1 - Assessment and Management of Acute Stroke Flashcards

1
Q

What is the acute stroke pathway from a patient calling 999 to treatment?

A

- Priority 1 Ambulance sent and they review

  • If they think stroke they call RAP phone
  • Front door take focused history, exam (inc NIHSS) and investigations (bloods, IV access, ECG)
  • Wheel straight to CT
  • Decide treatment immediately based on CT and history

- Hyperacute stroke unit

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2
Q

What happens after a patient has recieved their initial stroke treatment/assessments and they are on the hyperacute stroke unit?

A
  • Stay on ward for 24-48 hours or until medically stable then:
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3
Q

What are the initial questions you need to ask when managing an acute stroke?

A

Does the patient have vascular factors? (e.g HTN)

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4
Q

What is the definition of a stroke?

A

A clinical syndrome of rapidly developing clinical signs of focal disturbance of cerebral function lasting greater than 24 hours with no apparent cause other than that of vascular origin

Ischaemic 85% and Haemorraghic 10-15%

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5
Q

What is the imaging of choice for a suspected stroke and why is this carried out before treatment?

A

CT

- Rule out bleeding (white) to confirm it is ischaemic and can start reperfusion therapy without causing more damage

- Also rules out alternative diagnoses of focal neurology

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6
Q

Why is reperfusion therapy only suitable in around 20% of patients?

A
  • Patient may have bleeding tedency (anticoags, genetics, recent trauma or surgery)
  • May be over the time frame of >4.5 hours
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7
Q

What is the NIHSS score?

A

Looks at 11 different areas (e.g dysphasia, gaze palsy, hemianopias, motor and sensory weakness, level of consciousness) to quantify impairment caused by a stroke, not diagnostic

Usually taken on the door and then after treatment to see if improved

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8
Q

How are strokes classified and how does each classification vary with their mortality?

A
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9
Q

What causes a TACS stroke and how does it present?

A

Proximal occlusion of a large artery e.g MCA or ICA causing ALL three of:

  • Contralateral hemiplegia and/or sensory loss
  • Contralateral hemianopia
  • New disturbance of higher cerebral function (e.g aphasia, visuospatial problems/neglect)
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10
Q

What causes a LACS (lacunar) stroke and how does it present?

A

Occlusion of a single deep perforating artery, e.g lenticulostriate arteries. Often missed and high recurrence rate

  • Pure motor loss OR
  • Pure sensory loss OR
  • Ataxic hemiparesis
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11
Q

What causes a PACS stroke and how does it present?

A

Occlusion of a branch of the MCA and needs 2/3 of the TACS criteria OR

  • Higher cerebral dysfunction alone OR
  • Monoparesis (weakness in one limb with no sensory loss)
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12
Q

What causes a POCS stroke and how does it present?

A

Occlusion of a posterior vessel (basilar, vertebral, posterior cerebral) leading to cerebellar, brain stem, occipital signs that presents with complexity due to decussation of tracts but one of:

  • Ipsilateral CN palsy with contralateral motor and/or sensory deficit
  • Disorders of conjugate eye movement
  • Cerebellar dysfunction
  • Isolated homonymous hemianopia or cortical blindness
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13
Q

After a patient has recieved their life-saving stroke treatment, what is done for them on the HASU ward?

A

PROMPT SECONDARY PREVENTION AND

- Swallow assessment in an hour to check for high risk aspiration

  • Obs done every 15 mins
  • Patient reviewed by OT, SLT, and Physio

- Maintain homeostasis (nutrition, blood presssure, oxygenation, glycemia)

  • Treat and prevent complications (e.g secondary stroke)
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14
Q

What are the two methods of reperfusion therapy following an ischaemic stroke?

A

- Thrombolysis: alteplase (tPa) within less than 4.5 hours but can be safely administered up to 6 hours with ischaemic stroke

- Mechanical thrombectomy: can be used in conjunction with thrombolysis or when tPA is contraindicated. can be used up to 24 hours but better less than 6 hours

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15
Q

What is the most serious risk of reperfusion therapy?

A

HAEMORRAGHE (mainly intracerebral)

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16
Q

When are patients considered for mechanical thrombectomy?

A
  • NIHSS >4
  • Ischaemic stroke onset <6 hours
  • Large vessel occlusion seen on CT angiogram
17
Q

What happens with an ischaemic stroke if you do not treat it?

A

Black Infarction

18
Q

What patient’s are considered for intravenous thrombolysis?

A

Give bolus dose then infusion over the next hour

19
Q

What early secondary prevention measures are put into place after an acute ischaemic stroke?

A

- Aspirin or Clopidogrel (if in AF give anticoagulant such as deltaparin not antiplatelet)

- Statin

- Lower BP preferably <130/85

- Carotid surgery if carotid stenosis

20
Q

How do we manage a haemorraghic stroke?

A

- Identify and reverse any coagulopathy (take clotting profile)

- Control BP (systolic <150mmHg)

- Consider neurosurgery if haemorraghe with hydrocephalus, lobar haemorraghe with GCS 9-12, cerebellar haemorraghe

21
Q

What are some complications following a stroke and how do we prevent them from occuring?

A

- Pneumonia: sit up, safe swallow, early identification and treatment

- Seizures

- Pressure sores: position and turn

- Dehydration/Malnutrition: NG tube, IV fluids, dietician advice

- Conspitation/Incontinence/Retention: laxatives, hydration, enemas

- Depression

- DVT: IPCs

  • Spasticity
22
Q

What do you need to do in a stroke patient to prevent DVTs?

A

Give them intermittent pneumatic compression as elastic compression stockings do not work

23
Q

What are the most common causes of ischaemic and haemorraghic strokes?

A

Ischaemic: cardioembolism (e.g AF and prosthetic heart valves), atherosclerotic thrombus, carotid artery dissection, vasculitis, venous sinus thrombosis

Haemorraghic: hypertension, AV malformation rupture, amyloid angiopathy, secondary ICH e.g from tumours

24
Q

What are some differential diagnoses for a stroke like presentation?

A
  • Focalseizure
  • Space occupying lesion
  • Pre-syncope
  • Hypoglycaemia
  • Migraine
25
Q

Apart from doing a CT for this lady’s TIA, what other investigations can you do?

A

Likely to be TIA in left ACA as medial frontal lobe affected

  • ECG for AF
  • Carotid endarctectomy
  • Lipid profile
  • Blood pressure
26
Q

What imaging modality is useful in TIA? What might you find?

A

MRI with DWI: Excludes alternative diagnoses

  • In acute ischaemia - DWI positive lesions (bright white) with corresponding signal drop out (black holes) on the ADC map
27
Q

What % of those with a TIA go on to have a stroke?

A

Around 20% within 90 days. Most within the first 48 hours, therefore early diagnosis and treatment is crucial.

28
Q

What should you be looking for on a CT with an acute stroke patient?

A
29
Q

What is the NIHSS used for?

A
  • To assess the severity of a stroke and assess response to treatment
  • Done intially, then at 1 hour, then at 24 hours
30
Q

What are some clues in a patient history that point towards ICH over a ischaemic stroke?

A
  • High BP
  • Nausea and Vomiting
  • Headache
31
Q

What causes of stroke should be considered in younger stroke patients?

A

Same as in the older population (AF, hypertension, cholesterol etc…)

plus rarer causes:carotid/ vertebral dissection, vasculitis, thombophilia’s, genetic conditions, paradoxicalemboli from patent foramen ovale, illicit drugs

32
Q

Which type of strokes cause headaches and why?

A

ICH: Blood is irritant to brain/ meninges. Oedema formation around the haematoma causes raised intracranial pressure.

POCS (ischaemic or ICH) – Acute inflammation and swelling within posterior fossa may block 4th ventricle and cause obstructive hydrocephalus

33
Q

What vessel do most strokes originate from?

A
34
Q

What percentage of people will regain full independence after a TACS?

A
35
Q

What equipment helps to move patients from one bed to another after a stroke?

A

Hoist