Red Book - acute ischaemic stroke Flashcards
Classify acute ischaemic strokes
Bamford Class
TACS - (MCA)
all three of- homonymous hemianopia
higher cerebral dysfunction (dysphasia)
Unilateral motor/sensory deficit with 2/3 or arm/leg/face
PACS (partial, MCA, ACA)
two out three TACS
LACS (lacunar, small penetrating vessels)
Ataxia hemiparesis
Dysarthria
Sensorimotor deficit not covered by TACS/PACS
POCS (brain stem, cerebellum)
isolated homonymous hemianopia/cortical blindness
Brainstem/Cerebellar syndromes
LOC
Clinical features by territory - Anterior cerebral artery
Behaviour change
Weakness of contralateral leg
Clinical feature by territory - MCA
Weakness of contralateral face and arm
Aphasia, dysarthria
Hemianopia
Sensory deficit
Clinical feature by territory - Posterior Cerebral Artery
Visual field defects
Sensoriy def
Clinical features - vertebrobasilar
Dizzy
Ataxic
Change in voice/swallow
Clinical feature - cerebral vein and sinuses
Decreased conciousness
Headache
Vomiting
NICE criteria for imaging:
1Perform brain imaging immediately with a non-enhanced CT for people with suspected acute stroke if any of the following apply (see additional information):
indications for thrombolysis or thrombectomy
on anticoagulant treatment
a known bleeding tendency
a depressed level of consciousness (Glasgow Coma Score below 13)
unexplained progressive or fluctuating symptoms
papilloedema, neck stiffness or fever
severe headache at onset of stroke symptoms.
If thrombectomy might be indicated, perform imaging with CT contrast angiography following initial non-enhanced CT. Add CT perfusion imaging (or MR equivalent) if thrombectomy might be indicated beyond 6 hours of symptom onset. [2008, amended 2019]
1.3.3Perform scanning as soon as possible and within 24 hours of symptom onset in everyone with suspected acute stroke without indications for immediate brain imaging. [2008]
Other imaging in stroke
Non-contrast CT - rules out haemorrahge, doesnt reliably demonstrate infarct
MRI
Carotid doppler
TTE
ECG
TOE (and bubble echo)
TCD
When to thrombolyse
Alteplase is recommended within its marketing authorisation for treating acute ischaemic stroke in adults if:
treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms and
intracranial haemorrhage has been excluded by appropriate imaging techniques
When to control BP in ishcaemic stroke:
Anti-hypertensive treatment in people with acute ischaemic stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues:
hypertensive encephalopathy
hypertensive nephropathy
hypertensive cardiac failure/myocardial infarction
aortic dissection
pre-eclampsia/eclampsia. [2008, amended 2019]
1Blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for intravenous thrombolysis. [2008]
Contra-indications to thrombolysis
Acute or previous intracranial haemorrhage
BP> 185
Head trauama of stroke in last 3/12
Coagulopathy/thrombocytopenia (INR>1.7)
Oral anticoagulants
Surgery in 14 days
GI/GU bleed
Hypo/hyperglycaemia
Seizure
CNS lesions
Recent MI
BM range
4-10mmol/L
When to do decompressive craniectomy
should be performed within 48 hours of symptom onset
clinical deficits that suggest infarction in the territory of the middle cerebral artery, with a score above 15 on the NIHSS
decreased level of consciousness, with a score of 1 or more on item 1a of the NIHSS
signs on CT of an infarct of at least 50% of the middle cerebral artery territory:
with infarct volume greater than 145 cm3, as shown on diffusion-weighted MRI scan. [2019]
Age<60
Evidence for decompressive craniectomy
DESTINY, DECIMAL, HAMLET
Reduced mortality 71- 21%
But with no good outcomes in survivors
DESTINY II (age over 60) nearly all survivors disabled
Evidence for hypothermia
Cochrane - no effect on mortality or outcomes
EuroHYP-1 to 34C - no effect, struggled to achieve hypothermia
