ACT Neuro Flashcards
Describe a stroke and its common aetiology
A sudden onset loss of neurological function that lasts >24hrs due to hypoperfusion of the brain.
Ischaemic: AF, Carotid stenosis, Endocarditis, Shock
Hemorrhagic: Hypertension, Trauma, Aneurysm, Anticoagulation
What are the criteria for a Total Anterior Circulation Stroke
TACS = All 3 of:
Motor/sensory deficit in 2 or more of legs, arms and face
Homonymous Hemianopia
Higher cortical dysfunction eg. Dsyphasia, low GCS
What are the criteria for a Partial Anterior Circulation Stroke
PACS = 2 of the following:
Motor/sensory deficit in 2 or more of legs, arms and face
Homonymous Hemianopia
Higher cortical dysfunction eg. Dsyphasia, low GCS
What are the criteria for a Lacunar Circulation Stroke
LACS = one of the following Pure sensory stroke Pure motor stroke Senori-motor stroke Ataxic hemiparesis
What are the criteria for a Posterior Circulation Stroke
POCS = one of the following
Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
Isolated homonymous hemianopia
Describe Wernicke’s dysphasia
A receptive dysphagia: can speak but makes no sense
Describe Broca’s dysphasia
An expressive dysphagia: Cannot form words with mouth
How are strokes classified during examination
Oxford classification: Total Anterior Circulation Stroke - TACS Partial Anterior Circulation Stroke - PACS Lacunar Stroke - LACS Posterior Circulation Stoke - POCS
Assessment and Investigation of suspected Stroke
A to E
ROSIER score - 0 or less means stroke unlikely
Order CT head ASAP
Bedside: ECG - ?AF Bloods: Glucose! - essential for good outcomes FBC - ?infection, U&Es - ?dehydration LFTs - ?encephalopathy, Clotting - ?Haemorrhage Troponin - ?MI Lipids - 2" Prevention
What criteria are included in the ROSIER score
Loss of consciousness or syncope = -1
Seizure activity = - 1
Asymmetrical Facial weakness = +1 Asymmetrical Arm weakness = +1 Asymmetrical Leg weakness = +1 Speech disturbance = +1 Visual field defect = +1
Management of ischaemic stroke;
haemorraghic ruled out on CT
Thrombolysis with Alteplase / mechanical thrombectomy
- within 4.5hrs of onset of symptoms and no CI
- repeat CT at 24hrs for haemorrhagic transformation
- then Aspirin 300mg PO or PR for 2 weeks +/- PPI
No Thrombolysis = Give Aspirin 300mg stat
Admit to stroke ward
Assess swallow - ? NBM, refer SALT
IV fluids if NBM
Treat Fever - salvaging the ischaemic penumbra
Monitor Glucose - sliding scale, tight control 4-11mmol
Monitor BP - do not treat without senior input
No LMWH - incase of haemorrhage transformation
Modify risk factors eg. Statin after 48hrs
What are the contraindications for thrombolyisis of ischaemic stroke
Absolute:
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
Relative:
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in preceding 2 weeks
Management of haemorrhagic stroke, confirmed on CT
Refer to Neurosurgeons
If anticoagulated then reverse
- prothrombin complex concentrate and IV vitamin K
Assess swallow - ? NBM, refer SALT
IV fluids if NBM
Monitor BP - do not treat without senior input
Monitor Glucose - sliding scale, tight control 4-11mmol
Admit to stroke ward
Modify risk factors
Complications of stroke
Aspiration pneumonia, Further episodes, Dependancy, Pressure sores, Contractures, Constipation, Depression
Secondary prevention of ischaemic stroke
After 2 weeks of Aspirin 300mg switch to:
1st: Clopidogrel 75mg
2nd: Aspirin 7mg + MR dipyridamole 200mg BD
3rd: MR dipyridamole 200mg BD
If AF consider Anticoagulation after 2 weeks of Aspirin