Stroke — Advanced Nursing Guide | GCC Nursing Platform

BE-FAST Stroke Recognition

BBalanceSudden loss of balance or coordination

EEyesSudden vision loss or double vision

FFaceFacial droop — unilateral asymmetry

AArmArm drift/weakness on one side

SSpeechSlurred or absent speech; aphasia

TTimeCall 999/112 NOW — every minute counts

Stroke Mimics

Hypoglycaemia — always check BGL first (most common mimic)
Todd's paresis — post-ictal focal weakness after seizure
Hysterical/functional conversion — inconsistent exam findings
Complex migraine — aura with motor/sensory symptoms; headache history
Septic encephalopathy — diffuse; fever; no focal CT lesion
Brain tumour, MS relapse, subdural haematoma, hypertensive encephalopathy

⚠ BGL must be corrected before thrombolysis is considered. A BGL <3.0 or >22 mmol/L excludes thrombolysis.

Ischaemic vs Haemorrhagic

Cannot be clinically distinguished — non-contrast CT is mandatory

Feature	Ischaemic	Haemorrhagic
CT appearance	Hypodense / normal early	Hyperdense (bright)
Onset	Sudden; may wake-up stroke	Often during activity
Headache	Uncommon	Severe ("thunderclap")
BP	Variable	Often markedly elevated
Thrombolysis	Eligible if criteria met	Absolute contraindication
~Proportion	85%	15%

Stroke Time Clock

⏰

Last Known Well (LKW) — the last time the patient was confirmed symptom-free. This is the operative time for thrombolysis window, NOT time of discovery.

Document LKW immediately on arrival — ask family/bystanders
If wake-up stroke: LKW = time patient went to sleep
Target door-to-needle (DTN): <60 minutes
Target door-to-CT: <25 minutes
IV tPA window: 0–4.5 hours from LKW
EVT window: up to 24 hours with imaging selection

TIA Recognition & ABCD² Score

TIA: transient neurological deficit <24h (usually <1h) with no infarction on DWI-MRI

Criterion	Score
Age ≥60	+1
BP ≥140/90 at presentation	+1
Clinical features — unilateral weakness	+2
Clinical features — speech only	+1
Duration ≥60 min	+2
Duration 10–59 min	+1
Diabetes mellitus	+1

Score ≥4 = high risk (2-day stroke risk ~4%) → admit for urgent workup
Score ≤3 = lower risk → same-day TIA clinic within 24h

💊

Dual antiplatelet therapy (DAPT): Aspirin 300 mg + Clopidogrel 300 mg loading STAT for TIA/minor stroke (NIHSS ≤3) — continue dual therapy for 21 days, then aspirin alone.

NIHSS Scoring Overview

National Institutes of Health Stroke Scale — 15 items, max score 42. Assess on arrival, post-thrombolysis at 24h, and at discharge.

0–5
Minor stroke — may still be eligible for EVT

6–15
Moderate stroke

16–42
Severe stroke — high risk of SICH post-tPA

1a: LOC1b: LOC questions1c: LOC commands2: Gaze3: Visual fields4: Facial palsy5a/5b: Motor arm6a/6b: Motor leg7: Limb ataxia8: Sensory9: Best language10: Dysarthria11: Extinction

Stroke Unit Admission Benefits

↓ 17%
Reduction in death compared to general ward

↓ 25%
Reduction in death or dependency

MDT Care
24h neuro nursing, early rehab, protocol-driven management

⚠

Critical Rule: IV alteplase (tPA) must NEVER be given without confirmed non-contrast CT excluding haemorrhage and documented eligibility criteria assessment.

IV Alteplase (tPA) — Eligibility

Confirmed ischaemic stroke on CT — no haemorrhage
Symptom onset (LKW) ≤4.5 hours
Age ≥18 (no absolute upper age limit in most guidelines)
NIHSS ≥4 generally; may treat lower if disabling symptoms
BP <185/110 achieved before bolus
BGL 3.0–22 mmol/L
INR <1.7 if on warfarin; platelets ≥100 ×10⁹/L
Dose: 0.9 mg/kg IV (max 90 mg) — 10% as bolus over 1 min, remainder over 60 min

Absolute Contraindications Accordion

Previous intracranial haemorrhage (any time)
Active internal bleeding (excluding menses)
Recent major surgery or trauma <14 days
Recent head/spinal surgery or serious head injury <3 months
Ischaemic stroke <3 months
Intracranial neoplasm, AVM or aneurysm
CT showing haemorrhage or large established infarct (>1/3 MCA territory)
Platelet count <100 ×10⁹/L
INR >1.7 on anticoagulants
Heparin within 48h + elevated aPTT
Direct oral anticoagulants (DOAC) — last dose <48h or detectable drug levels
Aortic dissection
Infective endocarditis
BGL <3.0 or >22 mmol/L uncorrected

Nursing Monitoring During tPA Infusion

Blood Pressure Protocol

Check BP every 15 minutes for first 2 hours
Then every 30 min for 6 hours; then hourly to 24h
Target: BP <185/110 before bolus; maintain <180/105 during infusion
If BP exceeds target: labetalol 10–20 mg IV or nicardipine infusion (per protocol)

Signs to Monitor Every 15 min

Neurological change (NIHSS) Angioedema — tongue/lips Bleeding — IV sites, gums Haematuria Headache / vomiting O₂ saturation Pupil response

🛑

SICH Alert: Sudden neurological deterioration during or after tPA = symptomatic intracerebral haemorrhage until proven otherwise.
Action: STOP infusion immediately → urgent CT head → notify stroke team → coagulation screen → consider cryoprecipitate/aminocaproic acid.

Mechanical Thrombectomy (EVT)

Extended window: up to 24 hours with CT perfusion/MRI mismatch selection (DAWN/DEFUSE-3 criteria)
Large vessel occlusion (LVO): ICA, M1/M2 MCA, basilar artery
Can be combined with IV tPA (bridging therapy)
Preferred if tPA contraindicated and LVO confirmed

Groin Access Post-EVT Monitoring

Check femoral access site every 15–30 min for first 2 hours
Signs: haematoma expansion, pulsatile swelling, distal limb ischaemia
Maintain bed rest 2–4h; head of bed 30° maximum while flat
Pedal pulse check bilaterally; limb colour and warmth
Document activated clotting time (ACT) result post-procedure
Radial access increasingly used — check radial compression band

🧪 Thrombolysis Eligibility Checker

Onset-to-Door Time (minutes)

Blood Glucose (mmol/L)

Systolic BP (mmHg)

Diastolic BP (mmHg)

Platelet Count (×10⁹/L)

INR

Recent Surgery / Major Trauma (<14 days)?

On Anticoagulation (warfarin/DOAC/heparin)?

Previous Intracranial Haemorrhage?

Ischaemic Stroke in Last 3 Months?

Dysphagia Screening

Gugging Swallowing Screen (GUSS) — Preferred

Pre-test: Patient alert, able to sit upright, cough on request, clear secretions
Indirect test: Saliva swallowing — observe for drooling, voice change, coughing (max 5 points)
Direct test 1: Semi-solid (thickened pureed) — 1/3/5/10 mL trials (max 5 points each)
Direct test 2: Liquid — 3/5/10/20 mL water (max 5 points)
Direct test 3: Solid — piece of dry bread

Score 20/20 — normal swallow, full oral diet
Score 15–19 — mild dysphagia, soft diet + thick fluids, SALT referral
Score <15 — severe dysphagia, nil oral, NGT feeding, SALT urgent

⚠ Nil by mouth until formal screening completed. Nurse-led water swallow test acceptable initially — 5 mL first, then 50 mL if no coughing, wet voice or drooling.

🍴

All stroke patients: nurse-led screening before ANY oral intake including medications. Formal SALT assessment within 24h for those failing initial screen.

Aspiration Pneumonia Prevention

Head of bed 30–45° at all times (especially feeding)
Oral suctioning before feeding if secretions present
Nasogastric tube insertion if nil oral — confirm position with X-ray/pH
Check NGT residual volume every 4h; hold feed if >200 mL
Oral hygiene 4–6 hourly with chlorhexidine gel
Avoid supine position; log roll for pressure care
Document cough effectiveness — weak cough = aspiration risk marker

Blood Pressure Management

Scenario	BP Target
Ischaemic — first 24h (no thrombolysis)	Permissive up to 220/120 — do NOT lower aggressively
Pre/during thrombolysis	<185/110 before bolus; <180/105 during
Post-thrombolysis 24h	<180/105
Haemorrhagic stroke (ICH)	Systolic <140 mmHg (INTERACT2/ATACH-2 target)
Ischaemic — Day 2+ (stable)	<130/80 long-term

⚠ Aggressive BP lowering in acute ischaemic stroke reduces cerebral perfusion pressure in the ischaemic penumbra — causes extension of infarct.

Glucose, Temperature & Oxygen

BGL target4–10 mmol/L

Treat hyperglycaemia with insulin sliding scale if >10

Temperature — treat pyrexia above37.5°C

Paracetamol 1g QID + investigate source

O₂ saturation target≥94%

Do NOT give supplemental O₂ if SpO₂ normal

DVT Prevention

Stroke Type	DVT Prophylaxis
Ischaemic stroke (no HT)	LMWH from Day 2 + TEDS/IPC
Haemorrhagic stroke (ICH)	LMWH contraindicated — TEDS + IPC only; consider LMWH at 48–72h if haematoma stable
Post-thrombolysis	Wait 24h for CT confirmation no HT before starting LMWH

TEDS = thromboembolic deterrent stockings; IPC = intermittent pneumatic compression; HT = haemorrhagic transformation

Neurological Observation Frequency

Time Post-Admission	Frequency
First 4 hours	Every 30 minutes
4–24 hours	Hourly
Post-thrombolysis (24h)	Every 15 min during infusion, then hourly
24–72 hours (stable)	2–4 hourly
72h+ (stable)	Per ward protocol (4–6h)

Each Neuro Obs Must Include

GCS (E/V/M components) Pupil size & reactivity NIHSS (or abbreviated) BP & HR SpO₂ BGL if diabetic Temperature

Haemorrhagic Transformation (HT)

🚨

Sudden neurological deterioration after thrombolysis = SICH until proven otherwise.
Risk: ~5–6% with tPA; higher with NIHSS >20, large infarct, elderly.

Warning Signs

Sudden worsening of NIHSS by ≥4 points
New severe headache or vomiting
Acute hypertension spike
Declining GCS or new agitation
Pupil asymmetry (Hutchinson pupil = uncal herniation)

Immediate Actions

STOP tPA infusion immediately (if running)
Urgent CT head without contrast
Alert stroke consultant on-call
Coagulation screen — APTT, INR, fibrinogen
Consider cryoprecipitate if fibrinogen depleted
ICU/HDU transfer if GCS declining

Cerebral Oedema & Malignant MCA Infarction

Large hemispheric infarction causes oedema peaking at Day 2–5. Malignant MCA syndrome = >50% MCA territory, life-threatening brain shift.

Decompressive Hemicraniectomy Criteria

Age ≤60 years (relative benefit in older patients)
NIHSS ≥15 (dominant) or ≥10 (non-dominant)
>50% MCA territory infarction on CT/DWI
Within 48 hours of symptom onset (ideally <24h)
No severe pre-existing disability

Medical ICP Management

Head of bed 30°, neutral neck position
Osmotherapy: Mannitol 20% 0.25–0.5 g/kg IV OR hypertonic saline 3%
Avoid hypotonic fluids (worsen cerebral oedema)
Corticosteroids NOT recommended in ischaemic stroke
Target serum Na 145–155 in osmotherapy

Post-Stroke Seizures & Other Complications

Post-Stroke Seizures

Early seizures (<7 days): 2–3% — due to cortical irritation
Late seizures (>7 days): scar-related epilepsy — requires AED
Haemorrhagic stroke higher seizure risk than ischaemic
Status epilepticus = neurological emergency — lorazepam 0.1 mg/kg IV
Todd's paresis post-seizure = stroke mimic

Hydrocephalus

After cerebellar stroke: posterior fossa swelling compresses 4th ventricle → obstructive hydrocephalus — urgent suboccipital decompression or EVD
After subarachnoid haemorrhage: communicating hydrocephalus — external ventricular drain (EVD)
Monitor: expanding head circumference (paediatric), declining GCS, upward gaze palsy (Parinaud's)

Raised ICP Management Principles

Airway protection — intubate if GCS ≤8
Normocapnia (pCO₂ 35–40 mmHg); avoid hyperventilation except bridge
Avoid hypoxia, hyperthermia, hyponatraemia, pain
Minimise stimulation — cluster nursing cares
ICP monitoring via EVD if available and indicated

Item	Assessment	Score Range
1a. LOC	Alert, drowsy, stuporous, coma	0–3
1b. LOC Questions	Month + age — correct answers	0–2
1c. LOC Commands	Open/close eyes; grip/release hand	0–2
2. Best Gaze	Horizontal eye movement	0–2
3. Visual Fields	Confrontation — all 4 quadrants	0–3
4. Facial Palsy	Symmetric movement; upper/lower face	0–3
5a. Motor Arm (Left)	Arm drift — 90° (sitting) or 45° (lying) for 10s	0–4
5b. Motor Arm (Right)	As above	0–4
6a. Motor Leg (Left)	Leg at 30° for 5 seconds	0–4
6b. Motor Leg (Right)	As above	0–4
7. Limb Ataxia	Finger-nose / heel-shin test	0–2
8. Sensory	Pinprick sensation — compare sides	0–2
9. Best Language	Name objects + read sentences (aphasia screen)	0–3
10. Dysarthria	Read word list — slurring, unintelligibility	0–2
11. Extinction/Neglect	Double simultaneous stimulation	0–2

Maximum score: 42 | Score 0 = no deficit | Untestable items coded UN, not 0

MDT Roles in Stroke Rehabilitation

Discipline	Key Focus
Physiotherapy	Mobility, balance, gait re-education, spasticity
Occupational Therapy	ADL retraining, upper limb function, home assessment
SALT	Dysphagia, communication, aphasia therapy
Neuropsychology	Cognitive assessment, depression, behavioural changes
Dietitian	Nutritional assessment, NG/PEG feeding management
Social Work	Discharge planning, carer support, financial assessment
Stroke Nurse	Coordination, patient education, risk factor management

🦵

Early Mobilisation: Sit patient up within 24 hours of ischaemic stroke if haemodynamically stable. Out-of-bed activity from Day 1 improves functional outcomes (but avoid very early intensive mobilisation — AVERT trial).

Barthel ADL Index

Scored 0–100. Used at admission, weekly, and discharge. 10 domains.

Domain	Max Score
Feeding	10
Bathing	5
Grooming	5
Dressing	10
Bowel control	10
Bladder control	10
Toilet use	10
Transfers (chair to bed)	15
Mobility on level surface	15
Stairs	10

91–99 = minimal dependence | 61–90 = moderate | <60 = severe dependence

Secondary Prevention Checklist

Antiplatelet: Aspirin 75–100 mg OD (if no AF and no anticoagulation indication)
AF — Anticoagulation: DOAC preferred (apixaban/rivaroxaban/dabigatran) — start at Day 4–14 depending on infarct size; warfarin if valvular AF
Statin: High-intensity atorvastatin 40–80 mg regardless of baseline LDL — start within 24–48h
Antihypertensive: ACE inhibitor + thiazide-like diuretic first line; amlodipine in South Asian/African patients
Diabetes: Optimise HbA1c <53 mmol/mol (7%); SGLT-2 inhibitors have added cardiovascular benefit
Lifestyle: Smoking cessation, alcohol reduction, weight management, Mediterranean diet, exercise 30 min 5×/week
AF Detection: Holter monitor 24–72h; prolonged cardiac monitoring ≥72h increases AF detection; implantable loop recorder for cryptogenic stroke
Carotid Stenosis: Carotid duplex within 24h if TIA/minor stroke; CEA (carotid endarterectomy) for symptomatic stenosis ≥50%; CAS (stenting) if high surgical risk

Post-Stroke Depression

Affects 30–50% of stroke survivors
Screen with PHQ-9 at 1 month and 3 months post-stroke
PHQ-9 ≥10 = initiate SSRI (sertraline/escitalopram) + psychological support
Depression impairs rehabilitation participation and recovery

Driving Cessation

🚗

Patients must NOT drive for at minimum 1 month after stroke or TIA. Licence authority notification required (varies by GCC country). Assessment by OT driving assessor before return to driving.

Communication Aids for Aphasia

Use simple, short sentences — one instruction at a time
Allow extra time for response — do not rush or complete sentences
Yes/No questions with gesture support
Communication boards with pictures and symbols
AAC devices (apps: LetMeTalk, Proloquo2Go)
Written communication as supplement
Ensure hearing aids and glasses are available
SALT-led intensive aphasia therapy from Day 1–2

GCC-Specific Stroke Context

Younger average age — GCC stroke patients are younger than Western counterparts due to high prevalence of T2DM, dyslipidaemia, hypertension, and obesity
Metabolic risk factors — high-carbohydrate/high-fat diets, sedentary lifestyle, consanguineous marriage increasing monogenic risk
Road traffic accidents — traumatic brain injury (TBI) is a significant cause of acquired brain injury across GCC; differentiate TBI from stroke on imaging
Growing stroke unit network — UAE and Saudi Arabia have well-established stroke units in tertiary centres; access in rural/smaller emirates varies
Thrombolysis availability — IV tPA available in UAE (DHA/DOH-licensed centres), KSA tertiary hospitals, Qatar Hamad; still limited in some areas
Expat worker population — language barriers complicate stroke recognition, history-taking, and consent; use trained interpreters (not family for consent)

DHA / DOH / SCFHS Regulatory Context

DHA Stroke Pathway (Dubai) — mandatory FAST assessment and stroke code activation protocol; thrombolysis committee oversight in licensed hospitals
DOH Abu Dhabi — Integrated Stroke Network; hub-and-spoke model; telemedicine stroke consultations (telestroke) in outer islands/Al Ain
SCFHS (Saudi Commission) — neurology nursing competency framework includes stroke care, dysphagia screening certification, NIHSS training requirement for ICU/stroke nurses
MOH Kuwait/Qatar/Bahrain/Oman — individual national stroke guidelines broadly aligned with ESO/AHA guidelines with local adaptations
Stroke Helplines — "FAST" public campaigns in Arabic/Urdu/Malayalam across UAE; important for expat community awareness

Ramadan & Post-Stroke Anticoagulation

🌙

Patients with AF post-stroke may fast during Ramadan. Evidence supports continued anticoagulation during fasting.

DOACs can be taken with Iftar and Suhoor meals — twice-daily dosing often preferred
Dabigatran: take with food to reduce GI side effects — ideal for Ramadan dosing schedule
Warfarin: INR monitoring may be affected by dietary changes — increased INR fluctuation; consider switching to DOAC if appropriate
Dehydration during fasting → increased blood viscosity → increased stroke risk — counselling essential
Aspirin: can be taken with Suhoor — minimal impact from fasting
Patients should consult Islamic scholars regarding medication exemption (rukhsa) if clinically required — most scholars permit life-saving medications
Ramadan-specific medication education by ward pharmacist is best practice in GCC hospitals

Expat Worker Stroke — Language & Consent

Common languages: Arabic, Urdu, Hindi, Malayalam, Tagalog, Bengali — validated stroke assessment tools available in Arabic
Never use family members as interpreters for consent — use trained medical interpreters or professional telephone interpretation service
In-house stroke FAST posters in multilingual format required by DHA accreditation standards
When patient lacks capacity: next of kin consent in UAE; in Saudi Arabia, legal guardian (wali) for major decisions
Thrombolysis can proceed without consent if patient lacks capacity and it is in best interests — document clearly
Cultural sensitivity: gender-concordant care preferred by some patients; notify family promptly

DHA / DOH / SCFHS Exam Prep — High-Yield Topics

Thrombolysis Contraindications (Most Tested)

Previous ICH = absolute contraindication (most commonly tested)
Recent surgery <14 days = absolute
INR >1.7 = absolute contraindication to tPA
Platelet <100 ×10⁹/L = absolute
BP must be <185/110 BEFORE starting tPA
BGL <3.0 or >22 = treat first, then reassess
Window = 4.5 hours from LKW
Dose = 0.9 mg/kg, max 90 mg

Dysphagia Screening Key Facts

NIL ORAL until screening done
GUSS = Gugging Swallowing Screen (most validated)
Score <15/20 = severe dysphagia = NGT
Head-up 30° during and after feeding
Aspiration pneumonia = leading cause of death in stroke

NIHSS Key Points for Exams

Maximum score = 42; minimum = 0
NIHSS 0–5 = minor; 6–15 = moderate; 16+ = severe
Assess: LOC + gaze + vision + face + arm + leg + ataxia + sensory + language + dysarthria + neglect
Score ≥25 = higher SICH risk with tPA
Serial NIHSS every 24h minimum in acute phase

Secondary Prevention Key Facts

AF + stroke = DOAC (not aspirin alone)
Statin = start immediately regardless of LDL
Carotid stenosis ≥50% symptomatic = CEA within 2 weeks
PHQ-9 for post-stroke depression at 1 and 3 months
No driving for minimum 1 month post-stroke
ABCD² ≥4 in TIA = admit urgently
DAPT (aspirin + clopidogrel) for 21 days in TIA/minor stroke

Stroke — Advanced Nursing Guide