stroke Flashcards
1
Q
define stroke
A
clinical syndrome of presumed vascular origin characterised by rapidly developing signs of focal or global disturbance of cerebral functions which lasts longer than 24h or leads to death
2
Q
define TIA
A
transient (less than 24h) neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia, without evidence of acute infarction
3
Q
complications of stroke include
A
- neurological problems
- depression
- anxiety
- communication difficulties
- difficulties with activities of daily living
4
Q
once a person has had a stroke or TIA, they are at high risk of…
A
further vascular event(s)
5
Q
main differences between stroke and TIA
A
- TIA is caused by a temporary disruption in blood supply to the brain
- TIA does not last as long as a stroke, the effects last a few minutes to a few hours and fully resolve within 24h
6
Q
when to suspect TIA
A
- pt presents with sudden onset focal neurological deficit which has completely resolved within 24h onset
- most are thought to resolve within 1 hour, but can persist for up to 24h
7
Q
focal neurological deficits in TIA may include
A
- unilateral weakness or sensory loss
- dysphasia
- ataxia, vertigo, loss of balance
- syncope
- sudden transient loss of vision in one eye, diplopia (double vision), homonymous hemianopsia (loss of vision in the same halves of both eye)
- cranial nerve defects - pain, tingling, numbness, weakness, paralysis of face including eyes
8
Q
when to suspect stroke
A
- pt presents with sudden onset focal neurological deficits which are ongoing or have persisted for >24h and cannot be explained by other conditions e.g. hypoglycaemia
9
Q
clinical features of stroke vary depending on…
A
causative mechanism and area of brain affected
10
Q
list some clinical features of stroke
A
- confused, altered consciousness, coma
- unilateral weakness or paralysis in face, arm or leg
- sensory less - paraesthesia or numbness
- ataxia
- dysphasia
- visual disturbances
- gaze paresis, often hroiznonal and unidriectionla
- photophobia
- dizziness, vertiamo loss of balance
- specific cranial nerve deficits
- difficulty with fine motor coordination and gait
- neck or facial pain
11
Q
describe a headache in different types of stoke
A
- intracranial haemorrhage: usually insidious in onset and gradually increasing intensity
- subarachnoid haemorrhage: sudden severe headache which may be associated with neck stiffness
- sentinel headaches may occur in preceding weeks
12
Q
what is gaze paresis
A
inability to move both eyes together in a single horizontal (most common) or vertical direction
13
Q
what is diplopia
A
double vision
14
Q
isolated dizziness is usually a symptom of TIA - true or false
A
false
15
Q
state some specific cranial nerve deficits in stroke
A
- unilateral tongue weakness
- Horner’s syndrome e.g. miosis (small pupils), drooping eyelid, decreased sweating on affected side of face (anhidrosis)
16
Q
Posterior circulation stroke diagnosis
A
- can be difficult to diagnose
- suspect if pt presents with symptoms of acute vestibular syndrome (acute, persistent continuous vertigo or dizziness with nystagmus, n/v, head motion intolerance and new gait unsteadiness)
17
Q
Should you give an antiplatelet if suspected acute stroke or emergent TIA
A
NO! avoid until hemorrhagic stroke excluded
18
Q
After a stroke, follow up needs to be arranged on ….. (3)
A
on discharge, at 6 months, annually
19
Q
A follow up will consider of the following
A
- assess need for specialist review
- assess social and heart care needs of pt and family/carer
- optimise lifestyle measures and drug treatments for secondary prevention
20
Q
Management of suspected TIA
A
- aspirin 300mg OD ASAP until diagnosis established unless CI
- if CI or intolerant (even with +PPI), give suitable alt anti platelet
- pt presenting <24h of TIA who have low bleeding risk should be considered for DAT with C + A, following by C monotherapy
- alt: T + A, followed by either T or C monotherapy
- if not appropriate for DAT, give clopidogrel monotherapy
- consider PPI for pt with Hx dyspepsia associated with aspirin, or for concurrent use with DAT to reduce risk GI haemorrhage
- following confirmed diagnosis, give secondary prevention
21
Q
aspirin dose for suspected TIA
A
PO 300mg OD until diagnosis established
22
Q
aspirin dose for adult, disabling acute ischaemic stroke
A
- PO or rectal 300mg OD for 14 days to be started 24h after thrombolysis or ASAP within 24h of symptom onset in pt not receiving thrombolysis
23
Q
aspirin dose for TIA or minor stroke, in combination with clopidogrel in pt with a low risk of bleeding
A
300mg initially for one dose, to be started within 24h of onset of symptoms, then 75mg OD for 21 days
24
Q
management of ischaemic stroke - thrombolytics
A
- alteplase or tenecteplase (unlicensed use) recommended in treatment of acute ischaemic stroke if it can be administered within 4.5h of symptom onset and if intracranial haemorrhage excluded by appropriate imaging techniques
- needs to be given by experienced medical staff within a specialist stroke centre
- some pt: surgical management
- if intracranial haemorrhage excluded, pt who receive thrombolytics need to be started on anti platelet after 24h unless CI
25
management of disabling acute ischaemic stroke (after thrombolysis has been given, or in pt who are not recieving thrombolysis)
- start aspirin unless CI, ASAP within 24h and continue for 2 weeks after stroke onset, when long term anti-thrombotic treatment should be started
- if pt is being transferred to care at home before 2 weeks, ensure they are started on long term anti-thrombotic earlier
26
when to consider giving PPI
- pt with Hx dyspepsia associated with aspirin or for concurrent use with DAT to reduce risk of GI haemorrhage
27
ACs as an alternative to anti platelets?
not recommended in acute ischaemic stroke in pt who are in sinus rhythm
28
pt with immobility after acute stroke
do not routinely give LMWH or graduated compression stockings for prevention of DVT
29
use of warfarin in acute stage of ischaemic stroke
do not give!
30
pt who receive AC for prosthetic heart valve who have a disabling ischaemic stroke
at significant risk of haemorrhagic transformation - stop AC treatment for 7 days and substitute with aspirin
31
treatment of hypertension in acute phase of ischaemic stroke
can result in reduced cerebral perfusion so only give in the event of hypertensive emergency, or in pt considered for thrombolysis
32
long term management following TIA or ischaemic stroke to reduce risk of further CV events - anti platelet
- long term clopidogrel monotherapy (unlicensed TIA) recommended in pt who present with either (not associated with AF)
- if CI or not tolerated, give aspirin
- also consider PPI need
33
discuss AC use in long term prevention of recurrent stroke
- not routinely recommended, except when AF and other indications like cardiac source of embolism, cerebral venous thrombosis or arterial dissection present
- if TIA/ischameic stroke associated with AF or atrial flutter, give long term AC treatment, timing depending on stroke severity and individual pt factors
34
statin for long term prevention
- high intensity statin needs to be started in pt not already taking one as soon as they can swallow safely, irrespective of their serum-cholesterol conc
35
define and name the high intensity statin
- high intensity = % reduction in LDL-C over 40
- atorv 20, 40, 80
- simv 80
- rosuv 10, 20, 40
36
BB in management of hypertension following stroke
do not use unless indicated for a co-existing condition
37
summarise the drugs that are given as long term prevention following a TIA or stroke
- high intensity statin to all pt irrespective of their serum cholesterol
- clopidogrel monotherapy (aspirin if not appropriate)
- Not ACs unless other indications are present
38
initial management of intracerebral haemorrhage - surgery and BP
- surgical intervention may be needed to remove haematoma and relieve intracranial pressure
- rapid BP lowering treatment to pt with underlying structural cause, Glasgow coma scale score <6, early neurosurgery to evacuate haematoma, very large haematoma with poor prognosis
- consider rapid BP lowering in pt who present within 6h symptom onset and have systolic BP 150-220 and do not fit any exclusion criteria
- aim for systolic BP target 130-139 within 1h and sustained for at least 7 days ensuring the magnitude drop doesn't exceed 60 within 1hr of starting treatment
- also consider on case by case basis for pt who present >6h of symptom onset or who have systolic BP >220 and do not fit any exclusion criteria
- specialist advice in considering BP lowering in 16-17yr olds who do not fit any exclusion criteria
39
what is the Glasgow coma scale
- assesses pt level of consciousness
- 1-15, lower scores = more impairment, coma etc
40
initial management of intracerabral haemorrhage - AC
- pt taking ACs should have treatment stopped and reversed
- however, AC therapy has been used in pt with intracerebral haemorrhage who are symptomatic of DVT or PE
- in this situation, placement of a caval filter is an alternative
41
pt with immobility after acute intracerebral haemorrhage
do not routinely give LMWH or graduated compression stockings for prevention of DVT
42
long term management of pt after intracerebral haemorrhage
- specialist advice for pt with AF and pt at high risk of ischaemic stroke or cardiac ischaemic events - this is because aspirin and AC therapy not normally recommended after intracerebral haemorrhage
- measure BP and initiate treatment were appropriate; take care to avoid hypo perfusion
- avoid statins after intracerebral haemorrhage but can be used with caution when risk of vascular events outweighs risk of further haemorrhage
- assess for lipid lowering therapy on basis of overall CV risk and underlying cause of haemorrhage
