The management of stroke
Stroke kills approximately 90,000 women and 60,000 men annually in the UK. Although mortality rates have declined over the past 30 years, possibly due to improved awareness of treating risk factors such as hypertension and hyperlipidaemia, stroke still remains the third most common cause of death in the UK.1 The estimated cost of stroke attacks to the NHS and social services is £2.3bn per year, nearly twice that of coronary heart disease (CHD).1,2
Stroke causes long-term disability requiring specialised support and care for each individual patient, depending on the severity of the stroke and associated comorbidities. It results from either an occlusion of arteries (which reduces the blood supply to the brain) or rupture of an artery (which causes bleeding into part of the brain). Effective treatment needs to be targeted at the primary and secondary prevention of stroke, as well as the acute phase of stroke, so as to minimise cerebral ischaemia.
The two types of stroke are haemorrhagic stroke and ischaemic stroke. Rapid diagnosis of stroke needs to be focused on the following:
- Determining whether the symptoms are due to a stroke
- Localising the brain injury
- Establishing the type of stroke
- Establishing the most likely cause of the stroke, taking into account the risk factors
Many patients experience nausea, vomiting, headache and impairment in consciousness, reflecting dysfunction in areas of the brain. Panel 1 (p38) shows the differential features of the two types of stroke. However, there is considerable overlap in the presenting symptoms and clinical diagnosis without imaging should not be relied upon in making a definitive diagnosis.
The most important diagnostic test to differentiate the two types of stroke is brain imaging either by computed tomography (CT) or magnetic resonance imaging (MRI). These techniques have the ability to visualise bleeding and define the extent of cerebral damage. Until intracranial haemorrhage has been excluded, patients should not be treated with anticoagulants or thrombolytic agents.
Patients with intracranial bleeding caused by haemorrhagic stroke are more likely to have an increase in blood pressure and intracranial pressure than patients with ischaemic stroke. Apart from cerebellar haematomas, there is no evidence that surgical evacuation of haematomas is helpful. Management is therefore medical, with careful blood pressure control and maintenance of other physiological parameters such as temperature, hydration and oxygenation.
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Citation: Hospital Pharmacist URI: 10975292
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