Hyperacute care of Ischaemic and Haemorrhagic stroke

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Learning objectives

  • What is Hyperacute Stroke Care
  • What are the important priorities in the first 24 hrs
  • Appropriate investigations
  • Managing in the first 24 hrs


Care must endeavour to begin at the time of the stroke in order to minimise brain injury. This involves education of the public about the typical stroke presentations so that they seek help immediately and do not procrastinate. Once emergency services are summoned then patients need to be assessed by appropriately trained paramedical staff and if patients are likely to have a stroke then patients should be rapidly brought to a primary stroke centre with the ability to give reperfusion therapies 24/7. Various clinical screening tools for non trained lay people are available such a FAST. These have proven their usefulness and allow an early referral of a patient to a hyperacute stroke service.

As with all medical emergencies immediate access to healthcare will focus on the ABCs of acute care as needed but usually only a small number may need intubation and ventilation and intensive care. Early and speedy referral allows the potential access to reperfusion therapies such as Stroke Thrombolysis and now Mechanical Thrombectomy and the reversal of anticoagulation where appropriate. The staff at the receiving centres duties will be to determine the correct diagnosis and delivery appropriate directed care quickly, efficiently and safely. Hyperacute assessment must be quick with a very focused Clinical History and Clinical Examination that are both focused.

The overriding concept in hyperacute care is that "time is brain" (roughly 2 million neurons per minute) and that systems must be in place to rapidly receive acute stroke patients and quickly assess them. There are two real streams, those who may be suitable for urgent therapies and the rest. Urgent therapies would include Stroke Thrombolysis and Mechanical Thrombectomy and reversal of anticoagulation for those with ICH on anticoagulants and those deteriorating due to a massive stroke and raised intracranial pressure who may benefit from decompression, External ventricular drainage or craniectomy. These patients will become immediately apparent.

Training and Making Pathways Efficient

The key to rapid delivery of stroke care is to have stroke-trained staff receiving these patients with no needless delays holding up the process. Once seen, immediate CT scanning should be done and this will aid management. Locally we aim to deliver thrombolysis within 20 minutes of arrival so we meet and greet the patient, get a handover from paramedics, establish the time of onset (patient last seen well and stroke-free) and any possible contraindications to lysis such as anticoagulation. In the meantime, the patient is quickly booked on systems and CT head booked and it's straight off to CT with the stroke team doing the portering and at the same time taking a history and examining on the way and while waiting. The history is focused on in particular as is the examination. The family are kept close by to help information gathering and they may be involved in the consenting process. The doctor and stroke nurse push the patient to CT and help radiology staff and at no point should the patient be waiting with no productive activity in place. One the CT is done it can be inspected, the BP re-checked, the weight verified and a quick checklist of contraindications and consent checked then we can prescribe and administer Alteplase. There is no need to do an ECG or to await blood results (Other than a glucose in all and an INR is those on Warfarin) on the majority of patients. Each hospital has its own distinct preferences, some administer thrombolysis in the emergency department, others on the Hyperacute stroke unit. The main issue is to continually review your pathway to make sure it is efficient and safe and remove needless delays. Small improvements can all add up to significant reductions in door to needle times.

Critical therapies and Interventions

This involves rapid assessment to determine those who are suitable for acute therapies that can improve outcome and this is one of the key reasons for patients to be rapidly admitted to a hyperacute facility with the specialist care to assess for and manage these needs.

Ischaemic stroke

Ischaemic stroke
All people with suspected stroke should be admitted directly to a specialist acute stroke unit following initial assessment, either from the community or from the A&E department
Stroke Thrombolysis
Mechanical Thrombectomy
Decompressive Hemicraniectomy for malignant MCA syndrome
Decompressive Suboccipital Craniectomy for large cerebellar infarct
Carotid endarterectomy in those with significant symptomatic carotid stenosis
Anticoagulation for Atrial Fibrillation
Aspirin within 24 hrs

Haemorrhagic Stroke

Haemorrhagic Stroke
All people with suspected stroke should be admitted directly to a specialist acute stroke unit following initial assessment, either from the community or from the A&E department
Neurosurgical referral for Clot evacuation
Decompressive Suboccipital Craniectomy for cerebellar bleeds
Shunting for those with hydrocephalus
PCC for Warfarin induced bleeds
Consider PCC for NOAC induced bleeds

Subarachnoid Haemorrhage

Subarachnoid Haemorrhage
All people with suspected stroke should be admitted directly to a specialist acute stroke unit following initial assessment, either from the community or from the A&E department
Coiling or clipping for those with SAH due to Saccular (Berry) Aneurysms
Shunting for those with hydrocephalus
Management of Hydrocephalus
Managing and Preventing Early complications
Checking safe swallow before oral intake reduces aspiration
NG tube placement for feeding when appropriate
Using methods to prevent VTE - Intermittent calf compression, LMWH, Early mobilisation
IV fluids to prevent dehydration
Regular turns and monitoring to prevent skin damage and ulcers
Bowel management to prevent constipation
Prevention of shoulder damage and postural problems
Early rehabilitation to enable recovery
Management of seizures
Management of infections - UTI, RTI
Management of bowels and bladder, avoidance of catheterisation where possible