acute stroke units

The development of acute stroke units in most hospitals in the UK has been the major recent change in stroke care that benefits the majority of patients. The reasons for this are more difficult to determine but is likely to be due to concentration of skills, training & retention of staff with an interest in stroke and implementation of proven best practice.

They certainly appear to improve outcome in comparison to a mobile stroke team wandering the medical wards or normal general medical ward care. In hospitals with a small unit the patients likely to benefit the most are those with a stroke of moderate severity. All patients are likely to benefit to some extent though so admission is encouraged for all proven strokes.
Guidelines

RCP National Guidelines
NICE Home Page
Ongoing treatment of stroke patients

Secondary Prevention
Preventing a further stroke is a prime concern and the risk of a further stroke is highest soon after the initial event.  Antiplatelets, antihypertensives and statins are the mainstay of medical treatment.  Whilst lifestyle advice including stopping smoking, sensible eating and an active lifestyle are the main non-pharmaceutical benefits.

Anti-platelets
The current advice from NICE is that all patients who suffer a TIA or a stroke should be on aspirin and dipyridamole SR for a period of two years before reverting to aspirin alone for life.  If a patient is genuinely aspirin intolerant than clopidogrel monotherapy is recommended lifelong.  Dipridamole SR alone is probably inadequate but aspirin alone if a patient is intolerant of dipyridamole SR is considered satisfactory.  There is a suggestion that in high risk patients (arteriopaths) clopidogrel may have a small but significant advantage over aspirin.

Anti-hypertensives
Choice of anti-hypertensives is probably not as critical as some people whould have us believe.  The important factor is blood pressure control not strictly speaking how this is achieved.  It is likely that ACE inhibitors (such as ramipril) and thiazide diuretics (such as bendroflumethiazide) have some small additional benefit in stroke prevention on top of their anti-hypertensive effect and therefore may be considered first line.  Whatever works for the individual patient is probably the best philosophy of course.

Statins
Statin therapy again produces a small but significant reduction in recurrent stroke (less impressive than its effect in cardiac disease but then stroke is at least three different aetiologies).  Because it is likely to have little or minimal effect on haemmorhages and cardiac embolic strokes any effect on atherosclerotic stroke is watered down.  It is reasonable to use the cheapest statin which has proven to work in stroke at an effective dose so simvastation 40mg seems a good choice though my personal practice is not to change from another statin if the patient is already established on another type.

You are probably more likely to prevent a MI than a stroke by using statins in this way but that is of course no bad thing.  The current recommendations are that anyone with a random total cholesterol (within 48hrs of admission otherwise lack of nutrition may affect it) above 3.5 mmol/L should be considered for treatment so essentially everyone.  Other cholesterol lowering therapies (non-statins) do not currently have moratlity or stroke prevention data and therefore are difficult to recommend as first line.


Other interventions

Anticoagulations
Can only currently be recommended in patients with an ischaemic stroke with atrial fibrillation or other cardiac source of emboli.  Warfarin has no proven role in patients in sinus rhythm with multiple TIAs or strokes.

Carotid surgery
In patients who are both fit enough for surgery and have made a good recovery from a carotid territiory TIA or stroke should have a doppler assessment or other radiological investigations of their carotids.  General advice is that there must be a 70-99% stenosis on the correct side for the stroke to benefit sufficiently to warrant the risk of surgery.  There are other situations where surgery may be considered so speak to your local vascular surgeons if uncertain.

Saline bubble echocardiography
The above investigation is to look for a patent foramen ovale which can sometimes be responsible for a stroke.  However they are extrememly common in normal indivduals (25% of us) and so should only be looked for in patients with no risk factors for stroke who then unexpectedly have a proven cerebral infarction.  Best to discuss with your local stroke physician and cardiologist before routinely requesting this investigation.

Nutrition / Artificial Feeding
Nutrition in all patients is an important issue but is of course complicated in stroke medicine by the impaired swallow and increased risk of aspiration in this patient group.  Despite this blanket NBM orders on all stroke patients will deny many patients that are perfectly safe to swallow adequate nutrition and fluids

The recommendations is that all patients have a swallowing assessment early so that it can be determined whether they need restrictions and referral to a trained Speech and Language Therapist or whether they can be allowed to eat and drink. Dysphagia screening test are quick to learn and can be performed at the bedside by a suitable trained member of staff.

If after 48 hours inadequate nutrition intake is occuring then it is important to consider NG tube insertion in patients unless the expectation is that they are deterioating rapidly.  PEG insertion has not shown to be advantageous over NG and carries its own risks so is not uusally considered until three weeks has passed or there are repeated NG failures and there is still no sign of safe oral intake.

Neither method of artifical feeding is 100% safe.  Both carry a significant risk of aspiration still occuring.  This is presumably from feed refluxing and of course normal salivation produces about 250-500mls of fluid a day which can easily be aspirated also.


Treatments of no proven benefit

Neither helpful or harmful

Potentially harmful

Useful Scoring Scales

Modified Rankin Score
NIHSS (1 page)
NIHSS (8 pages with charts)
Barthel


Useful sites

NIHSS Online training