Stroke Flashcards
Give 6 risk factors for Stroke
>55 years old Hypertension Diabetes Smoking Excess alcohol High fat diet Family history Heart disease High cholesterol South Asian or African Atrial fibrillation Women= high oestrogen, pre-eclampsia, gestational diabetes
What is the pathophysiology of an ischaemic stroke?
Blood clot blocks an artery to the brain.
Clots occur from either via a thrombosis in situ, atherosclerosis from the carotids or cardiac emboli secondary to AF, IE, MI or prosthetic valves
What is the pathophysiology of a hemorrhagic stroke?
Blood vessel in the brain bursts and there is a bleed around the brain.
Due to hypertension, trauma, aneurysm rupture, anticoagulation or thrombolysis
Describe a TACS (total anterior circulation stroke)
Large cortical stroke affecting areas of the brain supplied by the anterior and middle cerebral arteries
All 3 of:
- Unilateral weakness +/- sensory deficit of the face, arm and leg
- Homonymous hemianopia
- Higher cortical dysfunction (dysphagia, visuospatial disorder)
Describe a PACS (partial anterior circulation stroke)
Less severe form of TACS- only anterior cerebral artery affected
Need 2 of:
- Unilateral weakness +/- sensory deficit of the face, arm and leg
- Homonymous hemianopia
- Higher cortical dysfunction (dysphagia, visuospatial disorder)
Describe a POCS (posterior circulation syndrome)
Damage to the area of the brain supplied by the posterior circulation. Affects cerebellum and brainstem
Need 1 of:
- Cranial nerve palsy + contralateral motor/sensory nerve deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement palsy (horizontal gaze palsy)
- Cerebellar dysfunction (nystagmus, vertigo, ataxia)
- Isolated homonymous hemianopia
Describe Lacunar Syndrome (LACS)
Subcortical stroke that occurs secondary to small vessel disease. No loss of higher cerebral functions eg. dysphasia
1 of:
- Pure sensory stroke
- Pure motor stroke
- Sensorimotor stroke
- Ataxic hemiparesis
What does FAST stand for in stroke management?
Face- fallen on one side, cannot smile?
Arms- can they raise them both above their head?
Speech- slurred?
Time- ring 999 immediately
Give 5 symptoms of a stroke
Sudden loss of vision/ blurred vision Dizziness Confusion Hemiparesis Poor balance and coordination Dysphagia Difficulty understanding Sudden severe headache
Give examples of primary prevention measures for stroke
Manage hypertension Statins- reduce cholesterol Manage BMs Stop smoking Increase exercise Good diet Anticoagulation?
How is whether or not to start anticoagulation decided after an AF diagnosis?
CHADSVASc
HAS-BLED score
What factors are involved in the CHADSVASC Score?
Chronic Heart Failure/LV dysfunction (1) Hypertension (1) Aged >75 years (2) Diabetes (1) Stroke/TIA (2) Vascular disease (1) Aged 65-74 years (1) Sex= female (1)
Anticoagulate if score >2, patient choice if >1
What factors are involved in the HAS-BLED score?
Hypertension (1) Abnormal liver/renal function (1+1) Stroke (1) Bleeding tendency (1) Labile INR (1) Elderly- aged >65 (1) Drugs/alcohol excess (1+1)
> 3= high risk of bleeding caution in prescribing anticoagulation
How is a stroke managed acutely?
Protect airway
Nil by mouth until swallow is assessed
Maintain homeostasis- aim for BMs 4-11mmol/L and BP <185/110
CT head/MRI within 1 hour
Why is a CT/MRI head done in acute stroke management?
Work out if stroke is ischaemic or haemorrhagic
Severity
Area of brain affected
Give the positive and negatives of doing a CT head in acute stroke management (compared to a MRI head)
+ = faster, readily available, less expensive, can do in patients with a pacemaker, less claustrophobic, haemorrhage clearly visible for up to 72 hours
- = high radiation dose
Give the positive and negatives of doing a MRI head in acute stroke management (compared to a CT head)
+ = see anatomy in greater deal, can detect early ischaemia, differentiate between old and new ischaemia
- = more expensive, time consuming
How is an ischaemic stroke managed?
Thrombolysis= Alteplase dissolves blood clots if given within 4.5 hours of stroke occuring.
Thrombectomy- large clots removed via catheter in femoral artery fed up to the brain
Antiplatelets- aspirin 300mg for 2 weeks
Anticoagulation- long term use of warfarin, apixaban, dabigatran or rivaroxaban
Secondary prevention- antihypertensives, statins
Carotid endarterectomy- reduce carotid stenosis
Give 4 contraindications of thrombolysis
Haemorrhage on CT Recent surgery Trauma Previous CNS bleed Aneurysm Liver disease Hypo/hyperglycemia Seizures at presentation Recent GI haemorrhage Known clotting disorder INR >1.7
How is a hemorrhagic stroke managed?
Antihypertensives
Reverse anticoagulation
Craniotomy- part of skull removed to repair blood vessels and remove clots. Skull replaced with metal plate.
What long term supportive management can be given to a patient who has suffered a stroke?
NG tube feeding
O2 therapy
IV fluids
Compression stockings
Give some long term physical effects of a stroke
Weakness
Stiff muscles
Loss of muscle function
What is aphasia?
No longer able to understand or use language appropriately
What is dysarthria?
Not able to use facial muscles well so difficult to speak clearly
What is post-stroke fatigue?
Extreme tiredness which does not improve with rest. Simple tasks require much more effort in stroke recovery.
How is swallowing managed in a stroke patient?
SALT input
Thickened fluids- makes swallowing easier
May need NG tube or PEG feed
What psychological conditions are commonly recognised after a stroke?
Anxiety
Depression
When can a patient drive again after a stroke?
At least 1 month
GP decides how well they are to drive or whether they need further assessment.
Give 8 people who might be involved in the stroke MDT
Stroke physician GP ANP Acute hospital nurses Community hospital nurses SALT OT PT Orthoptist Continence nurse Psychologist Social services Carers
Give 5 predisposing factors for a TIA
Smoking Hypertension Obesity Diabetes High cholesterol Excess alcohol AF >60 years old
What is the pathophysiology of a TIA?
Blood clot in the brain temporarily causes reduced blood flow to the brain but all symptoms resolve within 24 hours.
Most commonly due to a carotid embolism or a thrombus due to AF
Give 5 potential symptoms of a TIA
All resolve in 24 hours: Drooping face Weakness in 1 side of the body Slurred speech Dizziness and confusion Dysphagia Amaurosis fugax- curtain descending over vision.
What is the ABCD2 Score in TIA management?
Age >60 years (1)
Blood pressure >140/90 (1)
Clinical features- unilateral weakness (2), speech disturbance (1)
Duration of symptoms >1 hr (2), <1 hr (1)
Diabetes (1)
Score >4 = high risk of early stroke so should be seen by a specialist within 24 hours. >6 hours predicts high risk of stroke in the next 2 days.
What investigations should be done following a TIA?
FBC, U+Es, BM, Lipids, CXr, ECG, CT/MRI head, Echo, Carotid doppler
How is a TIA managed?
Antiplatelets- 300mg aspirin for 2 weeks
Clopidogrel for life
Antihypertensives
Statins
Carotid endarterectomy- if carotid stenosis found
Cannot drive for 1 month
