Stroke - Adverse Events

Haemorrhage

May occur with or without thrombolysis. rt-PA is rapidly cleared from the plasma. Fibrinogen is depleted in the first few hours (<40% at 4 hours) but is back to 80% of normal level by 24 hours. Bleeding after 36 hours is rarely due to thrombolysis.

Suspect Intracranial Haemorrhage if:

• Headache
• Nausea and vomiting
• Fall in GCS
• New focal neurological signs
• Acute hypertension

Action:

• Discontinue rt-PA infusion
• Call for immediate medical review
• Full Medical and Neurological reassessment with documentation of new neurological deficit
• Check fibrinogen (if thrombolysed), PT, APTT, FBC, group and save
• Arrange urgent CT head scan
• Inform relevant consultant on call for stroke

If Bleed Confirmed:

• Discuss with consultant on call for stroke (±Consultant Haematologist on-call and Neurosurgery if appropriate)
• If thrombolysed consider treatment with:
  • Fibrinogen 3-4 grams IV (aim for fibrinogen levels > 1.5 g/L); 4 grams of fibrinogen will elevate plasma fibrinogen by 1g/L
  • Or fresh frozen plasma 15mls/Kg; 1300 mls of FFP is equivalent to approx. 3 grams of fibrinogen
  • Platelets 2 pools (for platelet dysfunction and not thrombocytopaenia, as rt-PA can impair platelet function.)

Extracerebral Bleed Post Thrombolysis

• Discontinue rt-PA infusion
• Perform full set of observations
• O₂ 15 litres via non re-breathing mask
• Raise foot of bed if SBP>100 mmHg
• Immediate medical review (shock)
• Direct compression if possible
• IV canullae (large x2) FBC, U+E, PT, APTT, fibrinogen, group and crossmatch
• Transfuse as necessary
• Involve surgical team for haemostasis if appropriate

Anaphylaxis during thrombolysis

Orolingual Angioedema

• Is usually mild and transient and rarely causes airway compromise unlike anaphylaxis
• If there are no other signs of angioedema or anaphylaxis it would be reasonable to continue the rt-PA infusion
• More on Angioedema

Pyrexia

• Cooling measures
• Give paracetamol 1g if >37.5° C
• Ask for medical review if persists or >38°C
• Septic screen

Rapid fall in BP to <100 systolic

• Ensure accurate reading (caution in AF)
• Check manually if in doubt
• Raise foot of bed
• Administer 24% O₂ even if normal sats
• Medical review
• Consider drug effects and may need IV 0.9% saline
• Consider pressor agents

A drop in BP will reduce flow to the penumbral regions. Aim for MAP > 130 mmHg in hypertensive patients and 110 in normotensive patients in the first 24 hours.

Rise in Blood Pressure

• More on BP in stroke
• Aim to keep SBP <220 or DBP <120 mmHg in all patients with stroke
• Aim for a BP of >180/105 for patients who are receiving or have received thrombolysis
• Repeat and monitor every 15 minutes
• Check if any underlying cause such as distress, pain, urinary retention
• If persists on 2 occasions, ask for medical review
• Labetalol – give IV in 2mg doses, checking BP after each dose initially
• 10mg can be given IV over 1-2 mins
• May repeat or double every 10 mins to max of 300 mg; or give initial dose then infusion at 2-8 mg/min
• Aim for only 10-15% reduction in BP
• DO NOT use rapid acting Ca++ antagonists or short acting ACE inhibitors such as captopril
• More on BP in stroke

Acute Ischaemic Stroke Care

Schedule of observations from admission

1. Pulse, BP, O₂ Sats, T° &GCS every 15 min for first hour every hour for 4 hours every 4 hours for 24 hours
2. POST rt-PA/TNK: every 15 minutes for first hour every 30 minutes x 6 hours every hour x 17 hours
3. Capillary glucose: Measure on admission and - 4 hourly if abnormal or diabetic - 12 hourly if normal and nondiabetic
4. ECG: Continuous for 24 hours

General Management Post Stroke

• Bed rest for 24 hours (may not be essential if patient very stable)
• Pulse oximetry - maintain O₂ Sats > 95%
• Maintain normal temperature. Paracetamol if temp >37.5 C
• Blood Glucose: maintain blood glucose < 10 mmol/l using IV insulin if necessary
• No arterial punctures, IM injections, NG tubes or central lines for 24 hours
• No urinary catheters for at least 1 hour after infusion ended
• Avoid suctioning whenever possible, caution giving mouthcare
• Repeat CT head at 24-36 hours
• No Aspirin, Clopidogrel, Dipyridamole or anticoagulant (heparin, low molecular weight heparin or warfarin) for 24 hours post thrombolysis until repeat CT performed
• Hydration / Nutrition
• Falls prevention and pressure area care

CUH Admission policy

• Acute stroke units all stroke patients
• Admission to 1a obs or CCU post thrombolysis
• Remain in resus post thrombolysis until appropriate ward bed available

Indications for urgent repeat CT Scan

• New acute headache or worsening severity of headache
• Acute hypertension
• Nausea and vomiting
• Agitation
• Seizure

Neurological deterioration is significant if there is:

• A deterioration of >2 points on GCS
• A drop in the NIHSS >4 points
• Any potential motor signs on the opposite side to the patient's initial presenting weakness