THEME

Acute stroke patients

Stroke

Early hospital management

BACKGROUND
Patients with acute stroke have improved outcomes when managed in a stroke unit providing multidisciplinary care,
including early rehabilitation.
OBJECTIVE
Helen M Dewey This article provides an overview of early hospital management and rehabilitation for stroke patients.
MBBS, PhD, FRACP, FAFRM,
is Head, Inpatient Stroke DISCUSSION
Services, Austin Health and Stroke and transient ischaemic attack are medical emergencies. Both have time dependent therapy and the risk of a
Associate Director, National recurrent event is highest in the hours to days after the initial event. Important aspects of early hospital management
Stroke Research Institute, include: rapid confirmation of the stroke diagnosis with computerised tomography or magnetic resonance imaging,
Melbourne, Victoria. urgent investigations for the cause of stroke, acute therapy, early institution of specific secondary prevention strategies,
Julie Bernhardt comprehensive risk factor management including antihypertensive therapy, early rehabilitation, and discharge planning.
PhD, BSc(Physio), is Director, Investigation and management needs to be tailored to the individual patient, taking into account presentation and
Very Early Rehabilitation comorbidities.
Research Program, National
Stroke Research Institute,
Melbourne, Victoria, and
National Heart Foundation
Fellow. j.bernhardt@unimelb. There is compelling evidence that stroke unit care Community Stroke Project (OCSP) classification5 (Table 1)
edu.au
(organised care provided by dedicated staff within a is a useful schema for assessment of stroke subtype at the
defined geographic area) is not only cost effective, bedside and, together with brain imaging, can assist with
but highly effective in preventing death and long term prognostication and planning of further investigations.
disability in stroke patients compared to care provided The distinction between ischaemic and haemorrhagic
on general medical wards alone.1–3 Important aspects of stroke cannot be made on clinical grounds, and other
effective stroke unit care include: pathology (eg. subdural haematoma) may mimic stroke, so
• a ccurate and rapid confirmation of the stroke it is essential to urgently confirm the diagnosis of stroke
diagnosis, likely causation and associated risk factors with computerised tomography (CT) or magnetic resonance
• evidence based treatment imaging (MRI). Immediate brain imaging is also required to
• c lose monitoring of neurological status and confirm eligibility for intravenous alteplase.6 Early CT imaging
physiological parameters is frequently normal in ischaemic stroke, or changes may be
• p revention of the complications of stroke and subtle. Multimodal CT imaging adds useful diagnostic and
recurrent stroke, and prognostic information and is discussed in more detail in an
• early institution of multidisciplinary rehabilitation accompanying article.
focused on achieving functional goals and early If initial CT is normal and there is any doubt about the
development of an individualised discharge plan. diagnosis, CT imaging should be repeated in 3–7 days or
MRI performed. Topographic information is a guide to likely
Confirming a diagnosis of stroke causation and appropriate further investigations (Table 1).
Key clinical features of stroke are sudden onset and the Acute MRI has greater overall sensitivity for acute stroke
presence of focal neurological symptoms and signs. than noncontrast CT scanning (83 vs. 26%);7 however
Typically, the patient has been well before the event.4 Loss access to urgent MRI is limited. Additional imaging may be
of consciousness without focal neurological signs and appropriate when the aetiology of stroke remains uncertain
isolated vertigo are rarely due to stroke. The Oxfordshire or there are recurrent events.

904 Reprinted from Australian Family Physician Vol. 36, No. 11, November 2007
 Table 1. The Oxfordshire Community Stroke Project stroke classification (modified)
Subtype Defining features Usual cause and prognosis
TACI (total anterior Contralateral motor and/or sensory deficit, Large middle cerebral artery infarct due to embolism
circulation infarct) and higher cortical dysfunction (eg. dysphasia, from the heart or proximal arterial source; high
neglect), and homonymous hemianopia likelihood of death or long term dependency
PACI (partial anterior Two of three deficits necessary for TACI, or Smaller infarct but same arterial causes as TACI; better
circulation infarct) higher cortical dysfunction alone, or prognosis for recovery but high risk of early recurrence
restricted motor/sensory deficit (eg. confined
to one limb or face and hand)
LACI (lacunar infarct) Pure motor hemiparesis, pure sensory Small deep infarct due to small vessel disease;
stroke, sensory motor stroke, ataxic relatively good prognosis
hemiparesis
POCI (posterior Brain stem signs Infarct in the posterior cerebral hemisphere, brain stem
circulation infarct) Cerebellar dysfunction without ipsilateral or cerebellum due to large or small vessel disease or
long tract signs (ie. not ataxic hemiparesis), cardiac embolism; variable prognosis
or isolated homonymous hemianopia
ICH (intracerebral Signs depend on site and size of Multiple causes, worse prognosis than ischaemic stroke
haemorrhage) haemorrhage Deep location: usually due to rupture of small, deep
perforating artery, often associated with hypertension
Superficial/lobar location: cerebral amyloid angiopathy
often the cause, older patient
Other common causes: arteriovenous malformation/
cavernoma, ruptured saccular aneurysm, coagulopathy

Investigations for the cause of stroke

endarterectomy are greatest when performed early after
Stroke and transient ischaemic attack (TIA) are both medical first symptoms,10 therefore, patients with symptomatic high
emergencies, as there is time dependent effective treatment. grade (>70%) carotid stenosis should be referred urgently
Importantly, the risk of a recurrent event is highest in the to a vascular surgeon. Carotid endarterectomy is generally
hours to days after the initial event.8 Therefore, effective safe within 2 weeks after ischaemic stroke and should be
secondary prevention strategies should be initiated as soon performed as soon as possible after TIA.
as possible. All patients with acute stroke should have: Echocardiography may be indicated in some patients
• baseline electrocardiogram (to exclude atrial fibrillation, to search for a cardiac or aortic source of embolism. 13
acute coronary syndrome and evidence of structural or Transoesophageal echocardiography is more sensitive than
ischaemic heart disease) transthoracic echo to cardiac sources of emboli and allows
• electrolytes and renal function visualisation of the aortic arch. Thick (>4mm) and/or mobile
• blood sugar level aortic arch atheroma is now recognised as an important risk
• full blood examination, and factor for stroke.11
• erythrocyte sedimentation rate.
General management within a stroke unit
Further investigations need to be tailored to the individual
and their stroke syndrome (Table 1) and take into account Specific acute therapy for stroke
stroke severity and concomitant disease. Severe stroke Aspirin 160–300 mg/day should be commenced within 48
(eg. total anterior circulation infarct, large intracerebral hours of onset of acute ischaemic stroke.12
haemorrhage [ICH]) is associated with a poor prognosis Intravenous alteplase, a tissue plasminogen activator,
and a palliative care approach will be appropriate for some is a highly effective treatment for patients presenting
patients. within 3 hours of stroke.13 Currently, the most common
Carotid imaging should be performed urgently in reason for exclusion from treatment is delay in
all patients considered to be candidates for carotid presentation to hospital. Intravenous heparin is NOT
revascularisation to exclude a high grade (>70%) internal recommended standard treatment for acute stroke as its
carotid artery stenosis.9 In the Australian setting, carotid use is associated with an increased risk of ICH.14
duplex ultrasound is usually the most appropriate and Large hemispheric infarcts may be complicated by
accessible first line investigation. The benefits from carotid major brain swelling. Hemicraniectomy within 48 hours

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 THEME Acute stroke patients – early hospital management

has been shown to substantially improve outcomes from the positive outcomes achieved by patients receiving stroke
this complication.15 unit care.19 Comprehensive recommendations for postacute
rehabilitative care can be found elsewhere.20,21
Specific acute therapy for ICH
Management of complications
Intracerebral haemorrhage due to anticoagulation should
be urgently reversed. Surgical evacuation is not routinely Frequent monitoring of neurological status and vital signs is
recommended for ICH but may be considered in some important and allows early detection and prompt treatment
patients (eg. cerebellar hemisphere haemorrhage >3 cm). of complications (Table 3). Conscious level, neurological
status and physiological parameters (BP, pulse, oxygenation,
General care
respiratory pattern, temperature, fluid status, blood sugar)
Patients with stroke should be maintained in a euvolaemic should be monitored frequently (at least hourly) early after
state. Hyper- and hypo-glycaemia should be avoided. Oxygen stroke. Later, the frequency of observations should be
supplementation should be provided if the patient is hypoxic. tailored to the individual.
Complications after stroke are common, with
Blood pressure management
62–85% of patients experiencing at least one complication
It remains uncertain whether elevated blood pressure (BP) within the first few months after stroke.22,23 Neurological
should be lowered acutely after stroke. Current international worsening is common early after stroke, with stroke
guidelines recommend tolerating BP up to 220/120 without progression reported in up to 40% of cases.24 Secondary
treatment in the first hours to days after stroke unless there complications such as urinary tract and chest infections,
is serious concomitant disease mandating BP reduction pressure sores, falls, deep vein thrombosis, pulmonary
(eg. aortic dissection).6,9 In patients receiving intravenous embolism and musculoskeletal pain occur more frequently.
alteplase, BP is more tightly controlled to ≤185/110 as Disorders of mood, such as depression and anxiety, are
higher BP is associated with an increased risk of ICH.6,9 It thought to be under-reported.25
is generally accepted that BP lowering in ICH patients is Intrinsic factors (eg. comorbidities, stroke severity) are
indicated to keep mean arterial BP (MAP) below 130 mmHg associated with increased complication risk poststroke.
(MAP = diastolic BP + 1/3 systolic-diastolic BP).9 Although studies included in the systematic review of stroke
unit care lack detailed complication data,1 there is consensus
Specialised nursing care
that improved outcomes are likely to be related to reduced
Expert nursing care is a key aspect of effective stroke unit complication rates as a result of the provision of earlier and
care. Management of the impairments associated with more coordinated care.
stroke must be individualised (Table 2). However, stroke Common complications and recommended
nursing will include attention to bladder and bowel function, management are summarised in Table 3 (a strong
skin care, mouth and eye care, nutrition and fluid support. recommendation against an approach is highlighted).

Management of stroke related impairments Risk factor assessment and management

Stroke patients commonly experience difficulties with Hypertension
swallowing, communication, independent movement Hypertension is the most important modifiable risk factor
and personal care, continence, perception and mood for recurrent stroke. Most patients with stroke or TIA
(Table 2). Well trained multidisciplinary teams are best should be commenced on antihypertensive medication,
placed to manage these impairments and are an important regardless of baseline BP.9 Patients with both ‘normal’
part of good early stroke care. To date, research that helps and ‘high’ BP benefit from antihypertensive treatment to
guide acute management of these difficulties is limited. prevent recurrent stroke. The most direct evidence is for the
Notable exceptions include the growing body of research use of an angiotensin converting enzyme inhibitor (ACEI)
into early swallowing screening,7 and the FOOD trial, which or the combination of an ACEI + diuretic.26 However, the
aimed to identify best early nutritional practices.16 The large, choice of antihypertensive medication is less important than
multicentre early mobilisation trial (AVERT) is currently effective BP lowering. The best timing for commencement
underway in Australia,17 as is the United Kingdom based of antihypertensive medication is uncertain. Blood pressure
ACTNoW trial of acute aphasia therapy.18 Both trials will help lowering medication appears safe if commenced 2–4 days
inform early rehabilitation interventions, however, neither poststroke. Commencement of secondary prevention
will be completed for some years. Nevertheless, early strategies during inpatient stay has been associated with
commencement of rehabilitation is believed to contribute to greater adherence at 3 months poststroke.27

906 Reprinted from Australian Family Physician Vol. 36, No. 11, November 2007
 Acute stroke patients – early hospital management THEME

Table 2. Common early poststroke impairments and recommended management (consensus opinion guides these recommendations unless
level of evidence is included: Level I [meta-analysis of RCTs]; Level II [RCTs])9
Consequence Recommended management Not recommended
Dysphagia Early screening (<24 hours) by a trained professional is strongly The gag reflex is not
recommended before patients are given food or drink. No single screening a valid screen for
tool can be recommended to date, however the 50 mL water swallow test in dysphagia9
combination with monitoring oxygen saturation is well regarded39
Patients who fail screening should be referred to a speech pathologist
for a comprehensive assessment and be kept nil orally until the assessment
is complete
Malnutrition/ Close monitoring of hydration status and supplementation of fluids Percutaneous endoscopic
dehydration should be considered. Glucose containing fluids are generally avoided as gastrostomy (PEG) is not
hyperglycaemia is associated with poor outcome after stroke recommended within the
All patients should be screened for malnutrition using a validated nutritional first month poststroke
assessment tool and/or nutritional markers and supplementation offered
to those with poor or deteriorating nutritional status. A dietician should
be consulted where there is a risk of malnutrition (including patients with
dysphagia). Nasogastric feeding is preferred in the first month poststroke for
patients without a functional swallow
Communication deficits Patients identified as having a probable communication deficit after
screening should undergo detailed assessment by a speech pathologist.
There is some indication that early and intensive language therapy is helpful.
Training of carers in supportive communication techniques and providing
information to patients in an aphasia friendly format are both recommended
Reduced mobility Early mobilisation (getting out of bed, sitting, standing, walking) may
help recovery and no harm has been identified.40 The phase II AVERT trial
established that commencing mobilisation within 24 hours of stroke onset
was feasible and no safety issues were identified41
Based on available data, it is recommended that patients be mobilised as
early and frequently as possible
Reduced activities of Early formulation of a management plan targeting specific difficulties is
daily living recommended. An occupational therapist should advise staff and carers on
techniques and equipment to optimise performance
Incontinence Functional assessments by trained personnel and development of a Indwelling catheters
management plan for patients with confirmed difficulties is recommended. should be avoided as
A portable bladder ultrasound scan can aid diagnosis and management an initial management
A postdischarge continence management plan should be developed with strategy
the patient and carer before discharge and should include how continence
resources can be accessed in the community
Cognition/perception Screening is recommended, with full assessment of those with identified
difficulties problems. Postacute intervention strategies are included in guidelines21
Mood disorders: Patients with suspected altered mood (eg. depression, anxiety, emotional Routine use of
depression and anxiety lability) should be assessed using a standardised tool (Level II) antidepressants to
After discharge, use of a case management model focusing on education, prevent poststroke
screening and management, linked with the primary care physician, may depression is not
reduce poststroke depression (Level II) currently recommended
Antidepressants may be used for patients with emotional lability (Level I) (Level I)
Antidepressants and/or psychological interventions may be used for patients
with depression or anxiety (Level I)
Sleep apnoea Although it is unclear whether sleep apnoea is a risk factor for stroke or
a consequence of stroke (or both), continuous positive airways pressure
(CPAP) should be considered a first line treatment (Level I)

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 THEME Acute stroke patients – early hospital management

Atrial fibrillation has been associated with greater adherence at 3 months

Warfarin (INR 2–3) is appropriate secondary prevention poststroke.27 Before commencement of warfarin, aspirin
in patients with stroke/TIA and atrial fibrillation, valvular should be used.9
disease or recent myocardial infarction unless there is
Diabetes
a clear contraindication. For this subset of patients, the
benefits for stroke prevention clearly outweigh the risks Elevated blood sugar level is common in patients presenting
of serious haemorrhage.28 The most appropriate timing with stroke or TIA.6 Good glycaemic control is essential
for commencement of warfarin for secondary prevention for prevention of the long term micro- and non-vascular
poststroke remains uncertain and stroke physicians vary complications of this disease.
in their practice. There is consensus that warfarin should
Smoking
be commenced as soon as possible after TIA, once CT
scanning has excluded ICH.9 For patients with stroke, a Cigarette smoking is a potent risk factor for stroke. A range
delay of 1–2 weeks is reasonable.9 Commencement of of effective behavioural and pharmacological approaches to
warfarin before discharge as part of secondary prevention cessation are available and need to be individually tailored.

Table 3. Common poststroke complications and recommended management (where recommendations are supported by evidence, the level
of evidence is included: Level I [meta-analysis of RCTs], Level II [RCTs])9
Complication Recommended management Not recommended
Seizure Anticonvulsant medication may be used for people with recurrent
seizures (Level I)
Cerebral oedema Urgent referral to a neurosurgeon for hemicraniectomy should be Corticosteriods have no
considered for selected patients with significant middle cerebral artery benefit and may cause
infarction (Level I) harm (Level I)
Osmotherapy and hyperventilation may help while awaiting
neurosurgical consultation
Infections: chest, urinary tract, Antipyretic therapy comprising regular paracetamol and/or physical
other cooling should be routinely used where fever occurs (Level II)
Deep vein thrombosis, Antiplatelet therapy should be used to prevent DVT/PE in those with
pulmonary embolus ischaemic stroke (Level I)
In selected patients with ischaemic stroke, low molecular weight
heparin or heparin in prophylactic doses may be used with caution
(Level I). Treatment with heparin is associated with increased risk of
cerebral haemorrhage when used early poststroke, so risk/benefit
needs to be considered
Thigh length antithrombotic stockings (Level II) may also be used
with caution, as the benefits are inconclusive and risk of acute limb
ischaemia and peripheral neuropathy need to be considered
Early mobilisation and adequate hydration should be encouraged
(consensus opinion)
Pressure ulcers Immobile patients should have a pressure care risk assessment
completed (consensus opinion) and those at high risk of ulcers
(older, more severe stroke, immobile, incontinent, diabetic and with
poor nutritional status) should be provided with a pressure relieving
mattress (Level I)
Pain Musculoskeletal pain should be managed according to pain
management guidelines (www.nhmrc.gov.au/publications/synopses/
cp104syn.htm). In patients exhibiting central poststroke pain,
amitriptyline should be preferred over carbamazepine (Level II)
Falls There are no stroke specific studies to guide fall prevention in
acute stroke. However, general falls prevention guidelines should
be followed for this population (www.health.gov.au/internet/safety/
publishing.nsf/Content/falls)

910 Reprinted from Australian Family Physician Vol. 36, No. 11, November 2007
 Acute stroke patients – early hospital management THEME

Hypercholesterolaemia management plans, provision of equipment and support

Epidemiology studies have shown that higher cholesterol services, and outpatient appointments. Despite consensus
is associated with a higher risk of stroke but a lower risk about what should be done to ease the transition from
of haemorrhagic stroke.29 Two large randomised controlled hospital to home, currently there is insufficient attention
trials have provided evidence for the benefits of lipid and resources provided for this process.
lowering with statin therapy in patients with stroke or TIA,
with no significant increase in haemorrhagic stroke.30,31
Conclusion
Therefore statin therapy should be commenced in all Hospitalised stroke patients are best managed in a stroke
patients with stroke or TIA. unit where evidence based care can be delivered by a
skilled team in an organised, coordinated fashion. Better
Antiplatelet therapy
discharge planning could be achieved with improved
There is Level 1 evidence that in patients presenting systems and resources.
with stroke or TIA, antiplatelet therapy reduces the
risk of subsequent serious vascular events; 29 and Summary of important points
aspirin reduces subsequent serious vascular events • All stroke patients should be managed in a stroke unit
by ~13% compared to placebo, 33 and is effective in if available.
low (75–150 mg) and high (300–1300 mg) doses. • CT brain should be performed urgently in all patients
Low doses are associated with less gastrointestinal with suspected stroke/TIA. Key additional investigations
include ECG and carotid duplex ultrasound.
side effects. 32 Combination aspirin/extended release
• All patients with stroke/TIA are at high risk of further
dipyridamole (Asasantin SR) has been shown to be
vascular events. The risk of recurrent stroke is highest
more effective for secondary stroke prevention (18%
in the first hours to days after the initial event.
RRR compared to aspirin alone), however about 20%
• Patients with ischaemic stroke should receive aspirin
of patients cannot tolerate this medication because of
as soon as possible (within 48 hours) poststroke.
persistent headache. 34 Commencement of Asasantin
• In the acute setting, BP should not be routinely
SR at lower dose (1 tablet per day for the first week)
lowered. Patients with ICH should have MAP
is better tolerated.35 Clopidogrel 75 mg/day is modestly maintained below 130 mmHg.
more effective than aspirin in the prevention of vascular • Antihypertensive medication will be indicated for
events,32 but substantially more expensive. Clopidogrel is secondary prevention in the majority of patients with
indicated when aspirin is not tolerated (eg. allergy or risk stroke/TIA regardless of BP level.
of gastrointestinal haemorrhage). The combination of low
• Secondary prevention poststroke/TIA will usually include
dose aspirin and clopidogrel has not been found to be antiplatelet medication (aspirin, clopidogrel or aspirin/
more effective than clopidogrel alone, but is associated dipyridamole) and a statin.
with more bleeding.36
Conflict of interest: none declared.
A coordinated approach to discharge
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