ACUTE STROKE MANAGEMENT-TOSCE

A 77 year old right handed gentleman with a past medical history significant for HTN
and CCF presents to the Emergency department with abrupt onset left sided weakness.
The event was witnessed by his wife who accompanied him to the ED. According to his
wife his speech became difficult to comprehend at the same time.

What is your differential diagnosis?

Acute stroke-ischaemic/haemorrhagic
Atypical Migraine
Seizure
Hypoglycaemia
Electrolyte disturbance (hyponatraemia)
Left cerebral hemispheric tumour

What is the most likely diagnosis?

Acute ischaemic stroke

Outline your initial approach to management:

ABC
Only administer supplemental O2 if hypoxic
Rapid history (must establish time of onset and screen for Contraindications to
thrombolysis) & Exam-NIHSS
Urgent Non-contrast CT Brain
Laboratory Ix: FBC, INR (if on anticoagulant), Glucose, U&E, TN, Lipid profile
12 Lead ECG

Urgent Non Contrast CT Brain is unremarkable.

What is the next step in management?

IV Thrombolysis if eligible-Alteplase 0.9mg/kg (max 90mg). Give 10% as test

dose over 1 min. Give remainder over 60 min.
Consider Intra-arterial thrombolysis/mechanical thrombectomy if available.
Admit to Acute Stroke Unit or ICU post thromobolysis

What vascular territory has been affected given the history outlined above?

Left Middle Cerebral Artery

List 8 contraindications to thrombolysis:

Intracranial Bleed EVER

Stroke/Head Trauma </= 3/12
MI </= 3/12
GI/GU Bleed </= 3/52
 Major Surgery </= 2/52
Arterial Puncture at non-compressible site </= 1/52
Spontaneously improving symptoms
Minor symptoms (relative CI)
Seizure at stroke onset (if clinician is convinced that residual deficits are due to
postictal phenomenon and not stroke)
Persistent BP >/= 185 systolic
Persistent BP >/= 110 diastolic
Active bleeding on exam
Platelets < 100,000/mm3
Glucose < 2.8 mmol/L
INR > 1.7

What Investigations will you perform on this patient after the acute period?

Investigations aimed at establishing cause of stroke

TTE
Holter
Carotid Doppler
MRI/MRA
Other Investigations as appropriate
TOE
Vasculitic Screen

ECG reveals the following

What treatment option should be considered in this gentleman?

Rate control
Anticoagulation with warfarin (CHADS 2 Score is 3)

What other secondary prevention measures should be considered in this gentleman?

Start antiplatelet agent:

After 24 hr if thrombolysed
Aspirin 300mg for first few days: 75mg daily thereafter (low dose as effective as
high dose, and is associated with less bleeding and GI toxicity
complications).Cheap!
Aspirin + Extended Release Dipyridamole: Aspirin 25mg+Dipyridamole ER
200mg BDESPS2 Trial: more effective than aspirin alone at preventing
recurrent ischaemic stroke. Expensive!

Clopidogrel: 75mg dailyCAPRIE trial: compared aspirin with clopidogrel in

prevention of stroke/MI/vascular death in pts with recent stroke/MI/symptomatic
PAD. Risk slightly lower in clopidogrel group (5.3% vs 5.8% annually)
however most benefit was seen in pts with recent PAD. In pts with recent stroke,
there was no significant difference in the primary outcome whether on aspirin or
clopidogrel. Expensive!

Smoking Cessation
Tight BP Control-PROGRESS Trial: Measured risk of fatal/non-fatal stroke in pts
with previous stroke randomly assigned to Perindopril +/- Indapamide or placebo.
Half were hypertensive, half had high/normal BP at beginning of trial. Pts in
treatment group had lower risk of fatal and non-fatal stroke, regardless of their BP
at the outset, although the reduction in risk was greater in the hypertensive pts.
Tight Glycaemic Control
Lipid Control
Alcohol in Moderation
Exercise
2 hours post thrombolysis the patients condition worsens. He becomes drowsy and
difficult to rouse. Repeat non-contrast CT Brain is performed (shown below).
Outline the abnormality.