Stroke Flashcards
symptoms of stroke include:
- 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
percentage of ischemic stroke
85%
percentage of haemorrhagic stoke
15%
- intracerebral - vessel within the brain bursts
- subarachnoid - surface vessel bursts and bleeds into space between the brain and skull
How do we classify a stroke?
symptoms
neurology exam
CT (sometimes MRI)
modifiable and non modifiable risks for ischaemic stroke
Modifiable: Cardiac disease prev TIA smoking HTN AF diabetes obesity
Non-modifiable: Age Gender genetic predisposition Ethnicity
Modifiable and non modifiable risks for haemorrhage stroke
Modifiable Anticoagulation or anti platelet therapy HTN alcohol XS illicit drug use (crystal meth & cocaine)
Non-modifiable
Age
Ethnicity
Info in regards to alteplase
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)
Anti-Platelet therapy in stroke
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)
Anti-hypertensives post stroke
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.
Should we offer TEDS to patients post-stroke?
No - evidence suggests they have no benefit and cause skin damage.
Some patients are at high risk of VTE post stroke. What do we do?
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.
Should we give oxygen to these patients?
Only if they are hypoxic or sats <95%
What should we do if a patient is pyrexial?
paracetamol and fluids
What blood sugar range should we keep to?
5-15mmol/L
How do we reverse anticoagulants if a patient has a haemorrhage stroke?
vitamin K - warfarin
Idarucizumab - dabigatran
protamine will only partially reverse LMWH
What can we give to patients who have had a haemorrhage stroke and what does it achieve?
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.
Are we concerned about high BP in haemorrhagic stroke?
Yes we would treat this more aggressively that ischaemic stroke.
Secondary preventions
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.
How do we manage patients with AF who have a stroke
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
What is the target BP for patients post stroke?
130/80
What antihypertensives are recommended from the progress trial?
perindopril + indapamide
If a patient is on hypertension meds prior to admission we can continue these.
What antidepressant do we use post stoke?
sertraline - better cardiovascular safety profile.
Exclusion criteria for thrombolysis
History of diabetes
Seizure at onset of stroke
Systolic blood pressure of 200
Presentation 8 hours after symptoms
Is previous treatment with aspirin a contraindication for thrombolysis ?
No
