stroke Flashcards
define stroke + TIA
acute loss of focal cerebral function lasting more than 24 hours or resulting in death.
TIA- less than 24 hours, maj less than 1 hour. 1/4 the incidence of stroke.
10% stroke risk after TIA in the first week.
stroke s 11% of death in uk, most in 1st month. 3rd most common cause.
good stroke mimic differentiation.
driving rules for stroke / TIA
the symptoms are generally negative (loss of speech)
the mimics usually have positive symptoms also (aura, tingling)
focal acute onset
contiguous parts affected concurrently, no spread
after TIA/ stroke cant drive for 1 month. then based on symptoms.
assessment of strokes
FAST- 78% diagnostic when used by paramedics.
ROSIER- more better than fast PPV 86%. (syncopy, seziure, visual field etc)
MRI gold standard, CTA good.
carrotid doppler can be good but does not visualise posterior circ.
Bloods
ECG, echo, 7 day tape.
cxr
what do large vessel strokes affect
mca + aca strokes affect what.
attention
language
motor control and planning
hemianopia
ACA- legs trunk, behavioural changes.
MCA- arms face pharynx etx
discuss lacunar syndromes
pure motor
hemisensory loss
sensorimotor- most common
ataxic hemiparesis
dysarthria clumsy hand syndrome
no dysphasia, hemianopia, neglect.
most important cause of vascular dementia.-
caused by high blood pressure.
posterior circ strokes
sensory loss
ataxia- cerbellar
cranial nerve problems
can get hemianopia,
vertebrobasilar territory
haemorrhage strokes
10-15%
intraparenchymal bleeds.
can get 2’ sub arach
indistinguisahble clinically from ischaemic.
early worsening can be a clue, seziures, headaches more frequent in ICH
if bleeds preipherally- think amyloid leakeage rarther than hypertensive.
50% survival at one year, most have disability.
treatment of strokes - thrombylisis
alteplase- IV fibrynolytic agent. 0.9mg/kg (max 90) — give 10% as a bolus over 5 mins, then give rest over 1 hr.
tenecteplase- not yet liscenced
4.5 hours of onset.
CT immediately- r/o bleed.
no overall effect on mortality, but does on disability.
1/8 cured
1/3 better
1/18 bleed
if ‘wake up stroke’ - mid point of sleep + 9 hours is cut off of for alteplase.
mechanical thrombectomy
large vessel clot unlikely to be broken down by tpa
ischaemic large vessel (MCA, carotid, basillar)
within 6 hours
significant neuro defecit- NIHSS>6 + minimal ischaemia seen on CT
evidence saying that can be within 24 hours. no inc risk bleed.
discuss blood pressure management in stroke + antiplatelet treatment.
in ischaemic not reccomended unless its over 200mmhg.
clopi 75mg
aspirin 75 2’ line
no antiplatelet therapy should be given 24 following re-perfusion interventions.
surgery in ischaemic stroke
malignant MCA syndrome- young more at risk, distal caritod and M1 occlusion. gaze + hemiplegia + neglect.
headache and vomiting.
poor prognosis- 80% if untreated. -
large cerebellar infarction- pressure on brainstem dropping gcs
both get decompressive hemicraniectomy. - improved survival but not disability. -
refer to neurosurg in 24 hrs, done within 48 hrs.
emergency mgt of intracerebral haemorrhage
resusitation
urgent imaging
reverse antocoagulation
? surg refferal if needed
medically manage- HTN- under 140
vit K +PCC(factors2,7,9,10)- regular inrs
DOAC- monoclonal antibody- gen speak to haem- adexanet alfa (10a reversor) - decoy
discuss stroke 2nd prevention
clopidogrel 75mg od- 1st line
aspiring + dipyridamole 75 od, 200BD- in clopi intolerant.
warfarin- 2nd line- INR 2-3.
DOAC- 1st line in non valvular AF
24 hrs post reperfusion
immediately if TIA due to AF
2 weeks start warf or doac post ischaemic. ?????
antihypertensives + statinsi n stroke prevention
anti-HTN reduce stroke even in norm bp aim for less than 130
statins reduce stroke even in those with normal cholesterol. should be less than 4, ldl 2
caroted stenosis
assess for this after tia
rx with endarterectomy- 70-99% symptomatic stenosis
asymptomatic if 80 or greater stenosis can be operated on.
stenting can be done in people that cant tolerate endarterectomy.
