Stroke

Question 1

evidence for stroke rehab

Answer 1

biggest factor for M&M
early recognition and Rx of complications
improved outcomes: asp, nutrition, stay, M&M, independence
MDT team: coordinated care
staff interest and expertise
education, training, involvement: carers, staff, patients

Question 2

definition of stroke

Answer 2

vascular
rapid onset
focal/global cerebral dysfunction
>24h or death

(TIA

Question 3

importance of stroke

Answer 3

3rd leading M&M: 130,000 affected each year (1 every 5 minutes); incidence 174-216 per 100,000/y
TIA: 35 per 100,000; 1/3 stroke later; 5%

Question 4

dysarthria, dysphagia, dysphasia

Answer 4

dysarthria = speech issue due to muscle weakness

dysphagia = abnormal swallowing; 30-50% of strokes; asp pn. risk

dysphasia = language issue; receptive and/or expressive; can affect reading and writing

Question 5

stroke features

Answer 5

sudden onset
no seizure activity, syncope, or LoC
no secondary cause e.g. infection

motor/sensory: paresis/plegia
visual: homonymous hemianopia
language: dysphasia
parietal function: agnosia, asterognosia, neglect, dyspraxia
brainstem: CN palsy, ataxia, locked-in, ‘DANISH’
coortdination/balance/dizziness

crossed signs : ipsilateral CN, contralateral hemiparesis

Question 6

stroke assessment

Answer 6

history:
onset: gradual/sudden, exact time (/last normal)
what: body parts, vision; progression; define deficits
PMH: bleeding RF, clotting RF; falls, trauma, injury, AF
FH: clotting and strokes
DH: anticoags, COCP
SH: premorbid function and independence; support; substances; driving

examination: 
GCS + AtoE
CVS: RFs (HTN, AF, murmur)
resp: complicaitons (DVT, PE, pn)
neuro: locate lesion, confirm Dx
NIHSS: severity, ?location, ?thrombosis
Rosier scale: ?admission;

Question 7

stroke management

Answer 7

Investigations
bloods: baselines, Plt, Ua, clotting, BM
CT (exclude bleed -hyperdense): ?lysis, bleeding/anticoag, fluctuating/progressive Sx, ?SAH
ECG and CXR

treatment: time is brain
thrombolysis:
carotid endarterectomy: stop anticoag, keep asp
thrombectomy: wire corkscrew + angio
hemicraniotomy: ICP, malignant MCA syndrome
antiplatets: asp 300mg 2/52 then clop 75mg
anticoag and DVT PPx
supportive: hydration, O2, nutrition, anti-HTN, statins

Question 8

OT application

Answer 8

splinting: ROM preservation
home assessment
functional assessment: ADLs
cognition and perception: visspat, neglect/agnosia, dyspraxia, memory/attn, planning, problem solving
anxiety and depression 

promote independence
provide equipment
seating/positioning
driving/leisure advice
referrals

Question 9

PT application

Answer 9

optimise movement
sensorimotor stimulation (neural drive)
bone and muscle: alignment, activation, strength
reduced compensation and ineffective coping, and pain

NM perception, integration and response to environment
CNS coordination
normal movement: tone, posture, reciprocal innervation, sensory feedback (proprioception)

assessment and advice for MDT: positioning, transfer, exercise
provide equipment
weekly groups
nursing asistants
review, update, refer
advise family/carers: continue recovery

Question 10

stroke DDx

Answer 10

TIA:

Question 11

TIA stats

Answer 11

35 per 100,000;
1/3 stroke later;
5%

Question 12

classification (Oxford Bamford)

Answer 12

TACS: 3 domains, >2/3 arm/leg/face
PACS: 2 domains, or 3 domains with 1/3 arm/face/leg, or higher function only
LACS: pure/mixed sensory/motor, ataxic hemiparesis
POCS: crossed signs, bs signs, isolated homo hemianopia, vertigo/N&V

Question 13

stroke prognosis

Answer 13

TACS at 1 year: 60% dead, 35% dependent, 5% independent, 5% recurrence

PACS: 15% dead, 30% dependent, 55% independent, 20% recurrence

LACS (best): 10% dead, 30% dependent, 60% independent, 10% recurrence

POCS: 20% dead, 30% dependent, 50% independent, 20% recurrence

Question 14

stroke RF

Answer 14

ABCD2: age, BP, clinical, duration, DM; 2&7 day risk
CHA2DS2VASC: CHF, HTN, age (75), DM, stroke/sim, vasc disease, age (65-74), sex (F)

risk factors:
HTN (3-4x), DM (2-4x), AF, IHD (2-4x), CCF (2-4x), IE
smoking (1.5-3x), alcohol (4x) cholesterol, pro-thrombo, IVDU
age, male, PMH, FHx

age risk doubles every decade >55y

Question 15

thrombolysis

Answer 15

up to 4.5h (6h if young, 12h if PACS) and Sx >30m; exclude hge;
CI: improving, minor stroke Sx, bleeding risk, ?seizure, CNS damage uncontrolled HTN (>185/110), low benefit (pre-morbid state)
risks: 5% ICH, 1% fatal ICH; 3-5% get worse, 1% shortened life
benefits: 20-33% improve, 10% independent

monitor: neuro obs, BP, deterioration
avoid for 24h: ABG, CVP, IDC, NGT, aspirin/heparin

Question 16

stroke complications

Answer 16

DVT/PE
aspiration/hydrostatic pneumonia
pressure sores
depression
seizure
incontinence
post-stroke pain (common): opiates, amitriptyline, gabapentin, pregabalin, DBS