Saudi Stroke Standards

TIA treatment Purpose To assess and manage people experiencing a transient ischemic attack (TIA) or minor stroke rapidly, in order to minimize the chances of a full stroke occurring. Rationale There is a 20% risk of a full stroke within the first four weeks after a TIA. Stroke is a treatable and preventable when TIA is appropriately addressed and treated Investigating and treating high-risk patients with TIA within 24 hours could produce an 80 per cent reduction in the number of people who go on to have a full stroke.23 Standards Management of TIA Imaging 1. All patients with suspected stroke should have an urgent brain CT or MRI ( within 24 hours) 2. Echocardiography should be performed in patients with abnormal ECGs, history or heart disease and suspected cardioembolic source 3. Long term Holter monitoring should be performed in patients with suspected cardioembolic strokes. 4. Further, brain, cardiac or carotid imaging should be undertaken in selected patients: when initial assessment does not identify the likely source of the ischemic event Antithrombotic Therapy a. Anti-platelet therapy should be given, unless contraindicated 1. A loading dose of aspirin (160-325 mg may be given as the 1st dose), followed by 81-100mg daily. 2. Clopidogrel alone can be used in a dose of 75mg once daily 3. Dual antiplatelets (aspirin and clopidogrel) may be used in high risk TIA patients (ABCD2 score greater than 4) for 21-30 days, followed by a single antiplatelet (initial loading dose of clopidogrel of 300mg then 75 mg daily in addition to Aspirin) 23 https://www.thelancet.com/journals/lancet/issue/vol370no9596/PIIS0140-6736(07)X6044-6 b. The routine use of early anticoagulation in unselected patients following ischemic stroke/TIA is NOT recommended. c. A statin is recommended with a target LDL cholesterol of less than 1.7mmol/L and HDL cholesterol of greater than 1 mmol/L. d. Hypertension should be managed appropriately according to guidelines. e. All vascular risk factors should be addressed and appropriately treated accordingly. Chapter 5. Post stroke care Objective Patients who suffered stroke may develop a range of physical symptoms and complications as a sequel of the stroke which will impact on their function and care provision. These symptoms include muscle spasticity, joint contractures, pain, fatigue. For stroke patients and their family members to achieve a good quality of life, maximize independence, well- being and choices a holistic approach for their physical, psychological and social needs is required. Key facts 1. At present, provision of rehabilitation and long-term care is inconsistent across Saudi Arabia, with lack of consistent standards of care and lack of facilities to provide support and care to the patients and their families. 2. There is lack of support for the younger stroke patients who want to return to work. 3. A large proportion of stroke patients develop depression and long- term support needs to account for this. 4. A large proportion of stroke patients experience language difficulties. 5. Mortality rate is high in stroke patients within three months of a stroke. 6. One out of four stroke survivors may have recurrent stroke within 5 years 7. Stroke is preventable and a treatment plan that includes dietary modification, exercise, statin therapy, an antihypertensive medication and antiplatelets/anticoagulants could result in a cumulative risk reduction of another ischemic stroke by 80%. 8. Designing a stroke educational plan to improve health awareness is associated with increase health-related self-care and healthier lifestyle. 9. Effective behavioral and motivational strategies to achieve a healthy lifestyle are recommended for stroke secondary prevention. 10. Prevalence of spasticity after stroke ranging from 30-80% of stroke survivors and the incidence among paretic patients is reported to be 27% and 43% 1 month and 6 months post stroke respectively. 11. Currently there is limited expertise in assessment and management of post stroke muscle spasticity and other physical and psychosocial symptoms at a national level in Saudi Arabia. Introduction The Ministry of Health, health regulators, commissioners and providers of healthcare need to ensure delivery of appropriate level of health care and support to stroke patients and their families, to ensure that they can achieve the best possible quality of life. Integrated care is essential to provide continuity of care for patients who receive care from different organizations throughout their life due to the long-term nature of their illness. Stroke patients and their families need to receive good-quality, appropriate, tailored and flexible long-term care and rehabilitation; this will affect long-term recovery and reduce long-term disability. Symptoms related to stroke can improve over many years, so people need both a focus on rehabilitation to help them improve and recover and support to help them manage the disabling factors caused by a stroke that may continue in the long term. High quality and comprehensive non-medical services, support, and advocacy can be provided by the voluntary sector which can be extremely useful for the stroke patients and their families. This could include support for working age stroke patients to help them to get back to appropriate employment, day care services to support patients and their families or advice and support to patients to integrate back in the community. QM