Stroke (Cerebrovascular Accident - CVA)

Clinical assessment

Diagnosis based on rapid onset of characteristic focal neurological deficits. Use FAST acronym (Face drooping, Arm weakness, Speech difficulty, Time to call emergency) for public/rapid recognition. Differentiate stroke subtypes clinically if possible (see UCG table: Intracerebral Haemorrhage - gradual onset, reduced alertness; Subarachnoid - abrupt severe headache; Ischaemic (thrombotic) - gradual/stuttering onset; Ischaemic (embolic) - sudden maximal deficit). Important to rule out stroke mimics (seizure with post-ictal paralysis, migraine with aura, hypoglycaemia, tumour, infection, functional disorders).

Investigations

• Non-Contrast CT Scan (Head): Essential initial imaging. Rapidly differentiates ischaemic from haemorrhagic stroke (blood appears bright). Crucial before giving antiplatelet/anticoagulant/thrombolytic therapy. May be normal in early ischaemic stroke.
• MRI Scan (Head): More sensitive for detecting early ischaemia (DWI sequence), small infarcts, posterior fossa strokes, and helps identify cause (e.g., MRA for vessel occlusion/stenosis). Less readily available acutely.
• Blood Glucose: Rule out hypoglycaemia.
• ECG: Look for atrial fibrillation, signs of MI.
• Blood tests: FBC, U&Es, Coagulation screen (INR/PTT), Lipids.
• Echocardiogram: Assess for cardiac source of emboli (AF, valve disease, LV thrombus).
• Carotid Doppler Ultrasound: Assess for significant carotid stenosis.
• Lumbar Puncture: If subarachnoid haemorrhage suspected and CT negative (look for xanthochromia).

Diagnostic criteria

Clinical presentation of acute focal neurological deficit, with stroke subtype (ischaemic vs haemorrhagic) confirmed primarily by non-contrast CT head scan.

Non-pharmacological management

• Acute Phase (Hyperacute care often in Stroke Unit where available):
• - ABCs: Ensure patent airway, adequate breathing/oxygenation (target SpO2 >94%), maintain circulation.
• - Blood Pressure Management: Controversial in acute ischaemic stroke. Generally, permit 'permissive hypertension' (e.g., up to 220/120 mmHg) unless patient eligible for thrombolysis (target <185/110) or has other compelling indication (e.g., APO, MI, aortic dissection). Lower BP cautiously if extremely high. In haemorrhagic stroke, more aggressive BP lowering often indicated (e.g., target SBP <140-160 mmHg).
• - Blood Glucose Control: Treat hypoglycaemia. Treat significant hyperglycaemia (e.g., insulin if >10-12 mmol/L).
• - Temperature Control: Treat fever aggressively (antipyretics).
• - Swallow Assessment: NPO until swallow screen performed to prevent aspiration. NG tube for feeding/meds if dysphagic.
• - Mobilisation: Early mobilisation and physiotherapy/occupational therapy/speech therapy as soon as stable.
• - DVT Prophylaxis: Intermittent pneumatic compression devices +/- prophylactic heparin (usually delayed 24-48h after ischaemic stroke, contraindicated initially in haemorrhagic).

Pharmacological treatment

• Acute Ischaemic Stroke:
• - Thrombolysis (IV Alteplase/tPA): If patient presents within treatment window (typically <4.5 hours from symptom onset), meets eligibility criteria (confirmed ischaemic stroke on CT, no contraindications like recent bleed/surgery, high BP), and facility has capability. (Highly specialized).
• - Antiplatelet Therapy: Aspirin 150-300mg started within 24-48 hours (after excluding haemorrhage on CT, and ideally 24h after thrombolysis if given).
• - Statin Therapy: High-intensity statin (e.g., Atorvastatin 40-80mg) should be started.
• Acute Haemorrhagic Stroke:
• - Reverse anticoagulation if applicable (e.g., Vitamin K/PCC for warfarin).
• - BP control (e.g., IV Labetalol, Nicardipine).
• - Neurosurgical consultation for potential evacuation of haematoma (esp. cerebellar) or management of hydrocephalus/raised ICP.
• Subarachnoid Haemorrhage:
• - Neurosurgical/Neurointerventional management of aneurysm (clipping/coiling).
• - Nimodipine to prevent vasospasm.
• - BP control, ICP management.
• Secondary Prevention (Chronic management after ischaemic stroke/TIA):
• - Antiplatelet therapy: Aspirin 75-100mg daily OR Clopidogrel 75mg daily (or combination for short period in specific cases).
• - Statin therapy (high intensity).
• - Antihypertensive therapy (target usually <140/90 or <130/80 depending on guidelines/risk).
• - Anticoagulation (Warfarin or DOAC): If stroke due to atrial fibrillation.
• - Risk factor management (diabetes, smoking cessation, lifestyle).

Monitoring

• Neurological status (e.g., using NIH Stroke Scale).
• Vital signs (BP, HR, SpO2, Temp).
• Blood glucose.
• Swallow function.
• Monitor for complications (cerebral oedema, haemorrhagic transformation, aspiration pneumonia, DVT/PE, UTI, pressure sores).