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Acute interventions in stroke

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

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

Reference:


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