The Specialist Forum Volume 13 No 11 November 2013 | Page 66
CPD ARTICLE
will respond well to late intervention. However, most patients will have had
significant brain infarction by six to eight hours post-onset. The decision
therefore, on whom to intervene on, has to be individualised and strict time
guidelines are not appropriate.
Patients and methods
We make use of an acute ischaemic stroke management protocol based
on the following:
• Time interval from onset of stroke till admission to emergency unit.
• Severity of stroke graded as mild, moderate or severe using the NIHSS
scoring system.
• Co-morbidities and contraindications for tPA.
• Radiological imaging carefully looking at early infarct changes (Most
commonly CT scans using the Aspects score).
• NIHSS scoring on admission and daily to monitor response to therapy.
Mild strokes (NIHSS score of seven or less) are not subjected to reperfusion strategies, but we prefer to admit them to ICU as they sometimes
deteriorate and reassessment of management is then indicated. Moderate
strokes (NIHSS score eight to 16) get assessed for IV tPA according to the
NINDS criteria and eligible patients treated after admission to ICU.
Severe strokes (NIHSS scores of 16 or more) are regarded as an extreme emergency and are assessed for reperfusion therapy (mechanical
embolectomy device) following angiography usually done in the catheterisation laboratory with occasional patients having CT or MR angiography.
Our unit started giving IV tPA in the late nineties and mechanical embolectomy using the Merci Retriever began in 2007. For the past year or so
only the Solitaire or Trevo stent retrievers are used.
We did a retrospective analysis of all stroke patients admitted to the hospital from the beginning of August 2011 till September 2012. There were a
total of 196 patients (all referrals or direct admissions from Somerset West
and the surrounding areas). The average age was 71 years old and gender
distribution was equal (men [51%] and women [45%]). There were 90%
ischaemic and 10% haemorrhagic strokes.
A significant improvement at time of discharge (good functional recovery) occurred in 142 patients (72%), 19 died in hospital (9%), and no
improvement was seen in 34 patients at the time of discharge (17%). Ninety
patients (46%) were admitted to the ??FV?6?fR6&RV??B?F?RfW&vR??7?F?7F?v2R??F?2??F?RfW&vRF??RW&??Bg&??7F'B?b7??F??2F?F?76???v2 ???W'2?W6??rF?R?5266?&RF?R6WfW&?G?v2?VFvVBF?&R??B?????cR????FW&FRC"?#R??B6WfW&R3b??R????F?R??FW&FRF?6WfW&P?6???'B???s???#"F?V?G2?#?R?vW&RG&VFVBv?F??bE?B#?#rR???? ?f?wW&R#?#"?V"??BfV??R&W6V?G2v?F???????b??6WB?`?FV?6R?VgB?V??Vv???52?2??G&VFVBv?F??bE?'WB6??vV@???6???6?&W7??6Rc???7B??gW6????6??w2?66?W6????bF?P?&?v?B?FF?R6W&V'&?'FW'???FW&?f?Wr??"FV?B'FW'?f????v??p?V?&??V7F???6?R?FR?W?6V??V?B&V6?fW'???%3???vV?BF?F?R6F?WFW&?6F????&?&F?'?f?"?VB?B?V6??v??w&???f?F?RfV??&?'FW'???V6???6?V?&??V7F????666???????6?VF??p?6&?F?B?v???7G??6&?F?B7FV?B??"??G&?6W&V'&?E?v2W&f?&?VB?`?FVV?VB7V?F&?R'?F?R??FW'fV?F????7B??Gv?F?V?G2v?F?6WfW&R7G&??R?B?&vR'FW'??66?W6???2v??6??V?@??fR&VV?&VfW'&VBf?"?76?&?R?V6???6?V?&??V7F??66?&F??rF??W ?&?F?6???&V6V?fVB?bE??7FVB?GVRF?V?f??&??G??bF?R??FW'fV?F????7B?&?F?F?B??B&W7??BF??bE?BF?VB????RF?V?B??F?R??FW'fV?F????w&?W?B?76?fR7WFR??G&6W&V'&??V??'&?vRfWr??W'2gFW"7V66W76gV?V?&??V7F???b???66?VFVB&?v?B??FW&??6&?F?B'FW'??BF?VB??Rv2( ?v?RW7G&??^( ???GW&F???V????v??v??&W6V?FVBv?F?6WfW&R?WW&???v?6?FVfV7B'W@?GVRF?ff?W&&?R7V7G266?&R??5B66?v2v?fV?F?R&V?Vf?B?`?F?V'B?B&VfW'&VBf?"?V6???6?V?&??V7F????F&?R?7G&??RFF&6P?FFS???VwW7B#( 26WFV?&W"# ??F?F??V?&W"?bF?V?G3????`???66?V?0???P???V??'&?v?0??P??fW&vRvP??s??vV?FW ??SR?V??C?Rv??V??V?&W"?b?5RF?V?G0????CbR???F?&??&??F?2F?W&?&V6V?fVB#"?R??6F?W&?6F????&?&F?'????V6???6?V?&??V7F?????#?R???fW&vR7F?????7?F???R??F?0???WF6??W2?BF?66?&vR???V?6??vVC?#??RR????&?fVC?C"?s"R??v?'6V?VC?b?2R??FVF????R???6WfW&?G?????C???cR????FW&FS?C"?#"R???6WfW&S?3b??R??fW&vRF??R?7G&??RF???7?F?"??W'2W"F?V?@??F?67W76????FW7?FR?W"Vff?'G2F?VGV6FRF?RV&?2?B?'V??6R6W'f?6R???F?V?G27F???vWBF???7?F?F???FRf?"&WW&gW6???F?W&??gW'F?W&??&R?????&R7F????VFvVBF?&R??V?v?&?Rf?"?bE?B?V6???6???FW'fV?F????GVRF??F?W"6???&&?F?F?W2?f???6??6??6?FW&F???2?B??v??rfVGW&W0???F?6F??r6?v??f?6?B6W&V'&???f&7F?????vR&V?WfRF?BF??26???'B?bF?V?G2??vV?W&?F?BV?FRvV??6??&V@?F??F?W"V&?6?VB7G&??RV??BFF?BF?B?F?????vV?V?B??F?Rf?'7@?#B??W'2??W26?v??f?6?BF?ffW&V?6R???WF6??R?v?F?6??'FW"??7?F??7F??B&WGFW"gV?7F????&V6?fW'??vRv?V?B??RF?V?6?W&vR?F?W"??7?F?2??4F?7F'B7WFR7G&??RV??G2?B?76?&??ffW"?V6???6?V?&??V7F??F?F?V?"6WfW&R7G&??RF?V?G2v???F?W'v?6R?fR??6??6R?b6W&V'&?&WW&gW6????F?R7G&??vW7B&VF?7F?"?b???&?fVB6???6??WF6??R??&WW&gW6???F?W&?f?"7WFR?66?V?27G&??R?w2f"&V???B6?&??'???FW'fV?F???f?"7WFR??6&F????f&7F????F?R'&???2?V6????&R6???6FVB?BFV?6FR?&v??vR?VVB6??F??VVB&W6V&6??@???&?fV?V?G2????FW'fV?F????F?W&?W2F??F??6R7WFR7G&??R??FW'fV?F????B?V?&WGFW"6V?V7BF??6RF?V?G2v??v???&V?Vf?B??7Bg&??F?W6P?&?6VGW&W2??&VfW&V?6W2f??&?R??&WVW7B?("4`??vR???????????????fV?&W"#2?6&F????w?b7G&??Rf?'V??