The First 24 Hours

Initial assessment
It is important to make the diagnosis correctly as early as possible. Stroke is a clinical diagnosis not a radiological one and it is not always an easy diagnosis to make. Certainly our experience of running TIA clinics is that it is a diagnosis that is made incorrectly (with the benefit of hindsight of course) up to 50% of the time by A&E and GPs

Stroke physicians and neurologists themselves are by no means infalliable either and small studies have shown small but significant disagreements about both clincial signs and likely vascular territory of strokes and TIAs.

It is important (and reassuring therefore) to determine the likely area of the brain affected by a stroke and be able to tie all the neurological signs to that single area of the brain. Multiple simultaneous strokes are extremly rare and signs that sugggests this should make one suspicious and consider again other possible diagnoses.

A stroke on the background of one or more previous strokes can be challenging and clarity in the diagnosis may depend more on radiological investigations.

Immediate treatment
Aspirin 300 mg as a stat dose (which can be oral or PR) is recognised as standard therapy in ischaemic strokes followed by 75-150mg once a day after this. Subsets of the data from IST show that you do not need to wait for a CT in order to start this therapy. No significant harm will come to those patients that then turn out to have a cerebral haemmorhage provided the aspirin is then stopped. The ischaemic strokes meanwhile will benefit from a 1% reduction in mortality as a result of early treatment.

In centres and countries where the wait for a CT scan is likely to be minimal then most physicians elect to wait for the scan result first. This seems a reasonable course of action if the delay is short. However if the CT scan will be delayed significantly and the diagnosis is clincially likely to be a infarction rather than a haemmorhage then early treatment with aspirin is generally recommended.

Treatment of hypoxia / hyperthermia / hyperglycaemia
It is recognised that the cascade that results in irreversible nerve cell death occurs promptly after a stroke. There is however an area of brain tissue around the infarction, often referred to as the penumbra, which is at risk but is still potentially salvagable. Careful management of oxygen saturations with supplemental oxygen, treatment of hyperglycaemia with intravenous sliding scales of insulin, and reducing pyrexias with regular paracetamol / cooling / treating underlying infections is likely to be responsible for the improvements that good acute stroke care seems to generate.

More acute stroke units are recognising that continous physiological monitoring is essential to detect derrangements of normal physiological variables in sick stroke patients and are moving to system which allow this. Oxygen desaturations and rhythm disturbances are particularly likely to be missed in the event of very infrequent monitoring regimes.

Hypertension (in the acute setting)
It is unclear still (trials are awaited) as to how hypertension should be managed in the first day or two of an new stroke. Certainly there is a real risk that acutely lowering a patient's BP, with the loss of cerebral autoregulation that occurs, could extend the stroke further. It is also recognised that hypertension which is rarely absent in new stroke patients often settles after the first 24-48 hours to a level much lower than on presentation.

Unfortunately hypertension in acute stroke is significantly associated with a risk of recurrent stroke not only long-term but in the short term (i.e the first 14 days). On top of this uncontrolled hypertension is associated with both an increased risk of cerebral oedema and haemmorhagic transofrmation of infarctions.

Common practice is to not start or stop antihypertensive drugs for the first 48 hours unless there is a cerebral haemmorhage when treatment perhaps should be initiated in very hypertensive patients (i.e >200mmHg systolic) or in patients where there is either a hypertensive encephalopathy or cardiovascular emergency such as MI or aortic dissection.

Artificial food and fluids
Simple swallowing assessments can be undertaken by trained professional at the bedside (a formal SALT assessment may not be possible until the next working day). Patients who pass this assessment should avoid the common practice of making all stroke patients NBM provided care and observation of their feeding continues. Patients who fail this assessment will need a formal SALT assessment and IV fluids until oral intake is established.

There is not an immediate need to insert a NG tube in patients who fail their swallow assessments as there is a significant risk associated with the procedure and many patients will improve enough to eat within 48 hours. If after this there is not sufficient intake, in patients who are expected to progress, NG feeding is advisable. PEG tubes should be considered only if there is no improvement in the patient's swallow after three weeks or in the case of multiple NG failures and the patients is still expected to survive. Withdrawal of artificial food and / or fluids can be considered in those patients expected to deterioate despite treatment though these are exceptionally difficult decisions and should be discussed with the multi-disciplinary team and family members where possible.

the first 24 hours