Management of Stroke in a Non-neurointensive Care Unit
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Stroke is a leading cause of acquired adult disability and is defined as a clinical syndrome of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours. If a patient has a new neurological deficit for less than 4.5 hours they may be a candidate for thrombolysis.
Assessment of a patient with stroke involves clinical history, examination, blood investigations and CT/MRI imaging. Points to note on history include establishing if there is any history of trauma which may point to a haemorrhagic stroke or dissection as well as an assessment of cardiovascular risk factors. Clinical examination is useful in attempting to isolate where a particular brain injury may have occurred and there are a number of useful clinical signs to assist this evaluation. The National Institute of Health Stroke Scale (NIHSS) is a helpful clinical scale used to establish clinical stroke severity. Radiological investigation may be useful in confirming the clinical suspicion regarding stroke location and differentiating haemorrhagic from non-haemorrhagic (ischaemic) stroke.
It may be appropriate to admit a stroke patient to ICU for a number of reasons including the need for mechanical ventilation, haemodynamic monitoring/management, associated organ support(s), post-operative monitoring (e.g. post craniectomy) or, in the case of a catastrophic brain injury, the management of a potential organ donor.
Specific therapies for ischaemic stroke may include thrombolysis, antiplatelet agents and statin therapies as well as supportive therapies such as pneumatic compression devices (thromboprophylaxis), stress ulcer prophylaxis (for ventilated patients) and modest glycaemic control.
Haemorrhagic stroke (including haemorrhagic transformation of an ischaemic stroke as well as subarachnoid haemorrhage) requires urgent neurosurgical referral. In patients with posterior fossa ischaemic strokes and large anterior circulation ischaemic strokes, there should be a low threshold for neurosurgical referral for decompression surgery.
The perioperative management of the carotid endarterectomy patient requires careful haemodynamic monitoring as well as high clinical suspicion for new neurology which may require surgical re-intervention.
A number of stroke ‘mimics’ exist and should be considered when assessing a patient with a possible stroke. Prognostication in stroke can be difficult and requires experienced and multi-disciplinary inputs. Neurorehabilitation is key to returning patients to their functional baseline. Where appropriate, end-of-life care should be focused on symptom management. In the case of a catastrophic brain injury, management for potential organ donation should be considered if appropriate.
KeywordsStroke Intensive Care Unit Disabilities Long-term outcome Management
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