Stroke Flashcards
% of ischaemic vs hemorrhagic strokes
85% are ischaemic
- 20% caused by AF - greater mortality and morbidity
15% are haemorrhagic - higher mortality
- 2/3 intracerebral haemorrhage - most common cause HTN
1/3 subarachnoid haemorrhage
- 85% aneurysm
Risk of recurrent stroke:
- within 90 days = 5%
- within 1 year - 10%
- within 5 years - 25%
- within 10 years - 40%
Risk of stroke following TIA
At 2 days - 1.5%
At 7 days - 2%
At 30 days - 3%
At 1 year - 5% (7%)
When to suspect stroke
> 24h
1) Confusion, altered consciousness
2) Headache: gradual, increasing in ICH or sudden and severe in SAH. May have sentinel headaches in weeks prior
3) unilateral weakness/paralysis/sensory loss
4) ataxia, dysphasia, dysarthria, coordination, gait
5) Visual disturbance - homonymous hemianopia, diplopia
6) gaze paresis - horizontal and unidirectional
7) photophobia.
8) dizziness, vertigo, loss of balance
9) nausea/vomiting
10) specific CN defects - unilateral tongue weakness, Horners syndrome (mitosis, ptosis, facial anhidrosis)
11) neck or facial pain - arterial dissection
Posterior circulation strokes
Acute, persistent continuous vertigo/dizziness with nystagmus, nausea, head motion intolerance, new gait unsteadiness
Working out time of onset in stroke
If not clear, check when last known to be unaffected
If woke with symptoms this is when they were last awake and symptom free
FAST
> =1:
1) New facial weakness - asymmetry, mouth/eye drooping.
2) Arm or leg weakness.
3) Speech disturbance - slurring, dysphasia
Investigations if no delay to hospital
BM to r/o hypoglycaemia < 3.3
ECG
Managing suspected TIA in last 7 days
Symptoms resolved within 24h, typically 1h
2) 1) Apirin 300mg immediately (+PPI if dyspepsia associated with aspirin use)
- if CI d/w specialist team immediately
- if already taking low dose aspirin, continue this dose and do not give 300mg
2) Refer to be seen within 24h
- if on anticoagulant or bleeding disorder for urgent CT to exclude haemorrhage
- - will have MRI and carotid dopper
3) If > 1 TIA (crescendo TIA) - d/w specialist ?admission for observation
4) Do not use ABCD2 to assess risk of subsequent stroke or inform urgency of referral
5) Do not drive
Managing suspected acute stroke
1) Emergency admission to stroke unit
2) Inform hospital of time of onset, symptoms, current condition, meds (anticoagulants)
3) Do not start anticoagulants or anti platelet until ICH excluded
4) While awaiting transfer, monitor and give oxygen if SpO2 < 95%
Managing TIA > 7 days ago
1) Refer to specialise to be seen within 7 days
2) Do not drive until seen by specialist.
3) Safety netting advice to patient and family
When should you follow up TIA/stroke patients?
On discharge, at 6m, then annually
Also review carers of people with stroke at 6m, then annually to assess their health and social care needs
Offer verbal and written information on medications for secondary prevention - reason, how and when to take it and common adverse effects
Secondary prevention medications - stroke or TIA
1) Antiplatelet: if no paroxysmal or permanent AF
**- Clopidogrel 75mg OD
**- if clopidogrel not tolerated - aspirin 75mg OD + MR dipyridamole 200mg BD
- if clopidogrel and dipyridamole CI, use aspirin 75mg OD
- if at high risk of TIA or intracranial stenosis, secondary care may prescribe aspirin 75mg OD + clopidogrel 75mg OD for 30 days followed by mono therapy
2) Lipid modification
- atorvastatin 20-80mg OD -aim to reduce non–HDL by > 40% within 3 months
- do NOT prescribe vibrates, bile acid sequestrates, nicotinic idic and omega 3 fatty compounds to people with ischaemic stroke or TIA for secondary vascular prevention
- can only use ezetimibe in people with FHC
3) Anticoagulants: if also have paroxysmal, persistent or permanent AF or atrial flutter once IC bleeding excluded
- tretment starts immediately with TIA once haemorrhage excluded
- treatment starts within 14 days in non-disabling ischaemic stroke
- treatment starts > 14 days from onset in disabling ischaemic stroke with interim aspirin 300mg OD
-
Comorbidities to be managed/investigated after stroke or TIA
1) HTN
2) OSA - screen all patients for OSA and refer anyone suspected to have this
3) HF
4) Obesity
5) AF
6) Sickle cell disease
7) contraction - if premenopausal, do not offer COCP, offer PO methods instead
8) annual flu vaccine
Driving advice
1) 1x TIA:: do not drive for 1 month, but don’t need to notify DVLA
2) >1x TIA: notify DVLA & do not drive for 3 months, can resume if no further TIA
3) Stroke: do not need to notify DVLA initially, but do not drive for 1 month, can then Strat driving if satisfactory recovery. Notify DVLA id residual neurological deficit remains 1 month later (VF defect, cognitive, impaired limb function)
When should you screen for hearing problems in stroke patients?
Screen for hearing problems within first 6 weeks
Amsterdam Inventory Auditory of Disability (Hearing Handicap Inventory for Elderly - HHIE-S)
> 10 = >50% probability of hearng impairment -refer
