Stroke Management
A,B,C
BP and sugar
Permissive BP : 220/110mmhg
if for thrombolysis 180 / 110 - risk of hemorhagic transformation
aim not lower than 130/ 80 mmhg during 1st 72 hours
NIHSS
CT scan - TRO bleed
altepase / tenepase - thrombolytic window 4.5 hour , if not for thrombolysis
aspirin 300mg OD loading, with clopidogrel 300mg loading dose
thrombectomy - 24 hour
Post stroke - if thrombolysed - repeat scan to rule out bleed - start aspirin 24 hour after, if AF, change to DOAC after 7 days of aspirin
NIHSS < 3 - DAPT for 21 days, clopidogrel/ mono lifelong
ABCD score > 4 - DAPT for 21 days, clopi / mono lifelong
NIHSS > 3, monotherapy lifelong
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MRI if CT negative - not to proceed if will not change management
Stroke MDT ( SLT, physio, OT, rehab )
no driving - 1 month if stroke, TIA 2 weeks,
statin - high potency atorvastatin 40mg if frail or > 70/ rosuvastatin
prasuvastatin ? LDL < 2.8
telemetry to rule out AF
us carotid TRO carotid artery stenosis - surgical intervention if > 50% occlusion on ipsilateral side of stroke CAE
if telemetry non sustained VT - mg of 1, ?
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if AF
switch to DOAC
rivoraxaban - factor 10a inhibitor - OD dosing - for severe renal impairment ( cr 15 - 50), 15mg OD, otherwise 20mg OD
apixaban -OD dose
dabiagtran - reversible - idarucizumab 110mg OD ( > 75, creatinine clearance 15 -30) , full dose 150mg OD
hemorrhagic risk
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DVT prophylaxis
SCD - unless peripheral vascular disease / previous DVT
Clexane prophylactic dose - OD
DVT / PE
therapeutic dose BD - 1.5mg / kg
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Young stroke work up
echo with bubble study - PFO if positive
antiphospholipid syndrome work up ( beta2 glycoprotein, anticardiolipin, APS antibodies )
Stroke mechanism
LV thrombus - cardioembolic stroke - multi terrory ( cardio cause )
cranial stenosis ?
carotid stenosis