acute interventions in stroke

Last edited 06/2019 and last reviewed 10/2022

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:

• (1) NICE (May 2019). The diagnosis and acute management of stroke and transient ischaemic attacks
• (2) NICE (December 2010).Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events
• (3) Clinical Evidence (March 2005). Acute Ischaemic Stroke