Stroke

Question 1

symptoms of stroke include:

Answer 1

• paralysis (hemiplegia)
• loss of altered sensation
• speech and language problems (expressive dysphagia when someone just can’t find the words)
• emotional lability
• incontinence
• haemanopia (blindness over half the field of vision)
• personality changes
• dysphagia
• memory problems - dementia

Question 2

percentage of ischemic stroke

Answer 2

85%

Question 3

percentage of haemorrhagic stoke

Answer 3

15%

• intracerebral - vessel within the brain bursts
• subarachnoid - surface vessel bursts and bleeds into space between the brain and skull

Question 4

How do we classify a stroke?

Answer 4

symptoms
neurology exam
CT (sometimes MRI)

Question 5

modifiable and non modifiable risks for ischaemic stroke

Answer 5

Modifiable:
Cardiac disease
prev TIA
smoking
HTN
AF
diabetes
obesity

Non-modifiable:
Age
Gender
genetic predisposition
Ethnicity

Question 6

Modifiable and non modifiable risks for haemorrhage stroke

Answer 6

Modifiable
Anticoagulation or anti platelet therapy
HTN
alcohol XS
illicit drug use (crystal meth & cocaine)

Non-modifiable
Age
Ethnicity

Question 7

Info in regards to alteplase

Answer 7

NICE - Can only be given if less that 4.5 hours from symptom onset

RCP - 3 hours or 3-4.5 if <80 years old.

CT scan has to occur before to rule out haemorrhage stroke. BP has to be below 180/110 & no surgery in the past three months before we can give it. Other contraindications such as uncontrolled HTN.

CT 24 hours later to ensure it has not flipped to haemorrhage stroke. This allows us to go ahead with anti platelet therapy

dose 0.9mg/kg with the first 10% given as an IV bolus. (up to a maximum of 90mg)

Question 8

Anti-Platelet therapy in stroke

Answer 8

aspirin 300mg OD is given for 2 weeks or until the patient is discharged. This then reduced to 75mg for long term.

If patients can’t tolerate aspirin then we can give clopidogrel 75mg daily.

Some patients may require PPI cover.

We would not give an anticoagulant within the first two weeks along side anti platelet therapy as it may flip it to a haemorrhagic stroke.

Patients diagnosed with cerebral venous sinus thrombosis should receive anticoagulation, initially with a LMWH until warfarin therapy is established (INR 2-3)

Question 9

Anti-hypertensives post stroke

Answer 9

BP may increase straight after a stroke and then return to normal. We would not advocate antihypertensives straight after a stroke as it may reduce the perfusion of blood to the brain. We would continue if a patient came in on them but we would not start any new ones unless BP >180/110 and the patient is a candidate for thrombolysis OR if a patient has at least one of:

• Hypertensive encephalopathy
• Hypertensive nephropathy
• Hypertensive heart failure of myocardial infarction
• Aortic dissection
• Pre-eclampsia

IV labetalol or nitrate infusion are commonly used in these cases.

Question 10

Should we offer TEDS to patients post-stroke?

Answer 10

No - evidence suggests they have no benefit and cause skin damage.

Question 11

Some patients are at high risk of VTE post stroke. What do we do?

Answer 11

We do not give pharmacological prophylaxis 2 weeks after stroke but we should reassess the VTE assessment after 2 weeks. WE can use intermittent pneumatic compressions sleeves for up to 30 days.
No TEDS.

Question 12

Should we give oxygen to these patients?

Answer 12

Only if they are hypoxic or sats <95%

Question 13

What should we do if a patient is pyrexial?

Answer 13

paracetamol and fluids

Question 14

What blood sugar range should we keep to?

Answer 14

5-15mmol/L

Question 15

How do we reverse anticoagulants if a patient has a haemorrhage stroke?

Answer 15

vitamin K - warfarin
Idarucizumab - dabigatran
protamine will only partially reverse LMWH

Question 16

What can we give to patients who have had a haemorrhage stroke and what does it achieve?

Answer 16

Nimodipine oral or IV - to prevent ischaemic neurological deficits following aneurysmal subarachnoid haemorrhage

Dose being 60mg ever 4 hours for 21 days - patients need to set an alarm in the night so they can stick to this schedule.

Question 17

Are we concerned about high BP in haemorrhagic stroke?

Answer 17

Yes we would treat this more aggressively that ischaemic stroke.

Question 18

Secondary preventions

Answer 18

1) clopidogrel 75mg daily (licensed for use in ischaemic stroke but off-license in TIA)
2) MR dipyridamole 200mg BD can be used if aspirin and clopidogrel are CI.
3) aspirin 75mg daily is both C & D are CI
3) aspirin 75mg daily + dipyridamole 200mg BD if C is not tolerated.

We also start high dose statin - but they should not be started in the first 48 hours due to haemorrhagic transformation risk.
Atorvastatin 20-80mg
We aim for >40% reduction in non HDL cholesterol.

Question 19

How do we manage patients with AF who have a stroke

Answer 19

They will have a CHADSVASC score of at least 2 so after the 2 week antiplatet therapy we would start them on anticoagulation mono therapy

Question 20

What is the target BP for patients post stroke?

Answer 20

130/80

Question 21

What antihypertensives are recommended from the progress trial?

Answer 21

perindopril + indapamide

If a patient is on hypertension meds prior to admission we can continue these.

Question 22

What antidepressant do we use post stoke?

Answer 22

sertraline - better cardiovascular safety profile.

Question 23

Exclusion criteria for thrombolysis

Answer 23

History of diabetes
Seizure at onset of stroke
Systolic blood pressure of 200
Presentation 8 hours after symptoms

Question 24

Is previous treatment with aspirin a contraindication for thrombolysis ?

Answer 24

No