5 - Stroke Management Flashcards
What are some stroke mimics?
What are typical stroke syndrome symptoms that differentiate a stroke from a stroke mimic?
- Sudden onset
- Focal
- Predominantly negative
- Vascular territory hypoperfusion can explain collection of symptoms
Therefore stroke mimic if any of: gradual onset, evolution of symptoms, non-focal, positive symptoms or not related to vascular territory, stereotyping
What is stereotyping in stroke medicine?
Episodic recurrence of neurological disturbance in an identical fashion with complete resolution in between
Predictor of stroke mimic
What is the NIHSS score and how do we interpret the score?
Predictive score of outcome in stroke. Used to assess stroke severity, decide on consideration for thrombolysis and estimate prognosis
Out of 42:
- <4: good outcome
- >22: high risk of cerebral haemorrhage with thrombolysis
- 26 or more: CI for thrombolysis
What is the Rosier Scale?
Recognition of Stroke in the Emergency Room
Differentiate between stroke and stroke mimics
Score of 0 is unlikely but cannot be ruled out
What are the tools used to identify a stroke?
- FAST: in community, if positive need to go to HASU urgent
- NIHSS score
- Rosier Scale
What is the ASPECTS score?
Alberta Stroke Programme Early CT Score
10 point CT scan score for patients with MCA stroke
1 point deducted for every region involved
Helps predict outcome and helps decide whether to do thrombolysis
What is the OCSP classification?
Oxford Community Stroke Project classification
What is the Modified Rankin Scale?
Used to look at level of global disability/dependence following stroke.
Used to assess baseline function and evaluate outcomes after interventions
What are CHADVASC and HASBLED scores?
Guide to anticoagulation with AF
Stroke risk and bleeding risk
What is a ABCD2 score and how is the score interpreted?
Stroke risk assessment following TIA
Helps to guide when to see a patient following a TIA
What TIA patients are at very high risk of stroke and need to be seen within 24 hours in TIA clinic?
Everyone with TIA should be seen within 24 hours, especially:
- ABCD2 >4
- Multiple TIAs (>2 in 7 days)
- Patients in AF
- On anticoagulation
Start all patients on aspirin 300mg if not CI
Once a patient is screened in the community with FAST and they are positive, what happens next?
- If within thrombolysis time window urgent transfer to HASU
- NIHSS score
- Clinical assessment (see image)
- Urgent Non-Contrast CT +/- CT Angio
- Airway protection if reduced GCS and NBM for aspiration precaution
Why is an urgent CT head done in a suspected stroke?
Diffusion weighted MRI more sensitive for ischaemic stroke but quicker to do CT to rule out haemorrhage as this is CI for thrombolysis
What is the acute management if a patient has a CT and it is a haemorraghic stroke?
Biggest risk of death is raised ICP so:
- NBM and airway support
- Keep BP <140/90
- Correct any clotting abnormalities e.g Vit K/PCC for Warfarin
- Decompressive Hemicraniectomy
- Suboccipital Craniotomy for posterior fossa bleed
- Coil or clipping of aneurysm
Which patients with hameorraghic stroke should have a decompressive hemicraniectomy? (should be done within 48 hours of stroke)
Malignant oedema from MCA infarct
Can also do evacuation of haematoma and ventricular drains in some patients
What is the acute management if a patient has a CT and it is an ischaemic stroke (haemorraghe ruled out)?
- NBM and airway support
- Revascularisation therapy (see next card)
- Aspirin 300mg. If no intervention give straight away, if thrombolysis give 24 hours after, having CT head before to check no haemorrhage. Stay on this for 2 weeks then covert to Clopidogrel 75mg
- Monitor for complications
What are the revascularisation therapies used in ischaemic stroke and what criteria must be fulfilled for them?
Thrombolysis
- IV Alteplase (Tissue Plasminogen Activator)
- Within 4.5 hours since onset of symptoms
- No CI
Mechanical Thrombectomy
- Within 6 hours of symptoms if anterior circulation stroke
- Within 12 hours of symptoms if posterior circulation stroke
- Dependent on potential to salvage brain tissue according to CT perfusion or diffusion-weighted MRI.
What are the revascularisation therapies used in ischaemic stroke and what criteria must be fulfilled for them?
Thrombolysis
- IV Alteplase (Tissue Plasminogen Activator)
- Within 4.5 hours since onset of symptoms
- No CI
Mechanical Thrombectomy
- Within 6 hours of symptoms if anterior circulation stroke
- Within 12 hours of symptoms if posterior circulation stroke
- Pt must have good baseline and lack of significant early infarction on initial CT scan or CT perfusion
- Need CT angiography and ASPECTs score
What are some contraindications for thrombolysis?
- NIHSS <5 or 26 or more
- >4 hours since symptom onset
- Intracranial or GI bleeding
- Neurosurgery or Head trauma in past 3/12
- Active internal bleeding
- Known intracranial aneurysm or neoplasm
What are some investigations that may be done to locate the cause of a stroke?
Ischaemic stroke:
- Carotid US and CT/MR angiography to look for stenosis
- ECG and 24h tapes
- Echocardiogram for cardio-embolic source
- Vasculitis or thrombophilia screen in young patients
Haemorrhagic stroke:
- Serum toxicology screen to look for cocaine
Further investigations
- Serum glucose (all patients with stroke should be screened for diabetes with a fasting plasma glucose or OGTT)
- Serum lipids
After the acute management of stroke, what is some ongoing management that is put into place?
(NB card so memorise!!!)
- Blood pressure control
- Blood glucose control: maintain between 4-11 mmol/L
- Anti-lipid therapy: statin 48 hours after the initiation of a stroke unless already established. Avoided in cerebral haemorrhage.
- Anti-platelet/anti-coagulation: two weeks of aspirin 300 mg followed by clopidogrel 75 mg daily. Warfarin/DOAC may be appropriate (e.g. AF)
- Carotid artery assessment: carotid dopplers or CT angiography. Carotid endarterectomy if anterior stroke and significant stenosis
- Swallow and nutrition assessment: all patients. NBM if unsafe swallow, NG within 24 hrs SALT/dietician input essential.
- Rehabilitation: referral to local stroke unit
- Palliative care: early recognition and referral in those with suspected poor outcome.
After the acute management of stroke, what is some ongoing management that is put into place?
- Statin
- Antiplatelet
- BP control
- Weight loss
- Consider carotid endarctectomy
If a patient has a stroke and AF but is contraindicated to having anticoagulants, what other secondary prevention measure can be put into place?
Left atrial appendage closure
When are patients with a stroke given an NG or PEG tube?
- If made NBM due to unsafe swallow given within 24 hours
- If end of life avoid as meaningful gains, doesn’t improve QoL or extend life
If a patient has a stroke and the prognosis is poor, what is the recommended palliative options?
- Address pain
- Mouth and skin care
- Control agitation
- Communicate with family
- Oral feed with risk of aspiration, avoid enteral feeding and IV hydration
What might you see on CT with a stroke?
Ischaemic (due to fluid and electrolyte shifts as membrane transport stopped)
- Effacement
- Loss of grey/white matter differentiation
- Increased density of relevant blood vessel
Haemorraghic
- Increased attentuation
How may the location of a haemorraghic stroke help you to discover the aetiology?
Deep (e.g basal ganglia/cerebellum)
- Hypertensive
Peripheral
- Tumour
- Cerebral amyloid antipathy
- AV malformation
What is important to do before administering thrombolysis therapy?
GET CONSENT
Need to explain risks and benefits. If unable to get consent can do best interests form
How is thrombolysis given and what are some side effects of alteplase?
Calculated by patient weight. 10% is given as a bolus over 1-2 minutes with the rest given as an infusion over 1 hour. Patients monitored neurologically and haemodynamically regulary (every 15 mins during infusion) with checks of pulse, BP, GCS, pupil reaction and ask about headache
- Anaphylaxis
- Intracranial or Extracranial haemorrhage
Stop infusion and repeat scan if concern
