2- Stroke: Assessment and management (2) Flashcards
the stroke pathway
- Pre-hospital
- Pre-alert stroke team
- HASU
- discharge home, rehab facility or care home
Hospital will pre-alert stroke team
- Stroke team meet in A&E
- Specialist stroke nurse
- Junior doc
- Registrar/consultant
- Physician associate
- Focussed history and exam
- Initial investigations
- Bloods and IV access
- ECG
- CT (priority)
- Images looked at straight away to make decision about immediate treatment e.g. thrombolysis/thrombectomy (may start giving it straight away)
- Then more straight to Stroke unit
what are HASU (hyperacute stroke units)?
- Early treatment
- thrombosis
- thrombectomy
- haemorrhage management
- Dysphagia screening (nursing staff)
- Monitoring of neurological status and GCS Cardiac monitoring
- Early assessment by OT/Physio
- Early mobilisation and discharge planning
- SLT for detailed swallowing assessment and where communication is impaired
- Continence assessment
- Nurses: insert NG tubes and monitor
- Dietitian: monitor intake, prescribe NG regimes
- Emotional and psychological support and education (Stroke Association/ Neuro-psychology)
Stay on HASU for 24-48hrs (until medically stable) then…
- Discharge home
- Discharge home with intensive therapy at home
- Further in patient stay on stroke ward
- Transfer to rehab unit
Why do Stroke Units work?
*
- Prevention of and early recognition and treatment of complications
- Early initiation of secondary prevention strategies
- MDT working
- Co-ordinated and organised in-patient care with weekly MDT meetings
- Programmes of education and training for staff, patients, carers
- Involvement of carers in rehabilitation Staff interest and expertise
role of MDT in stroke
MDT members come together to deliver person centred co-ordinated care - aims to optimise hospital treatment and discharge and prevent readmision
- doctors
- nurses
- physios
- OT
- SALT
- healthcare assistants
- discharge nurse
- social workers
- geriatricians
steps in stroke workup
- Is it a stroke?
- What is the cause?
- Are there any complications? Are any likely?
- What treatment/intervention/information does this patient need (and when)?
- How well is this patient likely to do?
- When can they safely leave our care?
Is it a stroke: features of stroke
- Sudden onset
- Focal
- Predominantly negative
- Vascular territory hypoperfusion can explain collection of symptoms
why are strokes focal
In a stroke, hypoperfusion occurs only in a branch of the cerebrovasculature hence ONLY the NVUs in this vascular territory are affected. For this reason stroke symptoms are FOCAL.
why are symptoms negative
The dysfunction of the NVU in stroke is mediated by cessation of APs, hence typical stroke symptoms should reflect LOSS of function. Such symptoms are labelled NEGATIVE neurological symptoms.
why should symptoms be explained by which vascular territory is hypoperfused
Lastly when considered as a collection, stroke symptoms should be attributable to (or in other words fit the somatic representation of) a vascular territory. This is distinctly different to saying they are focal as we shall see.
how to fit symptoms into vascular territories
- Knowledge of vascular territories and relevant functional neuroanatomy helps
- Oxford Community Stroke Project classification - OCSP (TACS, PACS, LACS, POCS)
how to fit symptoms into vascular territories
- Knowledge of vascular territories and relevant functional neuroanatomy helps
- Oxford Community Stroke Project classification - OCSP (TACS, PACS, LACS, POCS)
good examples of symptoms which fit the stroke syndrome
Peripheral motor or sensory dysfunction (say in a dermatomal distribution) is a good example of symptoms that can have sudden evolution, be focal, predominantly negative but be near impossible to fit into a cerebral vascular territory.
Oxford/bamford Community Stroke Project Classification
is it a stroke: what are not typical stroke syndrome features
- Symptoms do not typically migrate
- motor/sensory deficit will not migrate like they do in migraine e.g. moving up the arm
- Episodes do not typically stereotype
- recurrence of symptoms in an identical fashion
capsular warning syndrome
recurrent stereotyped lacunar transient ischemic attacks (TIAs). This syndrome is associated with a high risk of developing a completed stroke. The presumed mechanism for this syndrome is angiopathy of a lenticulostriate artery
In capsular warning syndrome typically there is fluctuation of symptoms rather than complete resolution in between episodes. Because the relevant blood vessels are to the deep regions of the brain containing mostly white matter, most capsular warning syndrome events are LACS type.
which classification can be used to determine stroke aetiology
The TOAST classification denotes five sub types of ischaemic stroke.
- large-artery atherosclerosis (embolus / thrombosis)*
- cardioembolism (high-risk / medium-risk)*
- small-vessel occlusion (lacune)*
- stroke of other determined aetiology *
- stroke of undetermined aetiology
It is thought to carry good inter observer agreement and predict prognosis, outcome, and management
NIHSS
The NIHSS allows a digested examination of the stroke patient, gives clues about aetiology, prognosis, guides therapy choices and maps both recovery and/or deterioration.
The NIHSS has been found to be an excellent predictor of patient outcomes. A baseline NIHSS score greater than 16 indicates a strong probability of patient death, while a baseline NIHSS score less than 6 indicates a strong probability of a good recovery
Rules:
- Score what you see, not what you think.
- Score the first response, not the best response (except Item 9 - Best Language).
- Don’t coach.
Can either of these ICH (intracerebral haemorrhage) be managed surgically?
While the ICH on the left is superficial and accessible to surgical evacuation or aspiration, the patient (let’s say they have a GCS of 4 and were previously frail) will likely be too unstable to survive anaesthesia or improve neurologically after surgery because raised ICP has already caused irreversible harm.
The bleed on the right will be too deep for surgical evacuation. The only complication in this case that can be addressed surgically is insertion of a ventricular drain in the event of hydrocephalus.
what about these ICH?
The bleed on the left is again ideal for evacuation and chances patient will be stable enough for surgery, which will be indicated by deterioration of neurological observations.
The bleed on the right allow a degree of anticipation (hydrocephalus due to compression of the 4th ventricle) and should again pre-empt insertion of a ventricular drain if hydrocephalus develops.
