dizziness/ stroke Flashcards
what is important in history for dizziness
important to ask what the patient means by dizziness as this term is vague
Does the room spin around them – suggesting vertigo
Meniere disease
Vestibular neuronitis
Viral labyrinthitis (cannot hear)
BPPV
Do they feel unsteady – suggesting disequilibrium
Do they feel faint/ light headed – presyncope
did they loose consciences
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then I can ask for the duration ,
the frequency ,
///any exacerbating or relieving factors ///
and associated symptoms before or after or during the symptoms - such as nausea , chest pain , vomiting , headache
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any new medication
what and when medications are taken and how this relates to symptoms would also be useful.
examination of dizziness ?
focus on the eye movements and checking for nystagmus will be important.
In the peripheral examination, I would also make sure that I pay close attention to signs of cerebellar function – such as past pointing and dysdiadochokinesis.
I would also perform a ///Romberg test with this patient and observe their gait and test in-line walking.
There are specialist examination techniques such as Hallpike’s manoeuvre that could be useful for confirming a common cause of vertigo such as BPPV.
signs that would cause concern ?
headache,
double vision (diplopia),
vomiting or slurred speech
dizziness.
On examination, any peripheral neurological signs or signs of cerebellar dysfunction would also be red flags for this presentation.
cerebellar signs ?
Dysdiadochokinesia & Dysmetria
ataxia
nystagmus
problems(dysarthria)
vertigo
hypotonia
investigations I would order ?
Bedside - ECG as the patient is tachycardic and may have an underlying arrhythmia such as AF, which could be the cause of the stroke. I would also ask for a lying and standing blood pressure to make sure there is no obvious postural drop contributing to the patients symptoms.
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full blood count to specifically look at platelets and a coagulation screen to review INR and prothombin time and APTT.
Two group and save samples should be sent in case fresh frozen plasma is needed to reverse a coagulopathy in the event of an intracranial haemorrhage.
patient’s kidney function, as this will be important to know, as the patient may need contrast for their imaging.
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discuss this with my registrar. A CT head will be useful in ruling out an intracranial haemorrhage.
It may also pick up an infarct if it is established.
Once the patient is stable, an MRI could be arranged. This would be the best imaging modality for confirming an ischaemic stroke affecting the cerebellum.
blood pressure targets for stroke
if for thrombolysis or thrombectomy then below 185/ 110
otherwise blood pressure of below 220 systolic is acceptable for the first two weeks
if hemorrhagic <140/90
anticoagulation in a patient who has had an acute stroke and who is found to be in AF?
In patients with ischaemic stroke who have atrial fibrillation or other cardioembolic source anticoagulation should be delayed for 10 - 14 days. This is because the risk of early oral anticoagulation is suspected to increase the risk of potentially harmful intracranial haemorrhage, including haemorrhagic transformation of the infarct (REF). Any decision to start anticoagulation earlier than this should be led by the patient’s stroke consultant.
score to use to start anticoagulation
CHA₂DS₂-VASc score
use anticogulation if
1 or more for male
2 or more for female
c- congestive heart failure
h - hypertension
A (2) - age more than 75
D - diabetes
S (2) - previous stroke
V- vascular disease
A (2) - age more than 65
Sc - sex - female(1) male (0)
classificaton system for stroke
Bamford classification
The following criteria should be assessed:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
involves middle and anterior cerebral arteries
all 3 of the above criteria are present
Partial anterior circulation infarcts (PACI, c. 25%)
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of the above criteria are present
Lacunar infarcts (LACI, c. 25%)
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
Posterior circulation infarcts (POCI, c. 25%)
involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
Other recognised patterns of stroke:
Lateral medullary syndrome (posterior inferior cerebellar artery)
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
Weber’s syndrome
ipsilateral III palsy
contralateral weakness
stroke severity score ?
NIHSS can also be used to quantify stroke severity based on the signs elicited.
Contents
Score Stroke severity
0 No stroke symptoms
1–4 Minor stroke
5–15 Moderate stroke
16–20 Moderate to severe stroke
medication blood pressure management in stroke ?
control BP more aggressively on a case-by-case basis which may require intravenous treatment (for example with labetalol or GTN infusions).
When rapidly lowering blood pressure in people with acute intracerebral haemorrhage, aim to reach a systolic blood pressure of 140 mmHg or lower while ensuring that the magnitude drop does not exceed 60 mmHg within 1 hour of starting treatment
nicardipine, labetalol, sodium nitroprusside, nitroglycerine, enalaprilat, and hydralazine
treatment of stroke ?
TX stroke is dependent on the time of onset
mechanical thrombectomy, which is indicated in patients with stroke due to large artery occlusion. This can be effective when undertaken in the first 24 hours after presentation, but can only be carried out in some centres.
thrombolysis if in thrombolysis period
High dose antiplatelet therapy (300mg aspirin once a day for 2 weeks unless there is evidence of haemorrhage, followed by clopidogrel 75mg), high dose statins (atorvastatin 80mg) and blood pressure control (to achieve a systolic blood pressure of 130 mmHg or less)
The relatives of the patient admitted with the posterior circulation stroke have arrived. When you see them, they become extremely upset when you tell them their mother has had a stroke; they want to make a complaint because this wasn’t picked up on her initial visit to A+E earlier in the week. How would you manage this?
start with empathising with their situation
would again explain what steps have been taken since establishing the diagnosis of stroke with regards to the treatments given so far, as making sure the patient is safe and receiving the right treatment is the most important thing.
I would acknowledge their right to complain and explain to them the process for this in hospital.
I would also ask them if they wanted to speak to one of the senior clinicians on my team who may be able to further address their concerns
