Med C CBLs - Stroke Flashcards
Important questions to ask patient presenting with suspected stroke
- Nature of onset (acute, chronic, fluctuating)
- Timing of onset (w/i time for thrombolysis)
- Past medical history for risk factors
- Medication use
- Allergies
- Alcohol
- Right vs Left hand dominance for clues on dominant cerebral hemisphere
Important investigations in a patient with suspected stroke (6)
Sudden onset focal neurology –> stroke highly likely
- Blood glucose –> rule out hypoglycaemia
- FBC –> anaemia of chronic disease
- Coagulation profile –> if considering thrombolysis
- ECG ? –> Atrial fibrillation
- Cholesterol –> for secondary prevention
- CT brain –> rule out intracerebral bleed in context of potential thrombolysis
Testing power in neurological exam
MRC scale
5 = Normal power
4 = Active movement against gravity with resistance
3 = Active movement against gravity without resistance
2 = Active movement with gravity eliminated
1 = flicker of movement
0 = no movement
What is a commonly used measure of disability / dependence in people who have suffered a stroke or other causes of neurological disability?
MODIFIED RANKIN SCALE
0- no symptoms
1- can carry out DALYs despite some symptoms
2- can look after own affairs w/o assistance, unable to carry out all previous tasks
3- requires some help, can walk unassisted
4 - unable to attend to own bodily needs without assistance, unable to walk unassisted
5- severe disability, constant nursing care and attention, bedridden, incontinent
6-dead
Classification used for stroke
Bamford stroke classification
Total anterior circulation stroke
- Hemiparesis +/- hemisensory loss
AND
- Homonymous Hemianopia
AND
- Cortical dysfunction
- dysphasia
- perceptual problems
Partial anterior circulation stroke
**2/3 **
- Homonymous hemianopia
- Hemiparesis +/- hemisensory loss
- cortical dysfunction (dysphasia / perceptual problem)
OR
CORTICAL DYSFUNCTION ALONE
Lacunar stroke
Either:
*hemiparesis
*hemi sensory loss
*hemi sensorimotor loss
*ataxic hemiparesis
NO CORTICAL DYSFUNCTION OR HEMIANOPIA
Posterior circulation stroke
- brainstem nuclei or cerebellar signs and symptoms
- occipital signs
- diplopia
- vertigo
- ataxia
- bilateral limb problems
- hemianopia
- cortical blindness
Stroke assessment score used by non specialist trained clinicians
ROSIER score
- first check blood glucose treat if low
- Total score > 0 (1-6) = acute stroke likely
- Total score 0, -1, -1 = stroke unlikely
Name given to area of brain tissue where there is some salvageable tissue
Ischaemic Penumbra
- most patients no longer have ischaemic penumbra after 4.5 hrs
- hence timing is important for thrombolysis!
When is thrombolysis indicated in stroke patients?
Within 4.5 hours.
BP less than 185/110 mmHg
- CONTRAINDICATED IF BP is higher
Patient with suspected thromboembolic stroke, presents within 4 hours however has a BP of 190/100.
Management ?
Thrombolysis contraindicated
- give IV labetalol in boluses to reduce BP to safe range
Immediate transfer to stroke unit for monitoring
Supportive treatment including MDT review
Rehabilitation support with MDT.
What is given in thrombolysis?
IV Alteplase
- Bolus - 10% of total dose (0.9mg/kg)
- infusion over 1 hour (remainder of drug)
Repeat CT brain at 24 hours
- to exclude haemorrhage before commencing antiplatelet
—–> 300mg Aspirin OD
Other contraindications for thrombolysis
- Intra-cranial haemorrhage
- Neurosurgery/ head trauma/ stroke within 3 months
- Uncontrolled hypertension SBP > 185 DBP > 110 can correct and treat
- Active internal bleeding
- Known intra-cerebral AVM/ Cancer
- Endocarditis
- Anti-coagulant use/ impaired coagulation
- Plts < 100
- Significant hypoglycaemia as may be responsible for neurological findings
