Acute Stroke Assessment Flashcards
Key questions to ask
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
Stroke vs TIA
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
Epidemiology
4th biggest killer in UK
Leading cause of disability => 2/3d leave hospital with disability
-greatest risk of recurrence in 1st month
KEY SYMPTOMS OF A STROKE
Focal sudden loss of function maximal at onset
Mimics
Seizure => Todd's paresis Syncope - can present with facial drooping Sepsis - neurological impacts Functional Migraine - acute focal neurology
Chameleons
Vertigo Monoplegia Delirium - stroke can precipitate delirium Falls Vomiting
Watch out in elderly, alcohlics, IVDU, existing physical disabilities
Artery involvement and brain regions
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
How to assess severity of a stroke
NIHSS - marker of prognosis based on findings from neuro exam (0-42)
5+ - more likely to involve large vessels in brain
Is this a bleed or infarct
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
Consequences of
- ischemic stroke
- intracerebral bleed
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
Management of ischemic stroke
IV thrombolysis
Mechanical thrombectomy
Surgical decompression - hemicraniectomy
BP management
Management of ICH
BP management
Surgical decompression - hemicraniectomy
Thrombostatic agents - to reverse AC/AP
Homeostasis - lower temp, O2
Management of TIA
TIA clinic DAP Carotid endarterectomy/stent Secondary prevention -cholesterol -DM -HTN
Management of all strokes
Stroke unit admission
BP homeostasis
DVT, PE prophylaxis
Monitor for UTI
What is done in a stroke unit
MDT specialised to manage stroke
Frequent monitoring
Thrombolysis
Thrombectomy and timeframes
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
TIA clinic interventions
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
Common causes of bleeds
Superficial perforating arteries
Microscopic deep perforating arteries
Microscopic structural abnormalities - cavernomas, AVM
Determinants of prognosis
Age Time of presentation Location Severity Cause Treatment
Care pathway in a stroke
Acute care - HASU IP stroke rehab - SU Long term rehab - RU Early supported discharge - community Follow up - OPD
