stroke Flashcards
what is thrombotic disease
a blood clot blocks veins or arteries
what are platelets
-small circulating blood cells that circulate in isolation in our blood all the time
because they are small they are pushed by the white blood cells to the edges of the blood vessles
what does platelets closely measure
endothelial cells - detect any damages quickly
what is stroke
rapid death of brain tissues due to the disturbance in blood supply
what are the risk factors of stroke
inactivity age family and ethnicity HBP heart disease diabetics smoking obesity and unhealthy eating previous stroke and TIA
what are the different types of stroke
- ischemic
- TIA
- Haemorrhagic
what is the cause of ischemic stroke
Thrombosis (large/small arteries)
Damage caused by:
Atherosclerotic plaque rupture leads to thrombosis
Interrupts blood supply (oxygen, glucose & other nutrients) to neurons
Rapid death of brain tissues leads to loss of brain function
-embolism
- AF - left atrium is less effective in ejection of the blood
- if blood is not moving from LA To LV - blood stasis in LA - blood clot + stroke (if blood is in the atria for too long)
what is embolism
breakage of blood clots
-broken blood clots will go and effect other regions
low ejection fraction - heart failure - blood stasis - lead to thrombosis
How can atrial fibrillation cause stroke
- AF - left atrium is less effective in ejection of the blood
- if blood is not moving from LA To LV - blood stasis in LA - blood clot + stroke (if blood is in the atria for too long)
what is endocarditis
Endocarditis: fungal or bacterial growth (septicaemia) in heart valves forms clumps/vegetation and emboli to the brain
what is haemorrhagic stroke divided into
intracerebral
- within brain: due to hypertension, trauma, bleeding disorders & vascular defects,
HBP In avm cause rupture and bleeding form
haematoma - causing irreversable damage
subarachnoid bleeding (surface of brain): due to aneurysm rupture
Most of the aneurysm occur in circle of Willis
Risks: smoking, alcohol, hypertension, genetic, drug abuse, therapeutic drugs-anticoagulants, etc.
Occurs in circle of Willis such as at the junctions of anterior communicating & anterior cerebral arteries
Two types: saccular (berry) & fusiform
Damages: compression of tissue from expanding haematoma
direct toxic effects of blood cells (free iron)
interruption of blood supply to neurones
Surgical intervention required
what is tia
Transient Ischemic Attack (TIA) – Mini stroke
Temporary blockage of blood supply due to small blood clots
May overcome either in 30-60 minutes or 24 hours
Could occur repeatedly or in multiple regions
Leads to major ischemic stroke
what is the assessment for the risk for stroke
ABCD2
A - age: 60years of age or more = 1point
B- blood pressure at presentation: 140/90mmHg or greater = 1point
C- clinical features: unilateral weakness = 2points;
speech disturbance without weakness = 1point
D- duration of symptoms: 10 - 59minutes = 1point; 60 minutes or longer = 2points
presence of diabetes: 1point
ABCD2 score ≥ 4 = high risk of stroke
what is the limitation of ABCD2
cannot be used in patients with recurrent TIA or on
anticoagulant treatment
if abcd 2 higher than 4 what is the next action
aspirin (300 mg daily) started immediately
specialist assessment
investigation within 24 hours of TIA symptoms
what is the signs and symptoms of stroke
loss of consciousness or coma headache double vision/ loss of vision slurred speed or loss of speech numbness of the face/arm/ leg on one side weakness od face, arm, leg on one side loss of balance or coordination
FAST what does this mean
Face - fallen on one side, can they smile
arms - can they raise both arms and keep them there
speech - is their speech slurred
T- time to call 999
what is the management of stroke - daignosis
assess risk of stroke in patients with tia
brain imaging - CT or MRI
all existing treatment aim to prevent further stroke
pharmacological management after TIA - what should be done after assessment
ABCD2 High Score = ≥ 4
Aspirin 300 mg daily start immediately
Specialist assessment & investigation within 24 hours following onset of symptoms
Measures for secondary prevention including the assessment of individual risk factors
Crescendo TIA (≥ 2/week) should be treated as high risk even if the score is <4
ABCD2 Low Score = < 4
Specialist assessment within a week following onset of symptoms
Referral to brain imaging if needed
management of ischemic stroke
Alteplase given within 4.5 hours, 900 microgram/kg/over 60 minutes and in specialist stroke centre (to ensure correct delivery and management) or by trained staff
Aspirin started within 24 hours, 300 mg daily for 2 weeks (oral or via rectal/enteral tube, if dysphagic; if history of dyspepsia, give proton pump inhibitor) or clopidogrel 75 mg daily as alternative (if aspirin-intolerant)
Modified-release dipyridamole in combination with aspirin if clopidogrel is contraindicated or not tolerated
Others include anticoagulants, anti-hypertensives, statins, surgeries to remove blockages and place stent
surgery to remove plaque - carotid angioplasty
carotid endarectomy
management for hemorrhagic stroke
Removal or clipping of aneurysm
Anti-hypertensives
Reversing anticoagulants (if any)
Surgery (craniotomy) to remove blood or haematoma
Surgery to treat hydrocephalus (to drain CSF)
what is longterm management of stroke
Long-term Clopidogrel 75 mg/daily
Note: Clopidogrel can be used in other cardiovascular conditions/diseases if aspirin is contraindicated/not tolerated
Modified Release (MR) dipyridamole (200 mg twice daily) in combination with aspirin (75 mg/once daily) should be used in people who have had a TIA Ischemic stroke and Clopidogrel is contraindicated/not tolerated
rehab for stroke patients
Restoration of function (re-learning skills and abilities)
Physiotherapy (e.g. learning to walk)
Speech and language therapy (e.g. learning to talk)
Occupational therapy (e.g. shopping)
Psychologist/Psychiatrist (e.g. to adapt psychologically)
Learning new skills
e.g. occupational therapy
Adapting to some of the limitations (caused by a stroke)
e.g. smaller meals to avoid choking, physical changes to home, wearing incontinence pads, communicating in different ways, mobility aids
Support network
patience, positive, carers strike a balance between taking over and full independence
Peripheral arterial disease
Atherosclerotic plaques in lower extremities (e.g. legs)
Hardening of arteries supplying blood to legs
Block the blood supply and lead to ischemia
Results in myocytes death
More common in men than women
Mostly occur in diabetes, smokers
Can cause serious complications
Symptoms could be anywhere in legs
causes of PAD
-diabeties smoking obesity infections injury to the vessles sedentary lifestyle HBP
symptoms of pad
- coolness to touch
-poor skin
nail health
pain while walking
discolouration
diagnosis of PAD
Ankle-brachial index (ABI)
Blood pressure in ankle and arm should be measured Systolic blood pressure in ankle / arm = 0.9 - 1 (normal) <0.9 : represents PAD 0. 71 - 0.9 : mild PAD 0. 41 - 0.7 : moderate PAD <0.4 : severe PAD
treatment for pad
Change of lifestyle: regular exercise, smoking cessation, weight reduction for obese & reduce alcohol consumption
Medications for hyperlipidaemia, hyperglycaemia/diabetes & hypertension
Anti-platelet drugs: e.g. aspirin (75 mg daily)
Naftidrofuryl oxalate (vasodilator) (100-200 mg/ 3 times a day) alleviates symptoms of intermittent claudication and improve pain-free walking distance in moderate cases
Cilostazol (PDE inhibitor-vasodilation and inhibits platelet activation) is for second-line treatment where lifestyle modifications and other interventions failed
Surgical procedures: angioplasty and endartectomy
What is deep vein thrombosis
Occurs in deep veins in lower extremities (legs)
Blood flows back to heart due to muscle movement
Reduced/nil movement or injuries diminishes or stops blood flow in veins
So accumulation of platelets & plasma proteins leads to clotting
The clot could be smaller, so it can break up easily by fibrinolysis
Large clots can occlude the veins and prevent the blood flow permanently
Dislodged clots can travel to heart and then lodge in lungs (called pulmonary embolism)
Can cause serious complications if untreated
causes of DVT
Inactivity – immobile for a long period (e.g. during/after surgeries, due to other illness or long journeys
Stay at hospitals – long staying at hospitals with reduced activity
Blood vessel damage – injury to the blood vessels can narrow or block the blood flow. Vasculitis, varicose vein and certain medications can also damage the blood vessels
Medical conditions – can increase the clotting activity (cancer treatments – chemo & radiotherapy; heart & lung diseases; infectious diseases, e.g hepatitis
Genetic conditions – thrombophilia – blood is more likely to clot; Hughes syndrome – blood is abnormally sticky
Pregnancy – makes blood to clot quickly
Combined contraceptive pills & hormone replacement therapy (increased oestrogen can cause blood to clot easily)
Previous DVT, obesity, smoking, age (>60) and dehydration
Symptoms of DVT
Sometimes asymptomatic
Pain, tenderness and swelling in one of the legs
Heavy pain in the affected area
Warm skin in the area of the clot
Redness of the skin at the back of leg below the knee
If untreated, can lead to pulmonary embolism
Breathlessness
Chest pain – gets worse during breathing
Sudden collapse
diagnosis of DVT
-ultrasound
venogram
blood test for D dimer levels
Treatment for DVT
Anticoagulants to prevent the clots getting bigger and breaking off
Heparin (low molecular weight (mostly used form) & standard unfractionated) – an anticoagulant and inhibitor of thrombin
IV infusion or intermittent subcutaneous injection (Low molecular weight)
IV infusion, injection or subcutaneous injection – standard heparin
Warfarin sodium (oral anticoagulant-tablet) – should be started same time as heparin – prevents further clotting
Not recommended for pregnant women
Rivaroxaban (Factor Xa inhibitor)
Apixaban (thrombin inhibitor)
Compression stockings – to prevent formation of new clots or post-thrombotic syndrome
Waking exercise, raising legs at resting
Inferior vena cava filters when anticoagulants are not suitable
Small mesh device – prevent large clots travelling to heart and lungs
Placed into the vein using a catheter and ultrasound scan
