What are the management options for brain stroke?

Management of Brain Stroke

The management of brain stroke requires immediate specialized neurointensive care, often with neurosurgical intervention, particularly for swollen cerebral and cerebellar infarcts which are critical conditions that can lead to significant mortality and morbidity if not properly treated. 1

Initial Assessment and Management

• Urgent neuroimaging: All patients with suspected stroke should have an urgent brain CT or MRI within 24 hours to differentiate between ischemic and hemorrhagic stroke 1, 2

• Blood pressure management:

  • Initially maintain permissive hypertension to support cerebral perfusion
  • For ICH patients with hypertension history, keep mean arterial blood pressure below 130 mmHg 1
  • For patients receiving thrombolysis, reduce blood pressure to <185/110 mmHg 2

• Oxygenation: Ensure adequate oxygenation and ventilation; provide oxygen therapy if O₂ saturation is <92% 2, 3

Specific Management Based on Stroke Type

Ischemic Stroke (80-87% of strokes) 4

1. Thrombolytic therapy:

   • Intravenous alteplase (tPA) at 0.9 mg/kg (maximum 90 mg) with 10% as bolus and 90% as infusion over 60 minutes 2
   • Target door-to-needle time <60 minutes, ideally within 3 hours of symptom onset 5

2. Antiplatelet therapy:

   • Initiate aspirin (325 mg initially, then 81-325 mg daily) within 24-48 hours if no contraindications 1, 2
   • Consider dual antiplatelet therapy (aspirin plus clopidogrel) for 21-90 days in minor stroke 2

3. Management of cerebral edema:

   • For large hemispheric infarctions with significant swelling:
     • Decompressive craniectomy with dural expansion should be performed in patients <60 years old who continue to deteriorate neurologically, ideally within 48 hours 1
     • Uncertainty exists about efficacy in patients ≥60 years 1
   • Initial medical management includes:
     • Mild fluid restriction (avoid hypo-osmolar fluids) 1
     • Head elevation by 20-30 degrees 1
     • Treatment of factors that exacerbate raised intracranial pressure (hypoxia, hypercarbia, hyperthermia) 1, 3

Hemorrhagic Stroke (13-20% of strokes) 4

1. Anticoagulation reversal:

   • Immediately discontinue anticoagulation
   • For VKA-associated ICH with INR ≥2.0, administer 4-factor prothrombin complex concentrate over fresh-frozen plasma 2

2. Surgical management:

   • Surgery may be considered in specific situations (e.g., craniotomy for superficial ICH <1 cm from surface) 1
   • For cerebellar hemorrhage, surgical evacuation may be beneficial 1

Cerebellar Stroke

1. For swollen cerebellar infarcts:
   • Suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically 1
   • Ventriculostomy to relieve obstructive hydrocephalus should be accompanied by decompressive suboccipital craniectomy 1
   • Outcomes after cerebellar infarct can be good after suboccipital craniectomy 1

Prevention and Management of Complications

• Deep vein thrombosis: Use subcutaneous anticoagulants, intermittent external compression stockings, or aspirin for immobilized patients 1

• Infections:

  • Monitor for pneumonia, especially in immobile patients or those unable to cough 1
  • Provide prompt antibiotic therapy for suspected infections 1
  • Avoid indwelling bladder catheters when possible to reduce urinary tract infections 1, 2

• Seizures:

  • Treat recurrent seizures as with any other acute neurological condition 1, 2
  • Prophylactic anticonvulsants are not recommended 1

• Swallowing assessment:

  • Perform before allowing oral intake to prevent aspiration 2
  • Consider nasogastric or nasoduodenal tube feeding when necessary 2

Rehabilitation and Long-term Care

• Early rehabilitation: Initiate within 24-48 hours of stroke onset if the patient is stable 2

• Multidisciplinary team care: Care by a team with regular meetings (at least weekly) in a stroke unit improves functional outcome and reduces mortality 2

• Cognitive assessment: Recommended for attention deficits, visual neglect, memory deficits, and executive function difficulties 2

Family Discussion and Prognosis

• Discuss with family members that half of surviving patients with massive hemispheric infarctions, even after decompressive craniectomy, are severely disabled and a third are fully dependent on care 1

• For patients <60 years old with decompressive craniectomy performed within 2 days after a supratentorial ischemic stroke, nearly 3 of 4 patients survive, but nearly half will be severely disabled and nearly half will also suffer from depression 1

• The outcome after cerebellar infarct can be good after suboccipital craniectomy if there has been no evidence of brainstem infarction 1

Important Considerations and Pitfalls

• Time is critical: "Time is brain" - early intervention is essential for better outcomes 5, 3

• Avoid rapid drops in blood pressure which may compromise cerebral perfusion 2

• Monitor glucose levels: Hyperglycemia (>8 mmol/l) predicts poor prognosis; insulin therapy in critically ill stroke patients is associated with lower mortality 3

• Control body temperature: Hyperthermia worsens stroke prognosis; early treatment is important 3

• Public awareness: Only 16.4% of people recognize all five correct stroke symptoms and know to call 9-1-1 immediately 6, highlighting the importance of public education