Acute Stroke Assessment

Question 1

Key questions to ask

Answer 1

Is it a CVA?

Which part of the brain is affected and the severity? => aids with management

Is it a bleed or infarct => dictates treatment

Is the patient eligible for acute treatments

What caused the stroke, can we prevent further strokes

What are the outcomes for the patient

Question 2

Stroke vs TIA

Answer 2

Stroke
Rapidly developing clinical symptoms
-focal or global loss of cerebral function
-symptoms last for 24hrs+ or lead to death
-vascular origin

TIA

• focal cerebral/monocular loss
• symptoms last for U24hrs
• result of low blood flow/thrombosis/embolism
• DOES NOT INCLUDE HEMORRHAGIC CAUSES

Question 3

Epidemiology

Answer 3

4th biggest killer in UK
Leading cause of disability => 2/3d leave hospital with disability

-greatest risk of recurrence in 1st month

Question 4

KEY SYMPTOMS OF A STROKE

Answer 4

Focal sudden loss of function maximal at onset

Question 5

Mimics

Answer 5

Seizure => Todd's paresis
Syncope - can present with facial drooping
Sepsis - neurological impacts
Functional
Migraine - acute focal neurology

Question 6

Chameleons

Answer 6

Vertigo
Monoplegia
Delirium - stroke can precipitate delirium
Falls
Vomiting

Watch out in elderly, alcohlics, IVDU, existing physical disabilities

Question 7

Artery involvement and brain regions

Answer 7

Medial hemispheres => greater leg symptoms, behaviour
-ICA, ACA

Lateral hemispheres => greater arm symptoms, speech
-MCA

Posterior cerebrum, cerebellum, brainstem => cranial nerves, dense weakness

• vertebral
• basilar
• PCA

Question 8

How to assess severity of a stroke

Answer 8

NIHSS - marker of prognosis based on findings from neuro exam (0-42)

5+ - more likely to involve large vessels in brain

Question 9

Is this a bleed or infarct

Answer 9

Head CT

• majority are ischemic
• intracerebral bleeds, ischemic events => managed under stroke specialists

Hyperacute ischemia - very few obvious brain changes

• loss of greywhite differentiation
• can see static blood if thrombus is large
• more obvious changes present after hours

Hyperacute bleed - hyperdense blood => hypodense with time

SAH, SDH, extradural => managed under trauma or neurosurgeons

Question 10

Consequences of

• ischemic stroke
• intracerebral bleed

Answer 10

Central core - immediate area surrounding area of ischemia

• can expand into penumbra and increase damage
• mass effect, edema, seizures, immobility

Bleed can expand => compression of ventricular system => ICP, mass effect, hydrocephalus

Question 11

Management of ischemic stroke

Answer 11

IV thrombolysis
Mechanical thrombectomy
Surgical decompression - hemicraniectomy
BP management

Question 12

Management of ICH

Answer 12

BP management
Surgical decompression - hemicraniectomy
Thrombostatic agents - to reverse AC/AP
Homeostasis - lower temp, O2

Question 13

Management of TIA

Answer 13

TIA clinic
DAP
Carotid endarterectomy/stent
Secondary prevention
-cholesterol
-DM
-HTN

Question 14

Management of all strokes

Answer 14

Stroke unit admission
BP homeostasis
DVT, PE prophylaxis
Monitor for UTI

Question 15

What is done in a stroke unit

Answer 15

MDT specialised to manage stroke

Frequent monitoring

Question 16

Thrombolysis

Thrombectomy and timeframes

Answer 16

With standard CT and CTangio
IV thrombolysis - U4.5hrs
-improve mortality, but morbidity can be high

Thrombectomy - 6hrs

• improves mortality
• no increased risk of bleeding
• generally only used in large vessel strokes

With CT, CTA and CT perfusion (assess core and penumbra)
IV thrombolysis - U9hrs

Thrombectomy - U24hrs

Question 17

TIA clinic interventions

Answer 17

AP treatment => clopidogrel

Reduce CV risk factors

• AF => DOAC
• high cholesterol => statins
• HTN => BPmeds
• DM => metformin
• smoking, alcohol => cut down
• carotid artery disease =? endarterectomy/stenting

Question 18

Common causes of bleeds

Answer 18

Superficial perforating arteries
Microscopic deep perforating arteries
Microscopic structural abnormalities - cavernomas, AVM

Question 19

Determinants of prognosis

Answer 19

Age
Time of presentation
Location
Severity
Cause
Treatment

Question 20

Care pathway in a stroke

Answer 20

Acute care - HASU
IP stroke rehab - SU
Long term rehab - RU
Early supported discharge - community
Follow up - OPD