Limb Weakness 2 Flashcards
Why might the weakness be greater in arm and face than the leg? Which arteries supply these?
- ACA: supplies leg and foot primary motor cortex
- MCA: supplies rest of primary motor cortex
- so MCA affected in stroke
What else does the MCA supply?
right posterior paritetal cortex, where damage can cause a contralateral hemineglect
If the signs resolve in less than 24hr what is it?
TIA not stroke
What are the first line investigations for suspected right sided MCA stroke?
- Non contrast CT head
- FBC
- Blood glucose
- Blood clotting
- ECG
Why would you do a non-contrast CT head?
- determine if stroke is ischaemic or haemorrhagic
2. Help rule out other diagnosis
Why do you do a FBC?
can show cause for arterial occlusion (e.g. polycythaemia, thrombocytosis) or heamorrhage (thrombocytopenia)
Why do you measure blood glucose?
rule out hypoglycaemia
Why do you measure blood clotting?
esp if patient on warfarin - also to exclude haemophilia or coagulopathy
Why do you do an ECG?
looking for AF as cause of emboli
Which type of stroke is more common?
ischaemic (80%)
Why is it important to know if ischaemic or haemorrhagic stroke?
ischaemic potentially treatable with thrombolysis e.g. tPA
What is an ischaemic stroke caused by?
embolism or in situ thrombosis occluding a cerebral artery
How would you manage a haemorrhagic stroke?
suppportive therapy to aid rehabilitation and RF reduction
What is the acute management of MCA ischaemic stroke outside of the 4.5hr window for thrombolysis?
- antiplatelet drugs
- stroke unit/specialist ward
- VTE prophylaxis
Which antiplatelet drug do you prescribe?
aspirin - as soon as confirmed ischaemic stroke but delayed 24hr is thrombolysis given
Why do you transfer to stroke unit/specialist ward?
looked after by MDT, SALT
Why do you need to do VTE prophylaxis?
patient mostly immobile
How can you manage VTE prophylaxis?
- LMWH can be given if haemorrhagic stroke excluded and patient low risk of ischaemic stroke becoming haemorrhagic
- can give intermittent pneumatic compression device to calves
Should you use a neuroprotective agent?
not enough evidence safe or beneficial
What are 2nd line investigations for someone with ischaemic stroke or TIA?
- carotid doppler US
2. ECHO
Why do you do a carotid doppler US?
identify or exclude carotid artery atheromas that could be source of emboli causing stroke
Why do you do an ECHO? When indicated?
Help identify cardiac source of embolil such as arterial thrombus
(e.g. indicated by AF, recent MI, abnormal infarction, abnormal ECG, heart murmur, ischaemic events affect more than one cerebral artery) or patent foramen ovale
What medical complication of stroke can be managed in acute setting?
- pressure ulcers
- aspiration pneumonia
- VTE and recurrent ischaemic stroke
How do you prevent pressure ulcers?
regularly moving patient or special inflatable mattresses
How do you prevent aspiration pneumonia?
carry out swallowing assessment and if necessary NG tube
What are the elements of the disability screen in stroke?
- GCS score
- Swallow
- Speech and language
- Visual fields
- Gait - can walk or not
After the acute phase of a stroke what is the management needed?
- risk factor reduction
- drug prophylaxis
- discharge with community care
- follow up by GP
How would you manage the RF or carotid artery disease?
e.g if has right carotid bruit, should have duplex US or carotid arteries within a week to determine if referral to vascular surgeons necerssary
What drug prophylaxis is needed lifelong?
- Daily antiplatelet prophylaxis: started before discharge e.g. clopidogrel
- Daily statin: even if cholesterol levels normal
- Daily ACE inihibitor and/or thiazide diuretic, aiming for a lower BP
