Interventions for acute ischaemic stroke include:
- antithrombotic and antiplatelet drugs e.g. aspirin
- NICE state (1):
- all people presenting with acute stroke who have had a diagnosis of primary intracerebral haemorrhage excluded by brain imaging should, as soon as possible but certainly within 24 hours, be given:
- aspirin 300 mg orally if they are not dysphagic or
- aspirin 300 mg rectally or by enteral tube if they are dysphagic
- thereafter, aspirin 300 mg should be continued until 2 weeks after the onset of stroke symptoms, at which time definitive long-term antithrombotic treatment should be initiated. People being discharged before 2 weeks can be started on long-term treatment earlier
- any person with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is reported should be given a proton pump inhibitor in addition to aspirin
- any person with acute ischaemic stroke who is allergic to or genuinely intolerant of aspirin should be given an alternative antiplatelet agent
- anticoagulation treatment should not be used routinely for the treatment of acute stroke
- clopidogrel is the antiplatelet agent indicated for secondary prevention after acute management of stroke (2)
- if acute venous stroke
- people diagnosed with cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage) should be offered full-dose anticoagulation treatment (initially full-dose heparin and then warfarin [international normalised ratio 2 to 3]) unless there are comorbidities that preclude its use.
- if stroke associated with arterial dissection
- either anticoagulants or antiplatelet agents should be offered to people who have stroke secondary to acute arterial dissection
- oxygen supplementation (1)
- give supplemental oxygen to people who have had a stroke only if their oxygen saturation drops below 95%. The routine use of supplemental oxygen is not recommended in people with acute stroke who are not hypoxic
- neuroprotective agents
- thrombolysis in acute stroke
- thrombectomy in acute stroke
- decompressive hemicraniotomy in acute stroke
Reversal of anticoagulation treatment in people with haemorrhagic stroke
- return clotting levels to normal as soon as possible in people with a primary intracerebral haemorrhage who were receiving warfarin before their stroke (and have elevated international normalised ratio)
- achieved by reversing the effects of the warfarin using a combination of prothrombin complex concentrate and intravenous vitamin K
An evidence based review suggested that (3):
- aspirin treatment was a beneficial intervention
- a trade-off between benefits and harms:
- associated with thrombolysis in acute ischaemic stroke (increases overall mortality and fatal haemorrhages but reduces dependency in survivors; beneficial effects on dependency do not extend to streptokinase)
- associated with immediate systemic anticoagulation
- neuroprotective agents (calcium channel antagonists, ÿ-aminobutyric acid agonists, lubeluzole, glycine antagonists, tirilazad, N-methyl-D-aspartate antagonists) were unlikely to be beneficial
- acute reduction in blood pressure was likely to be ineffective or harmful
Interventions for other causes of acute stroke include:
- evacuation of an intra-cerebral haematoma:
- particularly important for cerebellar bleeds because the mass effect may be rapidly fatal and the surgical results are relatively good
- stroke due to inflammatory conditions such as cerebral vasculitis:
- rapid diagnosis and the use of steroids may prevent further deterioration
- stroke due to cardiovascular emergencies may be treated surgically:
- uncontrolled infective endocarditis
- aortic dissection
- left atrial myxoma
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