Stroke Flashcards
Types of stroke
- Ischaemia or infarction of brain tissue secondary to inadequate blood supply
- Intracranial haemorrhage
Ischaemic Stroke causes
Thrombus formation or embolus, for example in patients with atrial fibrillation
Atherosclerosis
Shock
Vasculitis
TIA
What is it: old vs new definition
Crescendo
Transient ischaemic attack (TIA) was originally defined as symptoms of a stroke that resolve within 24 hours.
It has been updated based on advanced imaging to now be defined as transient neurological dysfunction secondary to ischaemia without infarction.
Transient ischaemic attacks often precede a full stroke.
A crescendo TIA is where there are two or more TIAs within a week. This carries a high risk of developing in to a stroke.
Clinical Features
Sudden weakness of limbs
Sudden facial weakness
Sudden onset dysphasia (speech disturbance)
Sudden onset visual or sensory loss
Risk factors
Cardiovascular disease such as angina, myocardial infarction and peripheral vascular disease Previous stroke or TIA Atrial fibrillation Carotid artery disease Hypertension Diabetes Smoking Vasculitis Thrombophilia Combined contraceptive pill
Tool for Identifying a Stroke in the Community
F – Face
A – Arm
S – Speech
T – Time (act fast and call 999)
Tool for Recognition Of Stroke In Emergency Room
ROSIER is a clinical scoring tool based on clinical features and duration.
Stroke is likely if the patient scores anything above 0.
Score used for assessing patients with a suspected TIA to estimate their risk of subsequently having a stoke
ABCD2 score is used for assessing patients with a suspected TIA to estimate their risk of subsequently having a stoke.
A higher score suggests a higher risk of stroke within the following 48 hours.
The ABCD2 score is based on:
A – Age (> 60 = 1)
B – Blood pressure (> 140/90 = 1)
C – Clinical features (unilateral weakness = 2, dysphasia without weakness = 1)
D – Duration (> 60 = 2, 10 – 60 = 1, < 10 = 0)
D – Diabetes = 1
Score outcome:
≤ 3: specialist assessment within 1 week
> 3: specialist assessment within 24 hours
Ischaemic Stroke Management
Admit patients to a specialist stroke centre
Exclude hypoglycaemia
Immediate CT brain to exclude primary intracerebral haemorrhage
Aspirin 300mg stat (after the CT) and continued for 2 weeks
Thrombolysis with alteplase can be used after the CT brain scan has excluded an intracranial haemorrhage. It needs to be given within 4.5 hours.
Patients need monitoring for post thrombolysis complications such as intracranial or systemic haemorrhage. This includes using repeated CT scans of the brain.
Generally blood pressure should NOT be lowered during a stroke because this risks reducing the perfusion to the brain (should only lower if systolic greater than 180)
TIA management
Start aspirin 300mg daily.
Start secondary prevention measures for cardiovascular disease. (Statin 80mg, Clopidogrel 75mg)
If they have crescendo TIAs they should be seen within 24 hours by a specialist.
Perform an ABCD2 Score
≤ 3: specialist assessment within 1 week
> 3: specialist assessment within 24 hours
300mg aspirin in the meantime
Specialist Imaging
Aim
What is used
The aim of imaging is to establish the vascular territory that is affected. It is guided by specialist assessment.
Diffusion-weighted MRI is the gold standard imaging technique. CT is an alternative.
Carotid ultrasound can be used to assess for carotid stenosis. Endarterectomy to remove plaques or carotid stenting to widen the lumen should be considered if there is carotid stenosis.
Secondary Prevention of a stroke
Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily) [300mg aspirin for 2weeks then swap to 75mg clopidogrel]
Atorvastatin 80mg should be started but not immediately
Carotid endarterectomy or stenting in patients with carotid artery disease
Treat modifiable risk factors such as hypertension and diabetes
Stroke Rehab
Once patients have had a stroke they require a period of adjustment and rehabilitation. This is an essential and central to stroke care. It involves a multi disciplinary team including:
Nurses Speech and language (SALT) Nutrition and dietetics Physiotherapy Occupational therapy Social services Optometry and ophthalmology Psychology Orthotics
Posterior Stroke Syndromes
Locked in syndrome:
- due to Basilar artery occlusion
- features: quadriparesis with preserved consciousness and ocular movements), loss of consciousness, or sudden death.
Lateral Pontine Syndrome:
- due to Anterior inferior cerebellar artery occlusion
- features: lateral medullary syndrome with additional involvement of pontine cranial nerve nuclei (ipsilateral facial paralysis and deafness)
Wallenberg’s syndrome syndrome (lateral medullary syndrome)
- due to posterior inferior cerebellar artery occlusion
- features:
ipsilateral Horner’s syndrome
ipsilateral loss of pain and temperature sensation on the face
contralateral loss of pain and temperature sensation over the body
= cerebellar signs (nystagmus and ataxia)
[DANVAH - Dysphagia, Ataxia, Nystagmus, Vertigo, Anaeathesia (ipsilateral facial numbness, contralateral pain and temperature loss in women), Horner’s Syndrome]
Haemorrhagic Stroke Causes / risk factors
Cerebral Amyloid Angiopathy (amyloid builds up in the walls of blood vessels. Associated with hypertension)
Hypertension
Anticoagulation
Cerebral Aneurysms
Cerebral Neoplasm
Trauma
