Doctors Revision

Neurological System

Stroke

A medical emergency occurring when blood flow to a part of the brain is interrupted, either by a blockage (ischemic stroke) or bleeding (hemorrhagic stroke), leading to brain cell damage or death and resulting neurological dysfunction.

Also known as: Cerebrovascular Accident (CVA), Brain Attack

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Referral and warning signs

When to refer

ALL patients with suspected acute stroke require URGENT referral to a facility capable of performing brain imaging (CT scan - HC4/H/RR) and providing acute stroke care. Time is critical ('Time is Brain'). Refer for neurosurgical evaluation if hemorrhagic stroke with specific indications (large hematoma, aneurysm). Refer for comprehensive rehabilitation services post-acute phase.

Red flags

  • Sudden onset of focal neurological deficit (FAST signs)
  • Severe headache (especially 'thunderclap')
  • Decreased level of consciousness
  • Seizures at onset

Signs and symptoms

  • Sudden onset of focal neurological deficits. Common signs (FAST acronym):
  • - Face Drooping: One side of the face may droop or feel numb. Ask the person to smile.
  • - Arm Weakness: One arm may be weak or numb. Ask the person to raise both arms.
  • - Speech Difficulty: Speech may be slurred, difficult to understand, or the person may be unable to speak or understand speech (aphasia). Ask the person to repeat a simple sentence.
  • - Time to Call for Help: If any of these signs are present, even if temporary, seek immediate medical attention.
  • Other potential symptoms:
  • - Sudden numbness or weakness, especially on one side of the body (leg, face, arm).
  • - Sudden confusion, trouble understanding.
  • - Sudden trouble seeing in one or both eyes.
  • - Sudden trouble walking, dizziness, loss of balance or coordination.
  • - Sudden severe headache with no known cause (more common in hemorrhagic stroke, especially subarachnoid hemorrhage - 'thunderclap' headache).

Risk factors

  • Modifiable:
  • - Hypertension (most important modifiable risk factor).
  • - Smoking.
  • - Diabetes Mellitus.
  • - Dyslipidemia (high cholesterol).
  • - Atrial Fibrillation (major risk for embolic stroke).
  • - Other heart disease (valvular disease, heart failure, recent MI).
  • - Carotid artery stenosis.
  • - Sickle Cell Disease.
  • - Obesity.
  • - Physical inactivity.
  • - Excessive alcohol consumption.
  • - Illicit drug use (cocaine, amphetamines).
  • Non-Modifiable:
  • - Age (risk increases significantly with age).
  • - Family history of stroke.
  • - Previous stroke or Transient Ischemic Attack (TIA).
  • - Gender (slightly higher risk in men at younger ages, women at older ages).
  • - Ethnicity (higher risk in some populations).

Diagnosis

Clinical assessment

Based on sudden onset of characteristic focal neurological deficits (FAST signs). Rapid neurological assessment is crucial. Differentiating ischemic from hemorrhagic stroke clinically is unreliable; imaging is required. UCG notes clinical clues: Gradual progression over minutes/hours suggests intracerebral hemorrhage (ICH); Abrupt severe headache suggests subarachnoid hemorrhage (SAH); Gradual onset over hours/days suggests thrombotic ischemic; Sudden maximal deficit suggests embolic ischemic.

Investigations

  • Brain Imaging: URGENT CT Scan (non-contrast) is the primary investigation. Reliably distinguishes between ischemic and hemorrhagic stroke, which is critical for guiding acute management (e.g., thrombolysis eligibility for ischemic stroke). MRI brain is more sensitive for detecting early ischemia but less available/slower.
  • Point-of-care Blood Glucose: Rule out hypoglycemia/hyperglycemia.
  • Electrocardiogram (ECG): Check for atrial fibrillation, myocardial ischemia.
  • Basic Labs: CBC, Electrolytes, Renal function, Coagulation studies (INR/PT, aPTT - esp. if considering thrombolysis or anticoagulated).
  • Consider: Cardiac enzymes (if MI suspected), Lipid profile, Echocardiogram (assess for cardiac source of emboli), Carotid ultrasound (assess for stenosis), Chest X-ray.

Diagnostic criteria

Clinical presentation of acute focal neurological deficit consistent with vascular territory + Confirmation and differentiation (ischemic vs hemorrhagic) by brain imaging (preferably CT scan).

Management

Non-pharmacological management

  • Immediate Stabilization: ABCDE approach. Ensure patent airway (intubate if GCS<8 or unable to protect airway). Maintain adequate oxygenation (SpO2 >94%). Monitor vital signs closely.
  • Positioning: Keep head of bed flat initially (unless risk of aspiration/raised ICP).
  • Swallowing Assessment: Keep NPO (Nil Per Os) until swallowing ability assessed (risk of aspiration). If impaired, consider Nasogastric Tube (NGT) for hydration/nutrition.
  • Early Mobilization and Rehabilitation: Physiotherapy, occupational therapy, speech therapy initiated as soon as patient is stable to prevent complications (DVT, contractures) and promote recovery.
  • Supportive Care: Maintain normothermia, normoglycemia. Prevent/treat complications (pressure sores, infections).

Pharmacological treatment

  • Acute Ischemic Stroke Management:
  • - Thrombolysis (Alteplase/tPA): If patient presents within treatment window (typically 3-4.5 hours of symptom onset), meets strict eligibility criteria, and hemorrhagic stroke excluded by CT. Requires specialized stroke center (RR/NR level).
  • - Antiplatelet Therapy: Aspirin 150-300 mg PO/PR loading dose started within 24-48 hours of onset (after hemorrhagic stroke excluded). DO NOT give within 24h if thrombolysis administered.
  • - Blood Pressure Management: Permissive hypertension often allowed initially (e.g., up to 220/120 mmHg) unless patient received thrombolysis or has other compelling indication for lowering (e.g., aortic dissection, MI, heart failure). If lowering needed, do it cautiously (e.g., Labetalol, Nicardipine IV). Avoid excessive lowering which can worsen cerebral perfusion.
  • - DVT Prophylaxis: Low-dose heparin (e.g., Enoxaparin 40mg SC daily) or intermittent pneumatic compression devices for immobile patients, usually started after 24h.
  • - Statin Therapy: High-intensity statin (e.g., Atorvastatin 40-80mg daily) recommended regardless of baseline cholesterol level.
  • Acute Hemorrhagic Stroke Management:
  • - Blood Pressure Control: More aggressive lowering often indicated (target SBP typically <140-160 mmHg, depending on type/location). Use IV agents like Labetalol, Nicardipine.
  • - Reversal of Anticoagulation: If patient was on warfarin/DOACs, requires urgent reversal (Vitamin K, PCC/FFP, specific reversal agents).
  • - Neurosurgical Consultation: May be required for evacuation of large hematomas, clipping/coiling of aneurysms (SAH), management of hydrocephalus.
  • - Supportive Care: Manage ICP, prevent seizures.
  • Follow specific Ugandan treatment algorithms/guidelines, acknowledging resource limitations (e.g., thrombolysis often unavailable).

Monitoring

Frequent monitoring of: Vital signs (especially BP), Neurological status (GCS, NIH Stroke Scale if possible), Oxygen saturation, Blood glucose. Monitor for complications (cerebral edema, hemorrhagic transformation, aspiration, DVT/PE, infections).

Complications

  • Cerebral edema and raised intracranial pressure
  • Hemorrhagic transformation of ischemic stroke
  • Aspiration pneumonia
  • Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
  • Urinary tract infection
  • Pressure sores
  • Contractures
  • Malnutrition
  • Depression
  • Seizures (post-stroke epilepsy)
  • Chronic pain
  • Permanent neurological disability (weakness, spasticity, sensory loss, aphasia, cognitive impairment)
  • Death

Prevention

  • Secondary Prevention (after stroke/TIA):
  • - Antiplatelet therapy (Aspirin, Clopidogrel, or Aspirin/Dipyridamole).
  • - Anticoagulation (Warfarin or DOACs) if stroke due to atrial fibrillation.
  • - High-intensity Statin therapy.
  • - Aggressive Blood Pressure control.
  • - Strict Diabetes management.
  • - Smoking cessation.
  • - Lifestyle modification (diet, exercise, weight loss, limit alcohol).
  • - Carotid endarterectomy or stenting for significant symptomatic carotid stenosis.
  • Primary Prevention: Focus on controlling modifiable risk factors (hypertension, smoking, diabetes, dyslipidemia, AFib, obesity, inactivity).

Patient education

  • Educate patient and family on recognizing stroke signs (FAST) and acting quickly.
  • Explain the type of stroke (ischemic vs hemorrhagic) and the treatment plan.
  • Emphasize the importance of secondary prevention measures (medications, lifestyle changes) to reduce risk of recurrence.
  • Discuss rehabilitation goals and process.
  • Provide information on managing residual deficits and accessing support.

Uganda-specific notes

Hypertension is a major, often poorly controlled, risk factor in Uganda. Access to urgent CT scanning is limited, making clinical differentiation challenging but crucial. Thrombolysis for ischemic stroke is generally unavailable outside specialized centers. Management focuses heavily on supportive care, Aspirin for presumed ischemic stroke (after excluding clinical hemorrhage suspicion where possible), BP management, DVT prophylaxis, risk factor control, and rehabilitation. Subarachnoid hemorrhage in young people from ruptured aneurysms also occurs.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 4, Section 4.1.11

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