Stroke

Question 1

Background

Answer 1

Stroke is a focal neurological deficit due to the interruption of the blood supply to the brain.

Medical emergency sooner diagnosed = better.

Types:
2 main - ischaemic and haemorrhagic
- Ischaemic = thrombotic or embolic.
- Haemorrhagic = intracerebral haemorrhage OR subarachnoid haemorrhage

Question 2

Signs and symptoms (same for all types)

Answer 2

Facial weakness.
Arm/leg weakness.
Disturbed speech.
Visual defect.
Dizziness/fall.
Loss of consciousness.
Headache.

F - FACE - droop on one side of the face? Can the person smile?
A - ARMS - raise both arms and keep them there?
S - SPEECH - Slurred?
T - TIME - call 999 – if displaying any of the signs

Risk factors
Modifiable risk factor
HTN
Smoking
AF
Hyperlipidaemia
Diabetes
Diet, alcohol intake and exercise
Stress and/or depression
High waist to hip ratio
High ratio of apolipoprotein B to apolipoprotein A1*

Non-modifiable risk factor
Age
Ethnicity
IHD/PVD
Genetic predisposition (family Hx)
Gender
Sickle cell disease

Question 3

Diagnosis

Answer 3

investigation of choice:
CAT/CT scanning of the head. This takes only 5-10 minutes.

NEEDED TO ASSES WHICH TREATMENT TO DO AS ISACAHEMIC USES ANTIPLATALETS AND CAN INDUCE BLEEDING.

Question 4

Ischaemic Stroke

Answer 4

Thrombotic IS commonly from atherosclerosis - narrowed blood vessels = reduced blood flow to area beyond. Damaged areas of an atherosclerotic plaque can cause a blood clot to form = blocking blood supply
Embolic IS = blood clots/debris from elsewhere in the body travel through circulatory system. Main cause is AF.

Treatment
INTIAL -
Alteplase or tenecteplase IF give within 4.5hrs of symptoms and other strokes ruled out.
Aspirin 300mg daily oral>rectal ASAP within 24hrs for 2 weeks THEN Clopidogrel 75mg daily (see secondary prevention)
PPI if Hx of dyspepsia with drugs.

SURGERY OPTION: Give thrombectomy ASAP within 6hrs of symptoms with IV thrombolysis (above) If have acute IS and confirmed occlusion of proximal anterior circulation.

Anticoagulant not used unless DVT or PE.
IF already on anticoagulant for prosthetic heart valve who had disabling ischaemic stroke and at good risk for haemorrhagic transformation STOP Anticoagulant for 7 days and swap with aspirin 300mg.

HTN - only if severely hypertensive - IV labetalol ALT IV GTN

Question 5

TIA - Transient ischaemic stroke

Answer 5

TIA - temporary disruption in the blood supply to the brain, leading to ischaemia. Caused by clot or other debris. Short lived (few mins to hrs)

Treatment
ASAP Aspirin 300mg ALT another antiplatelet.
- PPI if get dyspepsia associated with aspirin use
- If already on low dose A continue dont increase.

IF they got 24hrs of TIA or Minor IS:
ASAP Aspirin as above +
if low bleeding risk - dual antiplatelet therapy options:
Clopidogrel+ Aspirin THEN C alone OR Ticagrelor + A THEN T or C alone.
DUAL ALT C alone.

Question 6

LONG TERM (secondary prevention) Ischaemic S & TIA

Answer 6

Lifestyle mods (weight loss, smoking cessation, alcohol reduction, Diet to reduce BP and cholesterol [Mediterranean]) 5 fruit & veg/day, 2 oily fish/week, reduced saturated fats, Keep low salt intake

Antiplatelet -
Clopidogrel monotherapy 75mg daily ALT aspirin 75mg daily + MR dipyridamole 200mg BD. IF C and A not tolerated - MR dipyridamole 200mg BD. IF C and D not tolerated Aspirin 75mg daily.
DUAL antiplatelet A + C (up to 90 days) or A + Ticagrelor (for 30days) for some (i.e. high risk of TIA or intracranial stenosis) THEN antiplatelet monotherapy.

PPI if Hx of dyspepsia with drugs.

Statin - if already taking continue if not should be started at least 48 hours after the stroke. Use high density statin (atorvastatin 20-80mg daily)

HTN - B blockers not used unless other co existing condition. can use thiazide-like diuretic, long-acting CCB, ACE I, or ARB.

Anticoagulants - not routinely recommended except when AF or other indications (eg cardiac source of embolism, cerebral venous thrombosis or arterial dissection) are present.
Patients with IS or TIA associated with AF or atrial flutter should be reviewed for long-term anticoagulant

Question 7

Haemorrhagic Stoke

Answer 7

Haemorrhagic strokes are caused by a rupture of blood vessels that then causes a compression of brain tissue from an expanding haematoma (collection of blood outside blood vessels)

Treatment
Initial -
May need surgery to remove haematoma.

Rapid BP lowering treatment DONT give if have underlying structural cause. Glasgow coma score <6, going to have neurosurgery for haematoma or large haematoma with expected poor prognosis.
- offer treatment if come in within 6hrs of symptoms Systolic BP of 150 to 220. Aim for 130 to 139 BP sustained for 7 days

Anticoagulants to be STOPPED and REVERSED. If immobile dont give LMHW or stockings.
Reversal agents -
- prothrombin complex concentrate or IV VIT K = warfarin.
- idarucizumab (Praxbind) = Dabigatran
- Andexanet alfa (Ondexxya) = apixaban or rivaroxaban

Long term -
AVOID STATINS for intracerebral - Can increase risk of haemorrhage but can be used in caution if risk outweighs.

Question 8

SAH stroke complication

Answer 8

Subarachnoid haemorrhage (SAH)

Main complications of a SAH is secondary cerebral ischaemia, which can cause death in those patients who survive the initial bleed.

Cause by cerebral vasospasm
Can be treated with CCB nimodipine