5.5 Stroke I Flashcards
What happens in a stroke?
Blood supply to the brain (or retina) is interrupted.
Stroke V TIA
Stroke – persistence symptoms
o >24 hours
TIA (transient ischemic attack/amaurosis fugax) – transient symptoms.
o A few minutes to up to 24 hours
o A mini stroke which is a warning sign of a full stroke – which requires urgent assessment
What does the acronym B.E.F.A.S.T. mean?
- Both
- Eyes
- Face
- Arms
- Speech
- Time
What does the acronym Very.F.A.S.T. mean?
- Vision
- Face
- Arm
- Speech
- Time
What are the two types of strokes?
Ischemic (clot) (85%)
o Blood supply to the brain abruptly distributed due to a blood clot.
o Subclassified: Bamford Oxford Classification – TACS, PACS, LACS, POCS
Haemorrhagic (bleed) (15%)
o A weakened blood vessel bursts with bleeding within the brain parenchyma, ventricular system, or subarachnoid space
o Further divided into intracerebral (ICH) and subarachnoid (SAH)
What is TACS?
Total Anterior Circulation Stroke (anterior cerebral and middle cerebral arteries)
What does TACS effect?
- Unilateral weakness +/- sensory deficit face and/or arm and/or leg
- Homonymous hemianopia
- Higher cerebral dysfunction – dysphasia, visuospatial dysfunction (e.g neglect, agnosia)
What is PACS?
Partial Anterior Circulation Stroke (anterior cerebral and middle cerebral arteries)
What does PACS effect?
2/3 of TACS
* Unilateral weakness +/- sensory deficit face and/or arm and/or leg
* Homonymous hemianopia
* Higher cerebral dysfunction – dysphasia, visuospatial dysfunction (e.g neglect, agnosia)
What is LACS?
Lacunar Stroke (deep perforating arteries)
What does LACS effect?
- Pure motor hemiparesis
- Pure sensory
- Ataxic hemiparesis
- Dysarthria-clumsy hand syndrome
- Sensorimotor
What is POCS?
Posterior Circulation Stroke (Vertebro-basilar arteries)
What does POCS effect?
- Brainstem or cerebellar syndrome
- Loss of consciousness
- Isolated homonymous hemianopia
- Diplopia/VF defects
- Dizziness/dysarthria & dysphagia/ataxia
- Brain stem syndromes
o Wallenberg/Lateral medullary syndrome (posterior inferior cerebellar A)
o Nystagmus, vertigo, ipsilateral Horners, ipsilateral facial sensory loss, contralateral pain & temp loss
o Locked-in syndrome/basilar artery occlusion – affects the pons with paralysis of all voluntary muscles except eye movement muscles.
What causes thrombus?
Local blockage due to atherosclerosis precipitated by vascular risk factors like hypertension and smoking or small vessel disease like sickle cell and vasculitis etc.
What causes embolus?
Propagation of a blood clot leading to obstruction typically due to atrial fibrillation or carotid artery disease
What causes dissection? (RARE)
Tearing of the inner layer of an artery typically the internal carotid which can occur spontaneously or related to trauma.
What can cause haemorrhagic stoke?
- Commonest cause – hypertension
- Other causes: vascular malformations, brain tumours, vasculitis, or bleeding disorders
- Trauma is also a major cause.
List risk factors of stroke
- Hypertension
- Diabetes
- Age
- High cholesterol
- Smoking
- Obesity
- Atrial fibrillation
- Carotid artery disease
- Sickle cell disease
- Thrombophilic disorders e.g. antiphospholipid syndrome
- Cocaine use, trauma, infections, vasculitis, genetics, vascular malformations
- Migraine
List signs and symptoms of stroke
- Begin suddenly, vary from person to person, depend on the part of the brain affected and the extent of the damage involved.
o Sudden blurring or loss of vision
o Diplopia
o Confusion
o Dizziness
o Loss of consciousness
o Balance or co-ordination difficulties
o Dysphagia
What are the assessments that need to be performed on stroke patients?
o Cranial nerves assessment – look for facial asymmetry
o Vision and VF
o Pupils
o Eye movements
o Motor assessment (arm drift) – sensory deficits, cerebellar testing, gait etc.
What are some common presentations of stroke patients?
o Headache
o Altered mental status
o Nausea and vomiting
o Seizures
o Focal neurological deficits
o Visual symptoms/loss of vision/VF deficit
What are some physical effects of stroke?
o Pain
o Muscle weakness
o Stiffness/changes in sensation
Touch
Temperature
What elements of communication are effected by stroke?
o Reading
o Speaking
o Writing
o Understanding
List some life effects of stroke
- Emotional
- Memory and thinking
- Hallucinations and delusions
- Sex and relationships
- Behavioural changes
- Memory and thinking
- Neuroplasticity
- Locked- in syndrome
- Vascular dementia
What are the stroke scales for NIHSS scoring?
0: No stroke symptoms
1-4: Minor stroke
5-15: Moderate stroke
16-20: Moderate to severe stroke
21-42: Severe stroke
What is the clinical relevance of the NIHSS scoring?
<4 - good clinical outcome
>22 - Significant brain ischemia with a high risk of a cerebral haemorrhage with thrombolysis
>26 - thrombolysis contraindicated in most cases.
What management may be considered for Haemorrhagic strokes?
o Neurosurgical intervention may be indicated depending on the extent of the bleeding and suitability for intervention, comorbidities, frailties etc
What management may be considered for ischemic strokes?
o If the CT scan does not reveal signs of intracerebral haemorrhage, then decision re thrombolysis is made based on
Timeframe usually within 4.5 hours
Severity NIHSS scale >5 and <26
Contraindications excluded, neurosurgery within 3/12, active internal bleeding
What treatment is available for stroke patients?
o Synthetic tPA tissue plasminogen activator Alteplase (“clot busting” drug)
o Mechanical thrombectomy is performed according to NICE guidelines by interventional radiologists
If thrombolysis/thrombectomy is not appropriate then start on PO aspirin 300mg OD for 2 weeks.
After 2 weeks start secondary prophylaxis PO Clopidogrel unless anticoagulation is appropriate eg for atrial fibrillation
PO aspirin is started 24-48 hours after thrombolysis/thrombectomy
How would orthoptists look at expanding a stroke patients visual field?
Peli prism
What are some lifestyle changes that need to be considered following a stroke?
- Improve eating habits – low saturated fat, avoiding trans fat, salt and added sugars
- Avoid smoking and second hand smoke
- Limit alcohol
- Regular BP checks and management if high
- Physical activity
- Compliance with medications
- Reach and maintain a healthy weight
- Regular medical check ups to manage underlying health conditions.
- Emotional support
- Decrease stress levels
- Adapting home environment
- Counselling
- Sex
- Driving
