Day 1 - Ischemic Stroke

Assessment:

  • Ensure airway is protected, apply supplemental O2 if hypoxia & ensure adequate IV access

  • Physical examination to establish NIHSS score

  • History must establish timing of event, use collateral if needed to determine when patient last seen normal (LSN)

Acute Management of Ischemic Stroke Within The Window:

  • Contact local stroke team/telemedicine stroke neurologist

  • Obtain urgent CT/CTA “arch to vertex” to rule out hemorrhage and assess for embolism & extent of infarct

  • Check CBC, lytes, INR, PTT and glucose to assess for potential mimics of stroke & determine TPA eligibility

  • If patient is eligible for TPA ensure SBP <180mmHg and DBP<110mmHg (otherwise permissive HTN to SBP 220)

    • TPA should be considered in patients with LSN time of <4.5hrs and with no absolute contraindications

    • Eligibility time for EVT is evolving and decided in consultation with stroke team based on multiple clinical and imaging parameters

Non-Acute Management of Stroke:

  • Goal is to identify etiology of stroke and address modifiable risk factors

Investigations:

  • CT head

  • MRI if concerns for posterior fossa stroke

  • Assess for atrial fibrillation with Holter, +/- echocardiogram if cryptogenic

  • Carotic dopplers if CTA was not initially done

  • Check HbA1C & lipids

Stroke.jpeg

Management:

  • Antiplatelet agents (ASA + Clopidogrel) if no afib

    • ASA 81mg PO daily for all-comers

    • POINT trial recommends DAPT therapy for patients with high risk TIA and low risk strokes (NIHSS < 3) x 21 days, then Plavix 75mg PO daily alone

  • Anticoagulation if evidence of atrial fibrillation

    • Initiation of anticoagulation timing will depend on size of stroke and evidence of hemorrhagic transformation

  • BP control as per Hypertension Canada

    • Target: 140/90 mmHg

    • Target if patient is Diabetic: 130/80 mmHg

    • PROGRESS trial demonstrated use of ACE inhibitor + Thiazide Diuretic (Perindopril + Indapamide) decreased blood pressure and prevented stroke

  • Statin therapy to target LDL<2.0

    • SPARCL trial used Atorvastatin 80mg PO qhs and demonstrated decrease stroke recurrence in acute stroke.

  • Individualized diabetes therapy to target HbA1C <7.0%

The Intern at Work -