Case 5 - stroke pathophysiology and clinical management Flashcards
how many stroke are there in the UK a year
100,000
how many people who are eligible for thrombolysis receive it
8 in 10 but 1 in 10 in Scotland
how many children have a stroke in the UK
400 per year
what happens within 48 hours of your stroke symptoms appearing
transferred to the acute stroke unit
what do paramedics use
the FAST test
what does the F stand for
face
what does the A stand for
arms - hold them up and keep them there
what does the S stand for
speech - slurred
what does T stand for
time to call an abylence
what is the WHO definition of a stroke
A clinical syndrome characterised by the rapid onset of focal or global cerebral deficit lasting more than 24 hours or leading to death with no other apparent cause than vascular ones
what are the main subtypes
ischaemic stroke - 85%
haemorrhage storke - 15% (intracerebral and subarachnoid)
transient ischaemmic attack - less than 24 hours lasting
what is the typical brain imaging appearances in an ischaemic stroke
wedged shaped hypo density with complete loss of grey-white matter differentiation
localised swelling with sulcal effacement
in a recognised arterial territory
what test is the only one that shows the penumbra
an angiogram
what is used in intravenous thombolysis
tissue plasminogen activator
characteristics of tPA
1mg/kg over 1 hour
only beneficial administered less than 4.5 hours after stroke
12% of stroke patients are eligible
what is a risk in tPA
patients can develop an allergic reaction called angioedma and there is a 1 in 14 chance of it happening
what is angioedma
swelling of the lips and tongue and if severe it can interact with the airway and block it
what is a mechanical thrombectomy
stent retriever
10-15% elegible
limited access
when can a mechanical thrombectomy be used
less than 6 hours from onset
what does secondary prevention include
identify the cause:
- athero-thrombo-ebolism: 50%
- cardioembolic: 20%
- small vessel disease: 25%
- miscellaneous rare causes: 5%
what treatment is given
aspirin then clopidogrel
what is an intracerebral haemorrhage different to stroke in the acute phase
because an ICH is a space occupying lesion
what is secondary brain damage driven by
thrombin
what now accounts for major of anti coagulant associated intracerebral haemorrhages
DOAC-ICH
what are the options for ‘reversal’
prothrombin complex concentrate (VKA antagonists, favour Xa agents)
idarucisumab (for dabigatran)
andexanet alfa - for factor Xa agents
table of anti coagulant reversal
what is the target for hyper acute BP management in practice after a stroke
130-14mmgHg over first 24 hours
what is the neuro surgery for infratentorial ICH
risk of brainstem compression, nervation syndromes and hyrocephalus
procedures: EVD / posterior fossa decompression / haematoma evacuation
what is the neuro surgery for a supratentorial ICH
early haematoma evacuation in the stable patient
haematoma evacuation in the deteriorating patient
EVD for hydrocephalus
what are minimally invasive surgeries for ICH
- MISTE procedure
- NICO brain path
- penumbra Artemis
what is the ABC hyper acute care bundle
A: anti coagulant reversal agent <90 minute from arrival
B: blood pressure lowering: deliver intense blood pressure lowering with needle to target time <60 minutes
C: care pathway: refer patients with good pre-morbid function and any of the following to neuro surgery:
- GCS >9
- posterior fossa ICH
- obstructed 3/4th ventricle
- haematoma volume >30mls
what is the structural aetiology of ICH
hypertensiev microangiopathy
Cerebral amyloid angiopathy
Neoplasm (primary/metastasis)
Haemorrhagic transformation of cerebral infarction
Inter cranial vascular malformation
Intracranial arterial aneurysm
Intracranial venous thrombosis
Dural arteriovenous fistula
Septic arteritis/vasculitis
what is the haemostatic/haemodynamic aetiology of ICH
Hypertension
Anticoagulation
Thrombolytic treatment
Antiplatelets
Clotting factor deficiency
Thrombocytopenia
