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S4 Stroke > Assessment & Management Of Acute Stroke > Flashcards

Assessment & Management Of Acute Stroke Flashcards

1
Q

How common are strokes?

A

1/4 ppl have a stroke

Third cause of death developed world

Commonest cause long term disability

25% under 65yrs
3% under 40yrs

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2
Q

What does FAST positive mean?

A

Face - face fallen on one side/ can’t smile

Arms - can’t raise both arms and keep up

Speech - slurred

Time - call 999 if one sign present

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3
Q

Steps in management of stroke

A

Ring 999

Paramedic ring hospital

Hospital ring stroke team - meet A&E - history (NIHSS) , cannula, bloods, ECG, immediate CT SCAN - decide on treatment (thromoblysis/ thrombectomy/ BP lowering/ surgery)

-> hyperacute stroke unit 24-48hrs, swallowing checked, observations 15mins, junior DR/ nurses/ consultant/ physiotherapy/ occupation therapy/ S&LT, nasogastric tube? ->

Home/ rehabilitation unit/ acute stroke ward

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4
Q

Questions to ask during initial assessment of a stroke

A

Vascular problem?

TIA (resolves <24hrs - transient occlusion intracebral vessel) or stroke

Intracebral haemorrhage or infarct (85% - occlusion intracerebral vessel)

Which part of brain

Which blood vessel

Aetiology

Oxford class

Severity

Can we give give clot busting treatment??

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5
Q

Define a stroke

A

Clinical syndrome

Rapidly developing clinical signs

Acute Focal/ global disturbance of cerebral function

> 24hrs (or leading death)

No apparent cause other than vascular

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6
Q

What is the NIHSS?

A

National institutes of health stroke scale

Quantifies the impairment caused by a stroke, good for measuring response to treatment

11 items
Score 0-42

1-4 minor stroke
5-15 moderate
16-20 moderate to severe
21-42 severe

Problems: underestimates servitude POCS, misses CN/ cerebellar signs

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7
Q

What are the different OCSPs, aetiology, how common and what is the mortality of each?

A

TACS (total anterior circulation stroke 20%) - 60% 1yr - proximal occlusion ICA/ MCA, large volume infarct superficial + deep

PACS (partial anterior circulation stroke 35%) - occlusion MCA branch, restricted infarct - mortality 16% 1 yr

LACS (lacunar stroke 20%) - single perforating artery basal ganglia/ pons - 11% 1yr

POCS (posterior circulation stroke 25%) - posterior vessel occlusion, PCA or branches basilar/ vertebral - 19% 1yr

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8
Q

What does the immediate CT scan show?

A

Normally normal in ischaemic strokes

Can see blood in haemorrhage

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9
Q

How can we reperfuse the brain?

A

Opening up blocked vessel in ischaemic stroke

Thrombolysis - clot busting (20% patients eligible)

Thrombectomy -mechanically removing clot (puncture femoral artery groin- pull out clot) number needed to treat 2.6, occlusion of large BVs e.g. ICA, MCA, basilar

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10
Q

When to give IV thrombolysis

A

Clinical diagnosis of acute ischaemic stroke causing 1+: NIH score _>4, aphasia, binocular visual field deficit, swallowing deficit

imaging appearance consistent with ischaemic stroke

Symptoms onset within 4.5hrs prior to initiation of treatment

No contraindications

1/3 improve
1/10 full recovery
1/14 IC haemorrhage
Quicker given less neurones die

E.g. tissue plasminogen activator - alteplase , eminase, retavase, streptase

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11
Q

What can be given as early stroke secondary prevention?

A

Aspirin/ clopidogrel
Statin first 2days
Control BP

Anticoagulation in AF - DOACs (direct oral anticoagulants)

Carotid surgery if needed

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12
Q

How to treat ICH strokes?

A

Reversal of coagulopathy
(Bleeding disorder)

BP lowering (IV labetolol, GTN)

Surgery to evacuate haematomma if: haemorrhage with hydrocephalus, lobar haemorrhage with Glasgow coma score 9-12, cerebellar haemorrhage

Management stroke unit
Specialist rehabilitation

Bloods - platelet count and clotting

Prevent high BP, hyperglycaemia, Hypoxia - exacerbate haematoma expansion

Intermittent pneumatic compression stockings - prevent venous thromboembolism

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13
Q

Causes of ischaemic stroke

A

Cardioembolism 30%

AF

MI

Prosthetic heart valves

Cardiac surgery

Cardio version

Infectious endocarditis

Atherothrombosis large vessels 15% , in issue intracerebral, embolism from atherosclerotic plaques extract real vessels (carotid, aortic arch, vertebral)

Lacunar 20%

Vasculitis
Thrombophilia
Carotid artery dissection

ICH 15% - hypertension, cerebral amyloid angiopathy, arteriole OJ’s malformation rupture, secondary ICH e.g. from tumours

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14
Q

What imaging modalities are useful in TIA, what would be expected to find?

A

MRI + diffusion weighted imaging to exclude other diagnoses

With acute ischaemia: bright white lesions with black holes on apparent diffusion coefficient map

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15
Q

What investigations should be performed with confirmed TiA?

A

ECG (AF!, IHD, LVH)

Bloods (glucose + lipid profiles)

Carotid USS (atherosclerotic plaque)

BP

Brain imaging (exclude other diagnosis and locate e.g. CT/ CT angiogram/ MRI)

Occlusion in situ = AF
Occlusion embolus = atherosclerotic disease (risk factors)

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16
Q

What percent of TiA patients go on to have a stroke?

A

20% within 90days

1/2 within 48hrs

17
Q

Most common complications of a stroke

A

Pneumonia

DVT

Poor nutrition

Dehydration

Depression

Venous thromboembolism

Incontinence

Pressure sores

Seizures

Spasticity

18
Q

Which types of strokes cause headaches and why?

A

ICH - blood irritant brain/ meninges + oedema around haematomma -> raised ICP (vomiting, v high BP)

POCS (ICH/ ischaemia) - acute inflammation & swelling posterior fossa -> block 4th ventricle -> obstructive hydrocephalus

19
Q

Treatment for TIAs

A

Antiplatelets

Anticoagulants if AF

Carotid endarterectomy if >50% stenosis

BP control

Statins

Smoking cessation

20
Q

When to give clot busting treatment

A

Clinical diagnosis of acute ischaemic stroke causing 1 or more:

  • NIH score _>4
  • aphasia
  • binocular visual field deficit
  • swallowing deficit
  • unable walk or self care independently
  • imaging appearances consistent IS (no bleed)

+ Symptom onset within 4.5hrs
+ No contraindications

21
Q

Causes of haemorrhagic strokes

A

V high BP

Atherosclerotic damage to small BVs (esp MCA branches) -> aneurysm

Cerebral amyloid angiopathy

Arteriovenous malformations

Anticoagulants

Secondary ICH (bleeding from tumours)

22
Q

What is dysphasia/ aphasia?

A

Language disorder
Expressive/ receptive/ mixed
Dysphasia - complete lack of bailout to understand speech
Aphasia - partial

Difficulty with:
Speaking
Understanding
Writing
Reading
Numbers
Gestures
23
Q

What is dysarthria?

A

Speech disorder
Can understand but can’t produce

Weakness/ abnormal muscle tone of muscles involved articulation such as lips/ tongue

Poor articulation / slurred
Poor respiration
Poor phonation
Poor resonance
Poor prosody

Slow, effortful, quiet, hoarse, prosodically abnormal

May see face paralysis and drooling

24
Q

Regions of the brain associated with dysphagia

A

Primary motor cortex
Brainstem

Thalamus
Cerebellum
Basal ganglia
pyramidal tracts
FrontL operculum
Insula

S4 Stroke (1 decks)

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