Stroke Flashcards
stroke, TIA or amaurosis fugax
Stroke - Neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours
TIA -Neurological deficit of cerebrovascular cause that persists less than 24 hours
Amaurosis Fugax - Painless temporary loss of vision – curtain descending over vision
definition of stroke
vascular
rapid onset
focal/global cerebral dysfunction
>24h or death
(TIA
importance of stroke
3rd leading causw of death 130,000 affected each year (1 every 5 minutes)
single biggest cause of sever adult disability
2.8 billion to NHS and 7 billion everall
neurology terms
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
hemianopia - loss one haf of visual fields
expressive aphasia
receptive aphasia
apraxia - motor task difficulty
asterognosis - inability to identify objects by touch alone
agnosia - inability to recognise objects
innattention (neglect) - inability to attend to stimuli bilaterally despite intact sensation
stroke features
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’ (cerebellar)
coortdination/balance/dizziness
crossed signs : ipsilateral CN, contralateral hemiparesis
Dysdiadokinesis Ataxia Nystagmas Intention Tremor Slurred Speach Hypotonia
stroke assessment
FAST
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:
General observation
GCS + ABCDE
CVS: RFs, Murmurs, BP, HR, HF, DVT, dissection
resp: complicaitons (DVT, PE, pneumonia)
neuro: locate lesion, confirm, umn or lmn
Ix
CT head for bleed
ECG - AF? MI?
Bloods (FBC, UE, LFTS, ESR, Glc, Lipids, platelets)
Dx
NIHSS: severity, ?location, ?thrombosis (NIH stroke scale/score) 0 = no stroke and 42 = most severe stroke
Rosier scale: ?admission; - assess between stroke and stroke mimics
stroke management
ABCDE
- Hx and exam (NIHSS-stroke severity score)-BAMFORD classification
- Within 4.5hrs-thrombolysis? (suspected I stroke and ruled out haemorhage with CT head)
- Thrombectomy within within 6-24 hrs depending where clot is (confirm with CTangiography or MRangiography
- 300mg aspiri within 24hrs for 2/52 then clop 75mg
Direct admission to stroke unit O2 Glucose level maintenance Hydration and nutrition (swallow assessment) Antiplatelets (if NOT a bleed) Statins Antihypertensives Assess/investigate risks (Echo, CDs) VTE prophylaxis Positioning Early MDT assessment
hemicraniotomy?: ICP, malignant MCA syndrome
OT application
splinting: ROM(range of movement) preservation and contracture prevention
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
PT application
optimise movement
sensorimotor stimulation (neural drive)
bone and muscle: alignment, activation, strength
reduced compensation and ineffective coping, and pain
-bobath concept and assisting neuroplasticity
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
stroke DDx
AKA stroke mimics (BEHIND_
- Brain tumour, haemorrhage, contusion
- Epilepsy (post ictal state)
- Hypoglycaemia/Hyponatraemia
- Intoxication/Infection
- Neuro: Peripheral/Migraine/MS/Myasthesia gravis/GBS/Mnd/ spinal cord lesions
- Dissection/Disc prolapse
Syncope
Electrolyte abnormalities
Functional disorders
Cerebral vasculitis
TIA stats
35 per 100,000; - 1/3 go on to have a stroke . . .most in the first 24hrs
classification (Oxford Bamford)
20% TACS = all of;
- Higher Dysfunction
- Dysphasia
- Decreased level of consciousness
- Visuspatial Neglect
- Asterognosis or Apraxia
- Dysphasia
2.Homonimous Hemianopia
- Motor/Sensory Deficit
- > 2/3 of face/arm/leg
35% PACS = higher dysfunction alone or 2/3 of the TAC domains
20%LACS = any one of;
- Pure Motor ( >2/3 of face/arm/leg)
- Pure Sensory ( >2/3 of face/arm/leg)
- Sensorymotor( >2/3 of face/arm/leg)
- Ataxic Hemiparesis
25% POCS = any one of;
- Cranial Nerve Palsy AND Contralateral Motor/Sensory deficit
- Bilateral Motor OR Sensory Deficit
- Conjugate Eye Movement problems
- Cerebellar Dysfunction
- Isolated Homonymous Hemianopia
stroke prognosis
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
stroke RF
ABCD2: age, BP, clinical, duration, DM; 2&7 day risk - NOT IN UK
CHA2DS2VASC: CHF, HTN, age (75), DM, stroke/sim, vasc disease, age (65-74), sex (F) - risk of stroke if AF
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
stroke complications
DVT/PE aspiration/hydrostatic pneumonia pressure sores depression seizure incontinence post-stroke pain (common): opiates, amitriptyline, gabapentin, pregabalin, DBS
MDT
Nurses and HCA Doctors Physiotherapists and rehab assts OTs SLTs Dietitians SW Nutrition assistants
Rehabilitation
Assessment Agreed goal setting Reassessment SMART Review and reassess with whole MDT MDT approach to goal achieving Impairments-activity limitations-participation-environmental factors (ICF)
(specific, measurable, achievable, relevant and time based)
cerebrovascular RFs
hypertention obeisty sedentary poor diet dm alcohol smoking hypercholesterolaemia AF (CHADSVASC score) male drugs fh age previous stroke/tia
SAH clinical manifestation
Sudden onset thunderclap headache
meningism
- nausia/vomitting
- stiff neck
- photophobia
- LOC
SAH ix
CT head
lumbar puncture - exclude in the last 2-3 weeks
