| Stroke | |
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The Problem: Stroke can be hemorrhagic or non-hemorrhagic. Here we focus on care for ischemic, non-hemorrhagic stroke. For information about hemorrhagic stroke, please see Intracerebral Bleeds and Subarachnoid Hemorrhage. |
What We Do: TIA and ischemic CVA patients need careful assessment to look for extracranial occlusive diseased, valvular heart disease, cardiac dysrhythmia such as atrial fibrillation, and coagulopathy. (These can be evaluated most efficiently in the TIA Clinic at the HGH.) TIA's need to be differentiated from focal seizures. If this is difficult, an EEG may be useful. It is useful to determine the NIH Stroke Scale classification for stroke patients. TIA patients who are stable need to start an antiplatelet medication such as acetylsalicylic acid, (Aspirin®, etc.), ticlopidine (Ticlid®), clopidogrel (Plavix®) and dipyridamole (Aggrenox®). Any one of these can be used, but ECASA seems the best first choice unless there is an allergy to it. Results of several big RCT's concerning antiplatelet meds are summarized and evaluated in a review in a Therapeurics Letter. Carotid endarterectomy needs to be considered within a few days of the onset of TIA symptoms from a plaque in the neck but is not normally done as a same day emergency. (see Canadian Guidelines for Carotid Endarterectomy). Atrial fibrillation needs treatment to control the pulse rate, correct the conduction defect if possible, and to prevent stroke. (Manitoba guideline for atrial fib treatment.) Patients presenting within 3 hours
of suspected ischemic infarction may be candidates for t-PA. For this
treatment to be useful, the evaluation needs to be very prompt. The Triage Nurse
initiates the t-PA
triage protocol. A set
of preliminary orders needs to be done stat. If all inclusion
/ exclusion criteria are met, proceed with orders
for stroke thrombolytic therapy. Protocols for calculating
doses and for administration of
r-tPA are available. Medicine or neurology will admit the patient (see stroke
admission orders.) Neurosurgery will normally become involved only if things
go awry and the t-PA is complicated by an intracerebral hemorrhage. |
| Authorship: Dr Valerie Taylor | Last Revised: 29 May 2002 |