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
two scenarios where the “appearance” of stereotyping (symptoms coming and going) may represent true symptom evolution due to focal cerebral hypoperfusion
- Capsular warning syndrome and
- Intracranial stenosis
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.
intracranial stenosis
The appearance of stereotyping can also be seen when intracranial stenosis dynamically interacts with ANOTHER cause of generalised cerebral hypoperfusion. In such cases although the whole cerebrovasculature undergoes hypoperfusion, there is disproportionate reduction of flow in the vascular bed supplied by the stenosed artery. The hypoperfusion in this case may drop below the threshold that achieves neural activity shutdown as discussed earlier. For all intents and purposes the details of individual episodes of neurological disturbance will be typical of the stroke syndrome i.e. sudden, focal, predominantly negative etc. The main clue is that these stroke syndrome episodes are associated with clinical markers of generalised hypoperfusion. These may include palpitations, dizziness, pallor, clamminess, or occur on standing in cases of postural hypotension etc. Targeted imaging with angiography will confirm the stenosis.
stroke mimics
- focal seizures
- migraine with aura- hallmark is cortical spreading depression
- functional syndtome
- apparent neurological deficits
- transient global amnesia
- benign positional vertigo
- vestibular neuronitis
possible chameleons
- Venous infarcts – gradual onset, preponderance for seizure activity
- Small cortical strokes – peripheral nerve lesions
- Limb shaking TIA – ?seizure
- Occipital strokes – predominant presentation with confusion ?delirium (visual field examination should still reveal field loss)
- Stroke amnestic syndromes
- Stroke mimicking vestibular dysfunction
what is the cause?
Need to do a
- Comprehensive clinical appraisal
- PC
- HPC
- PMH
- Dx
- Fx
- occupation, travel, leisure activities
- Clinical examination
- Brain imaging
- Special tests
- echocardiogram to look for dilated atria- AF
- Carotid US
- 24hr tape
- ECG
- thrombophilia screen
- angiography
what is the best generaotr of candidate aetiologies
comprehensive clinical appraisal
- PC
- HPC
- PMH
- Dx
- Fx
- occupation, travel, leisure activities
From this perspective one begins to realise stroke patients essentially have DIFFERENT diseases with the unifying feature of damaging the same organ. The elderly lady with a stroke, anaemia and history of headache may well have Giant cell arteritis and aspirin and simvastatin will do little for them. The young lady with previous DVT and miscarriages may have thrombophilia, and the stroke they have just had may be due to venous sinus thrombosis. The smoker with clubbing may be cooking a lung cancer with stroke a consequence of a hypercoagulable state. The middle aged lady with a history of migraine and a family history of early cognitive dysfunction may have CADASIL etc. The elderly lady with cognitive decline and multiple “TIAs” maybe having “amyloid spells”. The otherwise health young rugby player with a stroke 2 weeks after being involved in a pitch injury may have suffered a vertebral dissection
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
Are there any complications?
- Recurrent stroke
- Complications of immobility (bed sores, VTE, constipation)
- Raised intracranial pressure (malignant oedema, hydrocephalus, heamorr. transform)
- Infections
- Mood and other cognitive issues
- Post stroke fatigue¡Post stroke pain
- Spasticity&contractures, secondary epilepsy
