Integrating stroke services in health-care systems:
A practical approach
Integrating stroke services in health-care systems:
A practical approach
Integrating stroke services in health-care systems: A practical approach.
ISBN: 978-92-9022-813-4
© World Health Organization 2020
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contents
Acknowledgements
iv
Preface
v
List of acronyms
vi
1. BASIC OVERVIEW OF STROKE
1
What is transient ischaemic attack?
1
How does our brain function?
2
What are the risk factors of stroke?
7
2. RECOGNIZING STROKE
10
FAST Test
12
Other possible symptoms
14
First responder
15
3. STROKE MANAGEMENT AT PRIMARY HEALTH FACILITY
17
Airway breathing circulation (ABC) management
18
4. MANAGEMENT AT AN ADVANCED STROKE FACILITY
24
5. POST-DISCHARGE REHABILITATION
45
6. STRENGTHENING INTEGRATED STROKE SERVICES
56
7. STROKE SURVEILLANCE
66
Why a stroke surveillance system?
66
WHO STEPS stroke surveillance system
66
Establishment of stroke registries
70
Hospital-based stroke registry (HBSR)
70
Population-based stroke registry (PBSR)
71
8. ACOUNTABILITY AND PERFORMANCE MEASURES IN
STROKE CARE
73
ACKNOWLEDGEMENTS
The document was conceptualized by Dr Thaksaphon Thamarangsi and Dr Gampo Dorji of the WHO Regional Office for South-East Asia. The technical contents were prepared by Dr Jeyaraj D.Pandian, Dr Ivy Sebastian and Dr Dorcas Gandhi from Christian Medical College, Ludhiana, India.
The following experts conducted peer review of the document: Dr P.N. Sylaja, Dr Yogeshwar Kalkonde, Dr R.Sukanya, Dr Bo Norvving, Dr Peter Langhorne, Dr Yangchen, Dr Tashi Tenzin and Dr Kyaw Kan Kuang. Staff from WHO offices, Dr Sadhana Bhagwat, Dr Manju Rani, Dr Patanjali D. Nayar and Dr Thushara Fernando, reviewed the document.
Photograph demonstration was supported by Dr Radha Kumari (PT), Mr Arul Nathaneal SB, Ms Jerin Jose, Mr Harsimranjit Singh and Mr Deepak Kumar.
PREFACE
Stroke is a major public health problem across the world, including in the WHO South-East Asia Region. Worldwide, cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability. Globally, 70% of strokes occur in low- and middle-income countries, where the incidence of stroke has more than doubled over the last four decades. On average, stroke occurs 15 years earlier in people living in low- and middle-income countries when compared with those in high-income countries.
Up to 84% of stroke patients in low- and middle-income countries die within three years of diagnosis as compared with 16% in high- income countries. Stroke survivors often live with lifelong sequalae and disabilities.
WHO and its Member States in the South-East Asia Region are committed to identifying and implementing high-impact “best buys” to prevent and control noncommunicable diseases (NCDs), including stroke. Region-wide, hypertension is the most frequent risk factor for stroke, followed by diabetes mellitus and tobacco use. WHO is supporting all countries in the Region to prevent, detect and control hypertension and diabetes, control tobacco and alcohol use, and promote and enable healthy diets and lifestyles to reduce the incidence and impact of stroke.
In addition to supporting countries to prevent stroke, WHO is working to scale up the quality and reach of services that can deliver stroke care. As this publication details, countries have great potential to improve and streamline stroke services, for example by strengthening acute management and rehabilitation services, increasing the availability of CT scanners, and enhancing health workers’ knowledge and skills. It is imperative that health services at all levels can provide fast-track referrals and coordinated emergency care for stroke, in addition to ongoing support and rehabilitation for people living with stroke.
I urge all stakeholders in the Region to make full use of the practical actions, policy solutions and recommendations contained herein. Doing so will not only help avert deaths and improve the quality of life of stroke survivors but will also accelerate the Region’s progress on its Flagship Priorities on preventing and controlling NCDs and achieving universal health coverage. Together we can realize a Region in which stroke is more effectively prevented and managed, with fewer stroke deaths and disabilities, and greater health, wellness and productivity.
LIST OF ACRONYMS
ABC airway breathing and circulation AD assistive device
ADL activity of daily living BP blood pressure
CT computed tomography
DVT deep vein thrombosis GI gastrointestinal
HBSR Hospital-based stroke registry ICU intensive care unit
INR international normalized ratio
IV intravenous
LKW last known well
LMWH low molecular weight heparin MRI magnetic resonance imaging
NIHSS National Institute of Health Stroke Scale PBSR Population-based stroke registry
HBSR Hospital-based stroke registry
PE Pulmonary embolism
PTT partial thromboplastin time
SC subcutaneous
TIA transcient ishaemic attack tPA tissue plasminogen activator TR tele-rehabilitation
UTI urinary tract infection
BASIC OVERVIEW OF STROKE 1
A stroke is a serious life-threatening medical condition that occurs when the blood supply to a part of the brain is cut off. Stroke is one of the leading causes of death and disability worldwide. However, it is preventable, and the associated morbidity and mortality can be significantly reduced with timely recognition and treatment.
Like all the organs, the brain needs constant supply of blood for oxygen and nutrients. When blood supply is minimized or stopped, the part of the brain affected is damaged or the brain cells there die within a few minutes. That is why stroke is also called a “brain attack”.
A stroke occurs when blood supply to a part of the brain is blocked or when a blood vessel in the brain bursts. There are two major types of strokes:
1. Ischaemic stroke: Occurs when there is blood clot or a piece of fatty material causing sudden blockage of arteries supplying the brain. This results in total or partial cut-off of oxygen to brain cells, causing ischaemia and cell death. Most strokes (87%) are ischaemic strokes.1
2. Haemorrhagic stroke: When the walls of the blood vessels in the brain become weak and burst causing bleeding and spillage of blood into surrounding brain tissue, and cuts off oxygen and results in the death of cells. Haemorrhagic strokes can also occur as the result of the rupture of a balloon-like expansion of a blood vessel (brain aneurysm) and badly formed blood vessels in the brain.
Unfortunately, there is widespread lack of awareness about stroke. Moreover, in low- and middle-income countries stroke care services are hugely lacking or are not accessible to the large majority.
It is essential to educate the masses about stroke and how to quickly recognize it so that they can take steps towards early treatment. Furthermore, emphasis should be given to strengthen the primary prevention of stroke.
What is transient ischaemic attack?
¤ TIA is called a “mini-stroke” as it lasts shorter and does not cause permanent brain damage. But it is important as it serves as a warning sign for a future stroke. TIAs should be considered a medical emergency.
¤ About 10%–15% of people are likely to have a major stroke within three months of having a TIA.2
Clot formation
In our body, fats, cholesterol, calcium and other cellular waste gradually keeps depositing in the walls of arteries; this is called the “plaque”. The process is known as “atherosclerosis”.
There are two mechanisms by which a plaque can cause a stroke:
¤ Over time, as plaque builds up within the vessel walls, and the lumen of the arteries begins to narrow. The blood flow is lessened or blocked, resulting in ischaemia or death of brain cells causing ischaemic stroke.
Figure 1: Clot and blood supply blockage to brain
¤ Another mechanism by which plaque can cause stroke is due to a process called embolism. When the plaque becomes fragile, small pieces of plaque, known as the
“embolus”, break off. The embolic piece is pushed along the blood stream. This wandering embolus lodges in an artery of the brain blocking blood supply. This results in what is known as an embolic stroke.
How does our brain function?
To understand stroke, it is important to know the structure and functioning of the brain.
The brain is an extremely complex organ that controls all functions and emotions of the body. It controls movements of body parts, breathing and digestion, and helps us to perceive sensations such as pain, touch, temperature, speech, thought, memory and influences our behaviour and emotions.
Structure and functions of the brain
3,4The major parts of the brain and their associated functions are:
1. Cerebrum: It forms almost 80% of the brain. It is responsible for integration of information and making sense of all data coming into the brain. Billions of neurons and synapses are located in the cerebrum. It is made up of two types of tissues called grey and white matter. Grey matter is composed of neural cell bodies and forms the outer surface layer of the cerebral hemispheres, called the cerebral cortex. The white matter forms the layer below the grey matter and makes up the sub-cortex.
The cerebrum is divided into right and left hemispheres; the two hemispheres are connected by a bundle of nerves known as the corpus callosum.
Each cerebral hemisphere can be further divided into five lobes and their major functions are:
(a) frontal lobe: emotional control
(b) parietal lobe: sensation and reaction to environment (c) occipital lobe: vision
(d) temporal lobe:language, hearing and memory
(e) insular lobe: processes various sensations such as taste, visceral, pain and vestibular functions.
2. Cerebellum (back of the brain): Helps in motor control and coordination, also has motor memory.
3. Brain stem: It has three parts –medulla oblongata, pons and midbrain. Brain stem controls the fundamental functions of life, including breathing, beating of the heart, swallowing and digestion. It also sorts information going up and down the brain.
4. Thalamus (sits on the brain stem): This is like a router and sorts data and sends where it needs to go.
5. Hypothalamus: Maintains body temperature and osmolality and circadian rhythms.
6. Posterior pituitary: Controls secretion of hormones.
7. Basal ganglia is found below the cortex in the sub-cortex and performs motor control functions.
It is interesting to note that each hemisphere controls the opposite half of the body, i.e. the left brain controls the right side of the body and vice versa. This is because both hemispheres are joined by a bundle of fibres that transmits messages from one side to the other. Each hemisphere controls the opposite side of the body.
In general, the left hemisphere of the brain controls the language and speech. So the left brain is also called the “dominant” hemisphere. However, some left-handed people may have speech functions located on the right side of their brain.
Figure 2: Two sides of the brain
Blood supply of the brain
The detailed description of the blood supply to the brain is beyond the scope of the document. However, it is important to be familiar with the general layout of the arterial blood supply of the brain to understand stroke.
Figure 3: Blood supply of the brain
Arteries deliver oxygenated blood, glucose and other nutrients to the brain and veins carry deoxygenated blood back to the heart and move other metabolic products.
The arterial blood supply of the brain is derived from the vertebral artery and internal carotid artery (ICA) ascending from the neck. After entering the cranial cavity, arteries further branch into smaller arteries and go on to supply designated areas of the brain.
Broadly, in the cranial cavity, arterial blood supply to the brain can be described as having two systems:
¤ anterior (front) circulation
¤ posterior (back) circulation.
The vertebral arteries (right and left) supply blood to the “posterior circulation” and the carotid arteries (right and left) supply blood to the “anterior circulation”.
Anterior circulation
Two internal carotid arteries, one on each side, after ascending to the brain, split into anterior cerebral artery and middle cerebral artery: they are linked together by
communicating arteries. Together they supply the anterior part of the brain and contribute to 80% of the blood to the brain.
Posterior circulation
Two vertebral arteries, one on each side, fuse together to form the basilar artery. The basilar artery branches further to supply blood to the occipital lobe, cerebellum and brain stem. They contribute the remaining 20% of the blood supply to the brain.
However, the anterior and posterior systems are directly connected by communicating arteries in the front and back sides of the brain. These are physiological safeguards to ensure that there is a backup in case any route gets occluded. The connection between the vertebral and carotid circulations is called the Circle of Willis.
The failure of these safeguards results in cerebrovascular accidents commonly known as stroke. The level of brain damage will depend on the arteries involved. If a large artery is blocked, it may lead to long-term disability or death.
What are the risk factors of stroke?
Stroke can happen to anyone at any time. It’s not possible to completely prevent strokes because some things that increase your risk of the condition cannot be changed.5,6 The factors that cannot be modified include:
¤ family history
¤ age
¤ sex.
Medical history: Individuals with previous history of stroke, TIA or heart attack, are at higher risk for another stroke.
Figure 4: Nonmodifiable risk factors
Family History Age Sex/Gender
1. Family history: People with family history of stroke also have increased risk of stroke.
2. Age and gender: Risk of stroke increases as you get older. Although age-specific rates of stroke are higher for men, women suffer more frequent strokes due to their longer life expectancy.7
Figure 5: Modifiable risk factors
Unhealthy Diet High Cholesterol
High blood pressure: High blood pressure (BP) is the most important risk factor for both ischaemic and haemorrhagic stroke. BP more than or equal to 140/90 millimetres of mercury (mmHg) can damage blood vessels causing them to narrow, rupture or leak.
High cholesterol and heart disease: When there is excess cholesterol (fatty substance) in the body, it can cause plaque build-up in the arteries. This thick, hard plaque can clog the arteries like a blocked pipe, reduce blood flow and lead to a stroke or heart disease. The other causes of stroke can be due to problems in the heart such as ischemic heart disease and a type of irregular heart beat called “atrial fibrillation” which can also cause blood to clot within the heart and which in turn can lead to an ischaemic stroke.
Smoking: Tobacco smoke contains many toxic chemicals including carbon monoxide which reduces the amount of oxygen in blood, increases blood pressure and increases the risk of a stroke. Secondhand smoke can increase the risk for stroke.
Obesity/Lack of physical activity: This leads to excess fat in the body and can cause inflammation which causes poor blood flow and potential blockages,thereby greatly
increasing the chances of stroke. Physical activity lowers blood pressure, controls weight and decreases bad cholesterol levels in the body.
Diabetes: In diabetes, the body is unable to remove the extra sugar, and excess glucose can damage linings of blood vessels which in turn can increase deposits of fat or blood clots in the blood vessel walls. These deposits can restrict or completely block vessels in the neck or brain increasing the risk of stroke.
Alcohol: Excess consumption of alcohol is a risk factor for both ischaemic and haemorrhagic stroke.
Prevention of stroke
In most cases, risk of stroke can be significantly reduced by making lifestyle changes to avoid problems such as atherosclerosis and high blood pressure. This includes:
¤ having a healthy diet
¤ exercising regularly
¤ not smoking or quitting tobacco
¤ cutting down on amount of alcohol.
As atrial fibrillation can also significantly increase the risk of having a stroke, it is important to advice patients having an irregular heartbeat or if diagnosed with the condition to consult a doctor about the option of taking anticoagulant medications to lower stroke risk.
It is important to get help as soon as possible after a stroke for a better chance of recovery.
2 RECOGNIZING STROKE
A stroke is a medical emergency. Urgent recognition of symptoms and treatment is
necessary. The signs and symptoms of a stroke vary from person to person but usually begin suddenly. As different parts of the brain control different parts of the body, symptoms will depend on the part of the brain affected and the extent of the damage.
Depending upon which hemisphere of the brain and which region of that hemisphere is affected, the symptoms of stroke can vary. The common signs and symptoms of stroke are shown in the figure below.
Figure 6: Common signs and symptoms of stroke
Sudden numbness or weakness in the face, arm or leg, especially on one side of the body.
Sudden difficulty in speaking or understanding, or sudden state of
confusion.
Sudden trouble seeing in one or both eyes
Sudden trouble in walking, sense of dizziness, loss of balance or coordination.
Sudden and severe headache with no known cause.
FAST Test
Stroke can be quickly screened by using the “FAST test” method, which involves asking three simple questions:8
Figure 7: FAST Test
Face Is there drooping of one side of face?
Arms Is there weakness in one arm?
Speech
Is the speech slurred or strange?
If yes, Time to contact the nearest health facility
I ca...
sp..
Ask and observe
Ask the patient to show their teeth and smile and observe if the face droops to one side or if the smile is not balanced.
Ask the patient to stretch out both arms in front and observe if one arm drifts downward or if one arm shows some weakness.
Ask the patient to repeat a simple sentence such as ‘the sky is blue’ and listen if the speech is slurred or if they are unable to say it or understand.
If the patient shows any of these symptoms, it could be a stroke; call emergency services immediately.
If the answer to any of these questions is yes, act FAST and call for emergency medical help immediately.
Figure 8: Emergency referral
Other possible symptoms
Symptoms in the FAST test identify most strokes, but occasionally a stroke can cause different symptoms. It is important to look for other symptoms. Other symptoms and signs may include:
¤ complete paralysis of one side of the body
¤ sudden loss or blurring of vision
¤ difficulty understanding what others are saying
¤ problems with balance and coordination
¤ a sudden and very severe headache
¤ loss of feeling in one side of the body.
However, causes other than stroke can also present similarly, and should be ruled out.
Stroke is a serious medical condition that requires emergency care. As “time lost is brain lost”, it is critical that a person with stroke is recognized, and provided treatment on time to save life.
STROKE MIMICS
Many conditions can present with symptoms similar to a stroke but it may not always be a stroke. These conditions are called “stroke mimics”. It is very important to distinguish a stroke mimic from an actual stroke. Some of the common stroke mimics are:
Hypoglycemia: Low blood sugar can present with symptoms like weakness of limbs, speech difficulty, or unconsciousness, and can be mistaken for a stroke. That is why it is essential to check blood sugar in every stroke patient.
Seizures: After seizures, sometimes a patient may develop weakness of a limb which may mimic a stroke, however it is a transient phenomenon and resolves spontaneously.
Drug intoxication: Intoxication with certain sedatives or alcohol can result in difficulty in speaking, walking, imbalance of gait or unconsciousness, which may appear like a stroke.
Therefore, history of drug intake should always be considered.
WHY SHOULD YOU ACT FAST?
‘Time is brain’
2 million neuron cells in the brain die every minute that a stroke is left untreated.9 Therefore, it is crucial to identify stroke rapidly, act fast and reach a centre with stroke care services.
First responder
Anyone who is the first to encounter a suspected stroke patient is called a first responder.
This could be:
¤ patient’s relatives
¤ a bystander
¤ community health worker
If you are not a health worker, as a first responder you should:
¤ quickly identify the symptoms of stroke
¤ follow the instructions highlighted in the yellow box below.
If a patient has stroke symptoms, do the following 1. Identify stroke onset time
: ≤4.5 hours or
: ≥4.5 hours
2. Call the ambulance and rush to nearest health facility.
3. Make the patient lie down on his/her side with the head supported.
4. Loosen any tight clothing that may cause breathing difficulties.
5. Do not give anything to the patient by mouth.
THE GOLDEN PERIOD/WINDOW PERIOD
6. We already know that as soon as a stroke is suspected we have to act FAST, because
‘time saved is brain saved’.
7. Many studies have shown that if treatment is received within 4.5 hours of stroke onset, then the outcomes are better. This is because the medicine to dissolve clots will be effective if given within 4.5 hours of a stroke onset.10
8. This is called as the GOLDEN PERIOD or the WINDOW PERIOD of time, as it is the window of time within which first treatment should be provided.
Awareness in the community about recognition of stroke signs and the importance of acting fast and referring the patient to the nearest health centre can be spread through:
¤ Television and radio advertisements
¤ Community awareness programmes and camps
¤ Community health workers during house-to-house visits.
If the first responder is the community health worker or medical personnel, in addition to the above measures, one should:
9. Put the patient on the side.
10. Loosen any tight clothing.
11. Check blood pressure and note it.
12. Check blood sugar with a glucometer, and if it is less than 60mg/dl, administer glucose 50% IV bolus.
13. While waiting for the ambulance or transport, interview patient, family members and other witnesses to determine “last known well (LKW)” time and time of symptom onset.
14. LKW is the time when patient was last seen by a witness or relative to be normal.
15. If patient was sleeping prior to event, then LKW or symptom onset is determined from when patient was last seen to be awake and normal.
16. Take history of use of any drugs or alcohol intoxication.
17. Try to collect a list of medications (especially anticoagulants) that the patient is taking.
18. Obtain history of comorbid conditions (e.g. kidney or liver disease, recent surgery, procedures or stroke).
STROKE MANAGEMENT AT PRIMARY 3
HEALTH FACILITY
While it is not necessary that a stroke patient may follow a typical care pathway from community to primary health care facilities, and then to the upward tiers of health-care facilities, keeping in mind a typical health system, stroke management is described here in a serial manner beginning from a primary health care facility.
Once a patient with suspected stroke reaches the primary health facility the aim of the management should be to:
1. stabilize the patient,
2. provide preliminary treatment, and
3. quickly identify patients who should be shifted to a higher centre.
¤ Stabilize the patient
¢ As soon as a patient with suspected stroke reaches the primary health centre, the on-call doctor/health worker should be alerted.
¢ The doctor/health worker should quickly assess the general condition of the patient, including airway, breathing and circulation (ABC).
¢ Assess consciousness level; ask the patient simple commands such as name,and ask to open the mouth or extend the protruding the tongue.
¢ Simultaneously another staff should check the blood pressure (BP), pulse, temperature and random blood glucose levels.
¢ All vitals should be monitored every 15–20 minutes.
¢ Do not give anything by mouth.
¢ Ensure preliminary management.
¢ One large-bore intravenous cannula should be placed.
¤ Management of blood sugar
¢ Hypoglycaemia can sometimes present with stroke-like symptoms, therefore blood glucose should always be checked.
¢ If blood glucose is less than or equal to 60mg/dl, then 50 ml of 50% dextrose solution should be immediately given intravenously. Recheck the RBS from the other hand a few minutes after administering glucose IV.
Figure 9: 50 ml of 50% dextrose solution
Airway breathing circulation (ABC) management
In stroke, along with limb and face weakness, patients may also have weakness of the muscles required for breathing and swallowing. They may have pooling of oral secretions in the throat and difficulty in breathing. Thus they are unable to protect their airway. Therefore, identification of airway obstruction and assessment of airway patency is extremely important for every patient with stroke.
¤ How to assess airway?
¢ Open the patient’s mouth and check for any foreign bodies; if present remove them
¢ Listen for snoring, gurgling sounds, or if absent breathing sounds; this could indicate airway obstruction
¢ If patient is talking, then airway is probably clear
¢ Observe the skin colour for any bluish discolouration that could indicate poor oxygen supply.
Figure 10: Airway assessment
¤ How to assess breathing?
¢ Observe the patient’s breathing pattern
¢ Count respiratory rate, i.e. the number of breaths taken in one minute
¢ Look for signs of breathing difficulty such as laboured breathing, sweating or use of abdominal muscles
¢ If pulse oximeter is available, check peripheral oxygen saturation. Drop in oxygen saturation implies decreased oxygen reaching the body tissues.
Figure 11: ABC management
¤ How to assess circulation?
¢ Touch the patient’s hands and assess temperature; cold, clammy hands are indicative of poor circulation.
¢ Assess the patient’s heart rate by palpating the pulse from an artery that lies near the surface of skin such as radial artery in the wrist.
¤ Management of airway
¢ If patient is in respiratory distress, or if there is pooling of secretions, then gentle oral suctioning should be done if possible.
¢ If patient is unable to maintain saturation, then oxygen at 2–5L should be given via nasal prongs or face mask.
¢ If oxygen saturation is not enough as detected by pulse oximeter, arrangements to intubate the patient should be done. However, if such facilities are
unavailable, then make the patient lie on one side and prepare for urgent transport to a higher centre with facilities.
¤ Blood pressure management
¢ Careful management of blood pressures is warranted in stroke patients. Anti- hypertensives should be given only in case of very high BP recordings, because excessive lowering of blood pressures can result in decreased perfusion of the brain which can worsen the stroke or cause another stroke.
¢ If BP ≥220 mmHg systolic, a beta blocker, e.g. Labetalol 10 mg IV bolus, can be given; check BP 10 –15 minutes after bolus. If still high, injection can be repeated.
¢ Calcium channel blockers and sublingual antihypertensives should not be given as they can lead to a sudden drop in blood pressure and worsen stroke.
¢ If patient has hypotension, IV fluids should be rushed through IV cannula. If hypotension persists despite fluids then inotropic supports such as noradrenaline or vasopressin should be started.
¤ Investigations
¢ If facility for blood testing is available then CBC and PT, APTT and INR should be done.
¢ Obtain 12-lead EKG/ECG if the facility is available.
¤ Identify patients for transfer.
¤ Interview the patient, his relatives or other witnesses to determine last known well time and time of symptom onset.
¢ If patient was sleeping prior to event, then LKW or symptom onset is determined from when patient was last seen awake and normal.
¢ If time of symptom onset is less than 4.5 hours, then steps should be taken for urgent transfer of patient to a higher centre where CT scan facility and clot bursting treatment is available.
¢ If time of symptom onset is more than or equal to 4.5 hours, even then after initial stabilization, arrangements should be made for transfer to a higher facility.
(refer to transfer protocol).
¤ History of current medications (especially anticoagulants), history of comorbid conditions (e.g. kidney or liver disease, recent surgery, procedures or stroke), history of drug overdose, intoxication should be taken as it may impact decisions on clinical care of patient.
Referral to a stroke centre
¤ It is important to make the referral to a stroke centre as soon as patients are stabilized and as soon as the above steps are taken, and to reduce the inter-facility transfer time.
¤ Arrange an ambulance transfer with lifesaving facilities such as oxygen and suction equipment.
¤ Complete the referral form and hand over to the ambulance team.
¤ Briefly orient the ambulance crew on the patient.
¤ Make a prior call to the referral centre and inform the team of the probable time of arrival to ensure that the team at the receiving centre is fully prepared.
¤ Position of the patient during the referral: if consciousness is affected and airway is compromised or patient has excessive pooling of secretions, airway should be secured by intubation. If such a facility is not available in ambulance, then an oral or nasal airway can be put and patient can be placed in lateral position. Suctioning should be done as frequently as required during transport.
Figure 12: Transfer protocol for a suspected stroke patient
Patient with symptoms of
suspected stroke Suspicion: Sudden onset neurological deficit: Weakness/numbness of the face, arm or leg, especially on one side of the body.
Blurred or deceased vision in one/both eyes or double vision Difficulty speaking or understanding
Dizziness, loss of balance or coordination, sudden headache, loss of consciousness
Risk factors: Stroke or other previous vascular illness, smoking, high BP & DM.
Look for FAS: Facial weakness, Arm weakness, and Speech problems
Transient Ischaemic Attack (TIA): The neurological symptoms and signs has resolved by the time of the visit and usually does not last for more than one hour.
STROKE: Possible TIA or stable stroke of at least 48 hours’ evolution. It includes patients who come when the symptoms have already resolved and they have lasted for <24 hours (suspicion of TIA) and patients with stroke who are stable and
come to the health centre, 48 hours after the onset of symptoms.
History: risk factors Time of onset of symptoms
Examine (FAS)
Suspicion of acute stroke
Treat as per
diagnosis Yes, maybe ≤ 4.5 hrs
Activate emergency services/
arrange ambulance for immediate transfer
Assessment by specialist in
< 1 week High risk patient (recurrent
TIA or patient on anticoagulant therapy
Transfer to hospital with stroke unit/neurology
services Actions till transfer:
Make, patient lie down on the side with their head supported
Loosen any restrictive clothing that could cause breathing difficulties.
Check respiratory function, heart rate, BP, check glucose & O2 saturation if feasible.
If sugar is ≤60 mgs give intravenous 50%
dextrose
Yes, maybe > 4.5
hrs to 3 days Yes, onset of symptoms 4 days to
7 days
Onset of symptoms
> 7 days
No Yes
4 MANAGEMENT AT AN ADVANCED STROKE FACILITY
When a patient with suspected stroke reaches a higher centre or advanced stroke facility a standardized protocol should be followed for management at each step of care beginning with the Emergency Department. It is important that written stroke protocols are made available, staff are trained, and they practise diligently to ensure quality and uniformity of care.
The Emergency Department (ED) evaluation process involves the following:
¤ Confirm diagnosis and last-known-well time and perform NIHSS within 10 minutes of arrival in the ED by a stroke physician.
¤ Secure two intravenous lines and administer 0.9% normal saline (NS) at
75–100 ml/hour (unless other contra indications exist); avoid glucose solutions if not hypoglycaemic.
¤ Put on oxygen by mask if oxygen saturation is less than 95%.
¤ Brain CT scan within 25 minutes of arrival in the ED if patient reaches within the 4.5-hour window.
¤ Conduct an electrocardiogram.
¤ Test random blood sugar by glucometer.
¤ Start laboratory tests:
¢ Serum electrolytes, glucose, creatinine, complete blood count
¢ INR and Activated PTT
¢ Pregnancy test in selected patients.
¤ Treat BP to required level (For ischaemic stroke to be brought down only if >220/120 mmHg; if thrombolysis planned then to be brought down if
>180/110 mmHg. For haemorrhagic stroke aggressive BP reduction to less than 140/90 mmHg).
¤ Discuss treatment options with family, including risks and benefits.
¤ If Foley catheter is needed, insert prior to treatment if possible.
CT scan helps identify whether the stroke is ischaemic or haemorrhagic.
PERFORMANCE MEASURES FOR STROKE SERVICES11 Once a suspected stroke patient arrives in emergency of a stroke centre:
¤ Initial evaluation by emergency physician including patient history and LKW time
<10 minutes
¤ Notify stroke team including neurological evaluation <15 minutes
¤ Initiate CT imaging <25 minutes
¤ Interpretation of CT, review patient eligibility for thrombolysis <45 minutes
¤ Give alteplase bolus followed by infusion in eligible patients <60 minutes. The earlier the treatment, the better the outcome.
¤ Rehabilitation indicators: Patient should be able to stand on his own and take a few steps with or without support.
If time from onset of stroke is 4.5 hours, MRI can be done. MRI gives a better picture of brain parenchyma and the extent of tissue damage. Also, MRI angiogram done along with it can help assess the status of intracranial blood vessels.
Figure 13: Haemorrhage & ischaemic CT images of brain
Blood is seen as white on CT images. In this image, we can see a larger area of haemorrhage involving
Ischaemic stroke appears as a dark area on CT images. In this image we see an ischaemic infarct
Once diagnosis of ischaemic stroke is made and haemorrhage is ruled out next action would be:
If time of symptom onset is less than 4.5 hours then decision for clot bursting injection, known as thrombolysis, is taken by the doctor after informed consent from relatives
If time of symptom onset is more than 4.5 hours thrombolysis is not given.
Patient is managed with antiplatelet drugs and statins
Pre-thrombolysis evaluation:
Contra indications to IV tPA12:
¤ Brain haemorrhage (intracerebral haemorrhage or subarachnoid haemorrhage)
¤ Recent head trauma
¤ Recent surgery within past 21 days
¤ Any bleeding or clotting disorder, decreased platelets
¤ Recent use of oral anticoagulants or heparin.
¤ Instance of very high blood pressure
¤ Retinal haemorrhage.
What is thrombolysis?
¤ Thrombolysis is the treatment given in ischaemic stroke in which a “clot-bursting”
medication is given to lyse or break down the clot blocking the blood supply to the region of the brain.
¤ This medication tissue plasminogen activator (tPA) is an injectable preparation and is called alteplase.
¤ tPA has a high binding affinity for the clot, and so when injected into the blood it goes and attaches specifically to the clot and breaks it down and helps restore blood flow. Simply put, it breaks the clot and makes the blood thinner to flow easily.
¤ When given within 4.5 hours of onset of stroke, it has shown benefits and patient displays less disability and early recovery.
¤ When a clot cuts off the blood supply to a region of the brain, brain cells or neurons start to die.
¤ With each passing minute without blood supply, 2 million neurons die.
¤ The core area that is affected due to decreased or absent blood supply is called the “ischaemic core”.
¤ The area surrounding this region is called the penumbra.
¤ If timely treatment is given to stroke patients, and blood supply restored, then the penumbra can be saved from complete cell death.
¤ Thrombolysis with injection alteplase saves the penumbra from ischaemia and cell death.
How to give thrombolysis?
Patients with acute ischaemic stroke who present within 4.5 hours from time of onset can be treated with injection alteplase.
CT scan of the brain to rule out haemorrhage is a must before giving alteplase.
Dosing
Alteplase total dose should be calculated at 0.9 mg/kg IV. However total dose given should not be more than 90 mg. 10% of the total dose is administered as an initial IV bolus given over 1 minute. The remainder dose is given over 60 minutes as a slow infusion and then stopped.
Dos and Don’ts for thrombolysis
¤ Check blood pressure before thrombolysis and after every 15–30 minutes, for 24 hours after thrombolysis.
¤ Alteplase can increase the risk of bleeding in the brain, and in the presence of high blood pressure this risk can further increase. This is why during and after the injection, blood pressure should be monitored frequently and, if high, should be brought down quickly.
¤ If BP ≥220/120 mmHg, then injectable anti-hypertensives should be given to bring it down. Beta blockers like labetalol are safest to give and should be preferred.
¤ Do not give anything by mouth.
¤ Do not start any medications orally for 24 hours.
¤ In case of bleeding from any site (gums, skin, urine or gastrointestinal) during thrombolysis, stop infusion immediately. Check coagulation parameters and correct if deranged.
¤ If patient complains of headache during thrombolysis or if his sensorium worsens, stop infusion immediately and urgently arrange for CT-scan imaging of the brain to look for intracerebral haemorrhage.
Time goals for thrombolysis
‘Time saved is brain saved’
Thrombolysis if given timely can limit the extent of brain tissue damaged. Therefore, it is recommended to establish certain time goals for thrombolysis.
¤ It is recommended that the time from when a stroke patient reaches the door of the hospital to the time when he receives the injection for thrombolysis should be no more than 60 minutes. This time is called the “door-to-needle time.”
¤ All management including clinical diagnosis, blood investigations, CT scan of head, obtaining consent for thrombolysis, procuring the injection till giving the injection should be ideally done within this recommended time.
Figure 14: Door-to-treatment time
Treating haemorrhagic strokes
Bleeding in the brain from a haemorrhagic stroke can cause pressure to build up and clots to form. Often surgery is needed to drain the bleed and remove any blood clots – this is known as evacuation. There are different types of surgery to do this. It may include:
¤ Removing a piece of skull (known as craniotomy). During this procedure surgeon removes a small area of the skull which helps to reduce the building pressure inside the brain, drains the bleed and removes any clots.
¤ Drilling small holes in the skull and then draining the bleed and any clots. Surgeon uses a needle or endoscope (a very small tube-like telescopic camera) to do this.
¤ Using CT (computed tomography) to find out where the bleed is, and then a special piece of equipment is used to suck up the bleed and any clots.
As with ischaemic strokes, people who have had a haemorrhagic stroke may often suffer from high blood pressure. Patients need medicine to lower their blood pressure and prevent progression of stroke as well as thwart further strokes.
If patient was taking anticoagulants before the stroke, treatment may be needed to reverse the effects of the medicine and reduce the risk of further bleeding.
“Out-of-bed mobilization for patients with any type of stroke should be initiated after 24 hours provided they are medically stable. Multiple short sessions of out-of-bed mobilization tailor made for patient needs are essential”13
When can the patient go home?
Discharge from hospital shall depend on the individual status and readiness to continue care at home. The transition from hospital to home is associated with anxiety both for the patient as well as the caregiver. Discharge planning should involve the patient, family and caregiver along with rehabilitation and nursing staff.
Discharge planning is essential in order to:
¤ maintain the level of care received at the hospital,
¤ prevent and avoid post stroke complications,
¤ continue appropriate rehabilitation measures.
Preparatory measures for transfer from hospital to home
1. Patient and care-giver education(a) Provide tailored information in relevant language/format at different stages of recovery to patient and his/her family.
(b) Actively engage with patients and family in answering their questions regarding stroke/recovery/follow-up.
(c) Identify the potential caregiver who will be taking care of the patient after discharge (refer next section for roles of a caregiver at home).
(d) Provide information on local stroke-related resources to patients and family.
(e) Provide advise on oral and bladder/bowel hygiene.
2. Prepare home of the patient:
(a) Arrange bed in a way that allows access to the patient from the affected side.
Shift to an easily accessible room, move away small furniture that could cause falls, put grab bars or handles in bathrooms if possible. Make the room clutter- free:the lesser number of obstacles in the room, the better it is for the patient.
(b) Highlight changes in terrain inside the home with bright coloured tapes (beginning of staircase, thresholds between rooms, etc.) This will help patients take note of the changing terrain and avoid falls.
(c) Take measures to modify slippery floor tiles by carpeting the floor or placing foam sheets in areas of patient’s expected movements. Make sure to arrange for a cane/walker if prescribed by the hospital before the patient arrives home.
(d) As far as possible allow for patient accommodation on the ground floor for the initial phase post-stroke.
3. Follow-up schedule:
(a) Plan a follow-up schedule for the patient in consultation with the treating doctor.
A periodic follow-up is key to recovery after stroke.
(b) To whatever extent possible remind the patients of their upcoming follow-up appointments with the doctor.
Measures after discharge
1. Care at home
¤ While returning home, few changes should be made:shift to an easily accessible room, move away small furniture that could cause falls, put grab bars or handles in bathrooms if possible.
¤ Patients with moderate to severe disability will have balancing difficulty and should take the support of a cane or a walker.
¤ Continue prescribed medications to prevent recurrent stroke; regular follow-up with neurological team should be continued.
¤ Preparing a safe place for the patient is important.
Figure 15: Patient with walker
2. Caregiver/community health worker
It is important to identify a selected caregiver. They are usually family members such as the spouse, adult son or daughter, or sometimes a professional caregiver. The caregivers need to be involved in the therapy planning, goal-setting and sessions regularly to empower them to
The caregiver should make sure that:
¤ All prescribed medicines are taken timely.
¤ Diet, exercise, rest, and other health practices are followed
¤ Rehabilitation is strictly followed 3. Rehabilitation at Home
A stroke can damage the brain. Since brain controls everything, it needs to relearn skills and abilities, or learn to adapt to new ways of doing things after stroke. This is known as stroke rehabilitation.
The community health workers/caregivers should begin basic patient mobility training involving the caregiver.
¤ Position the patient appropriately with adequate pillow support.
¤ Make sure to avoid use of overhead pulleys and movements above 90 degrees at shoulders. When the patient starts having some amount of minimal effort in moving the arms, take note of it and consult a physiotherapist for further steps to be taken.
¤ Shoulder pain and subluxation is a common occurrence after stroke due to muscle weakness or spasticity. It is characterized by the upper arm bone (humerus) dropping out of the shoulder socket. The muscles may be too weak to hold the arm bone securely into the shoulder socket or spasticity can cause subluxation by pulling the bone into an abnormal position. In this case, prevention is better than cure.
¢ slings can be prescribed for prevention and cessation of progression of subluxation post-stroke.
Figure 16: Patient with sling
¢ Home-made slings with a long piece of cloth are also advisable in case of unavailability of prescribed slings.
¢ Do not pull the patient by his affected arm, rather help him at his waist/pull up the unaffected arm, during transfers.
¢ If physiotherapist supervision is available, you can initiate electrical stimulation of specific muscles around the shoulder joint.
¤ Enabling patient to take deep breaths through the nose and exhaling by blowing action of the mouth every hour.
¤ Train caregiver on bladder/bowel hygiene: keeping the area dry, use of adult diapers or correct use of the catheter if one is placed. Maintain a fluid intake and output chart with the help of a nurse.
¤ If patient is not responding to commands from his/her affected side, if they are ignoring their affected side as if it weren’t a part of their body, report to a medical staff/PT/nurse.
4. Nutrition and feeding
¤ Stroke patients may require feeding through a nasogastric (NG) tube for prolonged periods even after discharge.
¤ Caregiver should be trained on how to feed through NG tube.
¤ Mechanical soft diet is recommended for initial oral feeding, if swallowing is satisfactory.
¤ Diet should be according to recommendations keeping in mind associated comorbidities such as hypertension, diabetes or dyslipidaemia, if present.
5. Stroke-associated complications
¤ Patients recovering from stroke frequently suffer from medical complications which can extend the length of hospital stay and hamper their recovery and rehabilitation progress.
¤ Patients with severe, disabling strokes are particularly vulnerable.
¤ Pre-existing medical conditions, advanced age and pre-stroke disability increase a patient’s risk for developing complications.
Box: Common post-stroke complications 1. Pneumonia
2. Cardiac arrhythmias 3. Myocardial infarction 4. Congestive heart failure 5. Dysphagia
6. Gastrointestinal haemorrhage 7. Deep vein thrombosis
8. Pulmonary embolism 9. Urinary tract infection 10. Bed sores
11. Depression
1. Respiratory complications
Respiratory infections are one of the most common conditions complicating a stroke. Stroke patients usually demonstrate weakness of muscles used to swallow. If oral feeding is started early without assessing swallowing capacity properly, they aspirate food particles into the lungs resulting in pneumonia.
A. Pneumonia
Pneumonia is one of the most common complications after stroke. It may occur early during hospital stay or later after discharge. It is the most common cause of fever in the early post-stroke period. It occurs mostly from early oral feeding due to aspiration followed by secondary infection.
Figure 17: Respiratory complications
Management:
¤ Patients with moderate to severe strokes who are unable to handle their own secretions should be positioned in a semi-upright posture.
¤ Frequent oral suctioning should be done.
¤ Formal swallowing assessment should be done before initiating oral feeds.
¤ If pneumonia develops, patient should be managed with broad spectrum antibiotics.
2. Cardiac complications:
A. Cardiac arrhythmias
¤ Cardiac arrhythmias including atrial fibrillation, supraventricular tachycardia, ventricular ectopic beats and ventricular tachycardia have been seen after stroke.
¤ All these arrhythmias can lead to hemodynamic instability and death.
¤ Atrial fibrillation increases the risk of recurrent brain or systemic thromboembolism.
B. Myocardial infarction
Patients with TIA and stroke have a high risk of myocardial infarction, usually in the
Figure 18: Myocardial infarction
Management:
¤ Early identification of high-risk patients should be done.
¤ Cardiac enzymes may be elevated and are a useful marker.
¤ ECG may show abnormalities like variable R-R interval, premature ventricular complexes, tachy or brady arrhythmias, QTc prolongation.
¤ In-hospital hydration status should be carefully monitored, measurements of intake and output should be accurately charted.
3. Gastrointestinal complications A. Dysphagia
¤ Many stroke patients can develop dysphagia leading to decreased oral intake, poor nutrition and dehydration
¤ It is also a major cause of stroke-associated pneumonia resulting in prolonged hospitalization.
¤ The swallowing function gradually improves by itself; however, brainstem strokes and large strokes may have prolonged disability.
Figure 19: Dysphagia
Management
¤ Formal swallow assessment should be done before oral feeding is initiated.
¤ The Massachusetts General Hospital swallow screening test (MGH-SST) is a 2-part validated screening tool which can be used for assessment.14
Flow chart: Swallow assessment
B. Gastrointestinal bleeding
¤ Few patients can develop gastrointestinal (GI) GI bleeding after stroke.
¤ Patients of Asian descent have a higher risk of developing GI haemorrhage.
¤ GI haemorrhage occurs due to development of stress ulcers and mucosal irritation.
Figure 20: Gastrointestinal bleeding
Management:
¤ Antacid medication can be given prophylactically to prevent GI haemorrhage.
¤ If GI bleed occurs, stop antiplatelet or anticoagulation medications immediately.
¤ Proton pump inhibitors should be started.
¤ Regular blood sampling should be done to monitor drop in haemoglobin.
¤ Upper GI or lower GI endoscopy should be done if facility is available.
¤ If GI haemorrhage persists or if there is drop in haemoglobin, arrangements should be made for blood transfusion.
After haemodynamic stabilization, patient should be quickly referred to a higher centre with endoscopy facilities.
4. Venous thromboembolism A. Deep vein thrombosis (DVT)
¤ In stroke patients, prolonged immobilization leads to a risk of deep vein thrombosis.
¤ It is a major concern, especially in the early post-stroke period.
Figure 21: DVT on right leg
B. Pulmonary embolism
¤ Pulmonary embolism (PE) is the most feared complication of a DVT and is a prime cause of death after stroke.
¤ Patients may have sudden-onset tachypnoea, failure to maintain ventilation, tachycardia and sweating.
Figure 22: Pulmonary embolism
Management
¤ A high index of suspicion is required to make a diagnosis.
¤ Ultrasound doppler of the lower limbs can pick up DVT.
¤ Low-dose unfractionated heparin or low molecular weight heparin (LMWH) prophylaxis should be given in all stroke patients to prevent DVT and PE.
¤ Prophylaxis dose: heparin 5000 units SC q8–12hr; LMWH 40–60 units SC daily.
The duration will vary from patient to patient depending on the severity of stroke.
5. Urinary tract infections
¤ Urinary tract infections (UTI) are commonly seen in patients with acute stroke.
¤ Use of urinary catheters is one of the most common risk factors for UTI.
Management:
¤ Urine routine analysis and urine culture can be assessed in suspected UTIs.
¤ Avoiding unnecessary catheterization and early catheter removal minimizes frequency of UTIs.
Bed sores
¤ Prolonged immobilization without changing sides can result in bed sores over dependant areas like sacral regions, buttocks, heels, etc.
Figure 23: Bed sore
Management
¤ Keep skin clean and dry, check for blisters or ulceration.
¤ Patients with urine and stool incontinence using diapers should be changed and cleaned timely, as urine and stool can result in skin breakdown.
¤ Use of air or water mattresses should be done to reduce the occurrence of pressure sores.
¤ Frequent changing of side at least once every two hours is recommended to be done for disabled stroke patients.
¤ In the event of a pressure sore, pressure must be removed from that area by changing sides or using cushions to prop up the area.
¤ Regular dressings using normal saline and antibiotics should be done.
¤ In the case of severe bedsores, surgical intervention may be required.
¤ Negative pressure or vacuum-assisted therapy can be used in moderate-to-severe grade of sores.
6. Other complications Post-stroke depression
¤ Women, younger patients, and those with greater disabilities are at a higher risk of developing post-stroke depression.
¤ Such patients are less compliant with medication, may have suicidal ideation, and are less likely to involve in rehabilitative therapies with an even higher chance of developing depression during rehabilitation.
¤ Physicians should be vigilant about screening patients with stroke who have depression.
¤ Specific treatment strategies, including counselling, cognitive behavioural therapy, and treatment with antidepressants, have been used for treating post-stroke depression. Efforts to improve mental health can be addressed during rehabilitation as well (Refer to Chapter 5, Post-discharge rehabilitation: improving emotional and mental health).
¤ Drugs like tricyclic antidepressants, selective serotonin re-uptake inhibitors,
monoamine oxidase inhibitors, and others such as flupentixol/melitracen, reboxetine and trazadone have shown benefits in mood improvement.
¤ Psychotherapy, however, was found ineffective in improving mood or overall functioning.
Post-stroke pain
¤ This is another complication seen in stroke patients. They may complain of pain and abnormal sensations in the affected limbs.
Fever
¤ It is a common occurrence in patients post-stroke and is associated with poor outcomes.
¤ Fever can be indicative of an underlying infection, systemic stress or an impaired central thermoregulation.
Sexual dysfunction
¤ Stroke can change how your body feels, works and how you feel about yourself. It can also affect your relationship with your partner.
¤ Sexual activities can be impacted by physical changes including muscle weakness, stiffness, tightness, pain and altered sensation.
Patients may also experience different emotions such as anger, irritability, anxiety and sadness.
Stroke usually does not cause sexual dysfunction. However, patients sometimes may experience problems with maintaining an erection or vaginal lubrication.
POST-DISCHARGE REHABILITATION 5
The injury to the brain caused by a stroke can lead to widespread and long-lasting problems.
Some people may recover quickly while many others who have a stroke may need long-term support to help them regain a good level of independence.
Rehabilitation is a process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimum physical, psychological and social function.
The process of rehabilitation depends on the symptoms and their severity. A team of
different specialists including physiotherapists, psychologists, occupational therapists, speech and language therapists, dietitians, and specialist nurses and doctors provide rehabilitation.
It starts in hospital and continues at home or at a local clinic in your community.
The role of a primary health worker is to function as a mediator between the patient and caregiver at home. The rehabilitation specialist (physiotherapist or an occupational therapist) can provide tailormade therapy to patients according to the need, home environment, goals to be achieved through face-to-face (wherever possible) or remotely through telephonic rehabilitation. A comprehensive rehabilitation plan should also include vocational training, improvement of the patient’s social participation and overall quality of life.
General objectives of physical rehabilitation of post-stroke cases
¤ Improve performance in activities of daily living (ADL).
¤ Increase independence in ADL.
¤ Prevention of secondary complications.
¤ Integration into productive individual, social and vocational roles.
¤ Adherence to ongoing medical treatment and follow-up.
¤ Provision of assistive devices where appropriate.
1. Out-of-bed activities with sufficient support
(a) Start with rolling to side-lying in the bed to either side. Gradually progress to make the patient come to sitting position with support.
Keep looking for signs of distress such as increased respiratory rate, sweating, etc.
If the patient presents with such signs, take him/her back to the lying down posture.
Figure 24: Assisted transfer
Figure 25: Self-transfer to a wheelchair
2. Developing family and community support competencies.
3. Initiate therapeutic interventions for improving use of affected limbs in ADLs.
(a) With supervision of a PT, encourage the patient to use the affected limb, however weak, in ADL.
The normal arm of the patient can be restricted with a mitt or be tied along the trunk for improved results. Repetition is the key to improvement. Such exercises are to be performed numerous times everyday.15
Figure 26: Task-based constraint induced movement therapy
(b) With a mirror placed between the two arms or legs, encourage the patient to observe the reflection of the normal arms/legs while they are encouraged to move both limbs in various directions and be involved in ADLs.16
Repetition is the key. Perform as many times as possible
