Although there are many CIs for thrombolysis, but the absolute ones that stroke
physicians really look at urgently will be:

1) Any use of NOAC/warfarin INR >1.7

2) Sustained hypertension >180/105

IV labetolol 10mg over 1-2 minutes , is given as first line and can be
repeated at 10 minute intervals with max of 200mg + any other adjuncts
such as vasodilators (sodium nitroprusside).

Caution in those with asthma or > 1st degree heart block.

Stroke physicians will try their best to get the BP down to enable
thrombolysis, as this is usually modifiable.

3) Any recent surgeries (esp last 2 weeks)

The rest can be safely mentioned but these 3 are the main ones that they would
want to hear.

*IF THROMBOLYSIS is CI aspirin 300mg for 2 weeks and then 75mg

lifetime

CARE POST-THROMBOLYSIS
1) Admit to stroke unit.
2) Regular neuro-observation (can be as frequent as 0.5-1 hourly)- GCS and
vitals + manual BP reading
 Observe for any signs of raised ICP or intracranial bleed:
-Unequal pupils
-Sudden drop in GCS
-Onset of drowsiness
-Onset of nausea, vomiting (photophobia) Rising BP and falling pulse

3) Keep the BP down (<140 systolic, not too low as you dont want to risk
hypoperfusion and causing another stroke) especially for the first 24
hours
4) After 24 hours of thrombolysis, repeat CT scan to exclude bleeding
5) Give aspirin 24 hours after thrombolysis and can start LMWH for DVT
prophylaxis if bleeding is excluded
6) Avoid any ABGs, NG tube, IM injections or urinary catheterization within
24 hours if unnecessary to avoid bleeding.
7) Check for any urinary retention especially in older adults.
8) Swallowing assessment
(If they ask how would you test it, its a crude test where you ask the
patient just to swallow water and feel at the trachea for any swallowing
movements/they might cough/some physicians ausculate at the area of
the suprasternal notch for any gurgling)

9) MDT SALT, Physio, occupational therapy, dietician etc

10) Only start warfarin if needed 2 weeks after thrombolysis
11)Antihypertensives is started 2 weeks after too, and PERINDOPRIL is the
drug of choice in post stroke patients Keep BP under 140 if possible
12) Check glucose and lipid levels statins and anti-diabetics if known T1DM

THROMBECTOMY
1) Thrombectomy is shown to be superior as compared to thrombolysis in
an ESCAPE study done in Beaumont
2) Another study that has proven that is MR CLEAN study (can be mentioned
to impress examiners , as suggested by Prof Williams as everyone in the
stroke team mention these 2 studies everytime, especially as the base
centre for trials of the ESCAPE study was done in Beaumont)
3) Time frame for thrombectomy is 6 hours as mentioned by Prof but can go
up to 12 hours in certain cases.

INVESTIGATIONS
Investigations for the causes of stroke is done only after thrombolysis, as
establishing the cause is secondary priority.

Besides the bloods FBC, U&E, Coag, lipids, glucose everyone in Beaumont
gets:
1) ECG for atrial fibrillation
2) 24 hour/4-5 day holter monitor
3) TTE for any thrombus in left atrial appendage, valvular vegetations for
septic emboli
4) Carotid Doppler for carotid stenosis (carotid endarterectomy can be
done 2 weeks after)