Stroke Flashcards
What are the benefits of admission to a specialist acute stroke unit for all suspected stroke?
Early recognition and treatment of complications.
MDT working
Co-ordinated and organised in-patient care with weekly MDT meetings
Involvement of carers in rehabilitation
Staff interest and expertise
Patients are more likely to receive measures to reduce aspiration, early nutrition, shorter length of stay, less likely to die and more likely to discharge independent
What is aphasia
inability to comprehend or formulate language. Comprehension and formulation of language is affected.
Generally with left hemisphere stroke. Traditionally Broca’s or Wernicke’s are the site of problem, bzut can also be right hemisphere.
Reading and writing is affected. Gestures and drawings as well
difficulties with communication affect how a person maintain and sustains their relationships, how they control their live through making choices and how they see themselves
The emphasis should be on us to provide help rather than relying on the person with aphasia to produce alternative ways of communicating. without this support someone with aphasia may not be able to participate in discussion or consent to treatment, but with it they may be enabled to reveal more ability than appears on the surface
What is dysphasia?
Expressive: understands language, but cannot find the right words. Recognises incorrect language. Reading and writing may be affected
Receptive (Wernicke’s):
inability to understand language. Does not recongize error in speech. Reading and writing unaffected
there is often a combination of expressive and receptive dysphasia, as the two areas are closely related anatomically
What is dysarthria?
know what they want to say, but cannot get the words out corretly (weakness of tongue or facial muscles).
Flat sounding voice. May sound slurred
Understanding, reading and writing not affected
What is apraxia
Difficulty in performing tasks, despite intact motor function
What is asterognosis
Inability to identify objects in both hands by touch alone, despite intact sensation
What is agnosia
Inability to recognize objects
Persons, sounds, shapes or smells
What is inattention
Inability to attend to stimuli bilaterally, despite intact sensation
What is dyspraxia
Dyspraxia affects the person’s ability to respond voluntarily in conversation, but they may be able to do things automatically
Can greet normally, but then unable to answer any questions
Generally, unable to repeat things
How is dysphagia recognized and managed?
Doctors and nurses are often the first member of a team to notice. Nurses can be trained to carry out intitial screening assessment.
Speech and Language therapist (SALT) does further assessment to check risks for oral intake.
Physiotherapist will assess appropriate positioning for swallowing (sitting balance, head control)
Occupational therapist (OT) will assess seating for eating and drinking to ensure optimum positioning. Look at hand-mouth coordination and adaptations to help
Dietician will assess and monitor intake to ensure nutritional requirements are met
The healthcare Assistants and nurses may feed/supervise the patient when eating/drinking.
The support team assistant needs to be aware whether the patient is on a modified diet or thickened fluids and give appropriate meals/drinks
What are the signs of dysphagia
coughing
choking
becoming very short of breath (aspiration)
however, some people can aspirate silently and there are no obvious clinical signs to indicate this
Silent aspiration can only be detected using videofluoroscopy (similar to a barium meal)
What measures can be taken to reduce the chance of aspiration in dysphagia
Modified diet and/or thickened fluids to minimise the risk
Risk may be considered too high: NBM
Non-oral feeding needs to be considered. eg. NG tube or PEG
Considering the risk of malnutrition is as important as considering the risk of aspiration. Taking oral drugs are also affected. Need to find a different way
Management of daysphagia..
Consistency of food
Quantity of food (small portions)
Strategies such as chin tuck, extra swallows
Positioning, alertness
Therapy
Advise re prognosis. Liaison re non-oral feeding
Other than dysphagia, what other dysfunction may arise from a parietal lesion?
Sensory neglect (when bilateral confrontation)
Agnosia
Astereognosis
Dyspraxia (problem with performing tasks)
What are the risk factors for stroke
HTN Hypercholesterolaemia DM Smoking Alcohol Dietary Low exercise Increased weight AF Drugs - illicit, Warfarin Increasing age - but young people can also have stroke Male Personal Hx of stroke, TIA or migraine FHx of stroke or clotting disorders
Describe the oxford classification of stroke
Neurological deficit of cerebrovascular cause that persists beyond 24hrs or is interrupted by death within 24hrs
TIA - persists less than 24hrs
Total anterior circulation stroke (TACS) - 20% of stroke
Partial anterior circulation stroke (PACS) - 35% of stroke
Lacunar stroke (LACS) - 20%
Posterior circulation stroke (POCS) - 25%
Describe total anterior circulation stroke
ALL OF THESE
•Form of higher dysfunction: Dysphasia Reduced consciousness Visuospatial neglect Asterognosis
- Homonimous hemianopia
- Motor/sensory deficit (>2/3 of face/arm/leg)
Describe Partial anterior circulation stroke
Either:
Higher dysfunction alone (dysphasia, reduced consciousness, visuospatial neglect, asterognosis)
Or
2 out of 3 of TACS (higher dysfunction, homonymous hemianopia, motor/sensory)
Describe lacunar stroke
Any one of: (with 2 or more of face/arm/leg)
Pure motor
Pure sensory
Sensorymotor
Or
Ataxic hemiparesis
NONE OF THESE:
new dysphasia, visuospatial problem, proprioceptive sensory loss only
No vertebrobasila features
Describe POCS
Any one of these present:
Cranial nerve palsy AND contralateral motor/sensory deficit
Bilateral motor or sensory deficit Conjugate eye movement problems Conjugate eye movement problems Cerebellar dysfunction Isolated homonymous hemianopia
What are the risk factors for intracerebral haemorrhage
On anti-coagulation Bleeding tendency Depressed consciousness Severe headache HTN +++ Vomiting BM >11
Management of intracerebral haemorrhage
Reverse anticoagulants
Stop antiplatelet
Potential rapid deterioration:
roles of neurosurgery/ITU
Lower BP <140/90 ASAP!! (normally they can be very hypertensive)
Pre-hospital stroke assessment and later assessment
FAST (Face. Arms. Legs. Time)
Confirm history Exclude mimics: migraine SOL Seizure Syncope Metabolic disturbance (hypoglycaemia)
Peripheral neuropathy
Transient global amnesia
Psychiatric conditions
Time of onset is important for thrombolysis
Areas that can be affected usually show negative symptoms: eg. loss of: Motor Speech Vision Sensation Coordination Conscious level Memory
Which scale can be used for quick stroke assessment
National Institute of Health Stroke Scale (NIHSS)
Provides insight into location of stroke and severity
Identifies those who would benefit from thrombolysis
Investigations in suspected stroke
AIM: define arterial territory pathology exclude stroke mimics guide further investigation Aids treatment strategies Aids prognostication
RCP guidelines: all strokes to be scanned within 24hrs (soon to be 12hrs)
CT Brain is easily accessible, fast and has a sensitivity for bleeding, but it does have a high radiation burden. CRITICAL TO EXCLUDE HAEMORRHAGE
Bloods: FBC, U and E, LFT, TFT Glucose Lipids Coagulation ESR Thrombophilia screen Vasculitic screen
ECG: AF, LVH, ischaemic changes
Echo - valvular disease (SBE), mural thrombus, LVH
Indications for urgent CT brain
Thrombolysis? On anti-coagulation Bleeding tendency Unexplained progressive fluctuating symptoms Depressed conscious level Suspicion of SAH
What are the indications for thrombolysis
Alteplase (0.9mg/kg)
Up to 4.5hrs Clear time of onset Clinical symptoms and signs of acute stroke Haemorrhage excluded Age - no upper age limit
Contraindications for thrombolysis
Rapidly improving or minor stroke symptoms
Stroke or serious head injury 3 months
Major surgery. obstetrical delivery, external heart massage last 14 days
Severe haemorrhage last 21 days
Bleeding tendency
History of central nervous damage (neoplasm, haemorrhage, aneurysm, surgery, haemorrhagic retinopathy)
What is a carotid endarterectomy?
Incision is made to open the carotid artery. Plaque is removed,. Then, the artery is repaired and closed.
Carotid endarterectomy may prevent a stroke if the carotid is severely narrowed
Which antiplatelet drugs are used for prophylaxis
Acute: Aspirin 300mg PO/PR for 2 weeks
Stroke - clopidogrel 75mg
TIA - clopidogrel 75mg
Which anti-coagulants can be used for secondary prevention of stroke
Heparin (UF/LMWH), but increases risk of bleeding
Warfarin for AF
CHAD2VASC score
Anti-platelet for 2 weeks then switch to clopidogrel
DVT prophylaxis
Because of being bed-bound or less active.
Enoxaparin - started on day 3 in ischaemic stroke
TED stockings. But it increases risk of skin complications
Mechanical compression stockings have evidence for use in stroke
What are the potential complications of stroke management
DVT Pulmonary embolism Aspiration and hypostatic pneumonia Pressure sores Depression Seizures Incontinence Post-stroke pain
