Stroke Flashcards
what is the WHO defintion of a stroke?
rapidly developing clinical signs of disturbance of cerebral function lasting for more than 24 hours (or leading to death) with no apparent cause other than that of vascular origin
what are the 2 types of stroke?
- Ischaemic stroke
* Haemorrhagic stroke
what is an ischaemic stroke?
– 70% strokes
– Cerebral thrombosis from atherosclerotic disease
– Distal embolism from cardioembolic disease
what is a haemorrhagic stroke/
– Intracerebral haemorrhage (rupture of small vessel in brain)
– Subarachnoid haemorrhage (rupture of intracranial aneurism in the subarachnoid space)
what are the symptoms of a stroke?
F acial weakness: can the person smile? Has their mouth or eye drooped?
A rm (or leg) weakness: Can the person raise both arms (or legs)?
S peech: Can the person speak clearly and can you understand what they say?
T ime: to call 999
• A stroke is suspected if ANY of these symptoms are displayed
• Also ROSIER (recognition of stroke in emergency room) scale used
what are the non-modifable risk factors of a stroke?
age - risk doubles every decade over 55
gender - men are at higher risk but more women die
- family history
- afro-caribbean
what are the modifable risk factors of a stroke?
- hyper tension
- atrial fib
- diabetes
- hyperlipidaemia
- smoking
what investigations need to be carried out?
- CT quickly
- MR scan
- BP
- ECG
- FBC
- Blood Glucose
- inflammatory markers
what would you see in a CT scan of a ischaemic stroke?
demarcated hypodense zone (although often difficult to spot)
what would you see in a CT scan of a haemorrhagic stroke?
haemorrhage clearly visible – areas of high attenuation (appear bright)
what are the acute treatments of a stroke?
- Patients should be transferred to a hyper-acute stroke unit as soon as possible
- Investigations performed to confirm diagnosis
why do you need to know what type of stroke it is?
– One is a blockage give anticoagulants
– One is a bleed this would kill them if you gave anticoagulants
what is thrombus management?
the window for treating a stork if smaller, the longer you wait the less likely it is to be effective.
if you wait TOO long you are likely to have another bleed on top of it
what is thrombolysis?
clot busting drug to try and break the clot and allow oxygen to get round to parts of the brain which will have been damaged
- ALTEPLASE
when is Alteplase needed to be given?
• Give within 3 hours of symptom onset – very first time tingling/speech issues you have 3 hours to get to hospital and get a CT scan.
– (licensed up to 4.5 hours, but efficacy drops off massively during this; much safer the more under 80s safer, as over this the risk of bleeding is much higher and need to check that this is still eligible)
– But twice as effective if given before 1.5 hours
it is the gold standard if given within the correct time scale
what is thrombectomy?
procedure to remove the clot with or without thrombolysis
- but needs to be done fairly quickly
what antiplatement should you give to an ischaemic stroke?
Aspirin 300mg
• Give as soon as possible (once bleed ruled out), even without a Rx as soon as the risk of bleeding has gone
• Give PR or via NG tube if necessary – dispersible aspirin can be given or given rectually
• Continue for (up to) 14 days not just a stat dose
– This depends on if they are ready to go home, we may change there treatments for long term secondary prevention, also AF needs a different set up
what happens if a patient has been thrombolysed?
NEED TO WAIT 24 HOURS BEFORE GIVING AN ANTIPLATELET
- this increases risk of bleeding if you give them together
what is acute treatment of a haemorrhagic stroke?
• Stop anything that will be making the bleed worse
– Anticoagulants – reverse them. So if they are on warfarin give them Vitamin K or transfusion of a prothrombin complex
• Neurosurgical intervention sometimes necessary
– Operate and stent that part of the brain and stop the bleed
• Anticoagulants stopped plus reversed if INR >1.4
– Vitamin K
• Prothrombin complex concentrate
how do you control blood pressure?
- Fluctuating BP (esp high BP) common after acute stroke
* When you have a stroke the body increases blood pressure to try and increase oxygen to the brain. NORMAL response
what is the treatment of Blood pressure for an ischaemic stroke?
- Only manage high BP if hypertensive emergency with complications of hypertension (e.g. MI) or if patient is eligible for thrombolysis
- Less than 185/110 mmHg required for thrombolysis if you are within the 3 hour window and this is the only reason you would treat the high blood pressure
- If hypertensive emergency heart attack you would reduce blood pressure as you don’t want any further complications
what is the treatment of high blood pressure for a haemorrhagic stroke?
• Treat if greater than 150mmHg systolic (up to 6 hours after symptom onset) or if greater than 220mmHg systolic beyond 6 hours. Aim for 130 - 140mmHg systolic for at least 7 days. This would increase risk of bleed becoming uncontrolled if you did not treat.
what are general measure you need to bare in mind post stroke?
- ability to swallow
- ensure fluid balance
- monitor temp
- control blood glucose
- DVT prophylaxis
why do you need to monitor blood glucose levels?
– If it falls within the diabetic range then you need to treat this – finger prick test every few hours
– Patients with metformin chances are it will be stopped and just keep the glucose levels very steady by giving iv insulin
how do do DVT prophylaxis?
– LMWH NOT routinely used (risk of bleed)
– Anti-embolism stockings NOT used
– Intermittent pneumatic compression should be used if patient is immobile – ballons around calves that inflate and deflate
what is secondary prevention for a stroke?
– Antiplatelet (or anticoagulant in embolic stroke) –clopidogrel 1st line
– If patient has had an ishaemic stroke but also has AF, then the AF puts them at higher risk so we would give them an anticoagulant INSTEAD of an antiplatelet
• NOT in haemorrhagic stroke
– Lower cholesterol (ischaemic) slow the disease process down, doesn’t matter what there cholesterol was
– Control hypertension
– Control blood glucose
what would you give as long term antiplatelet?
– Clopidogrel, better then just low dose aspirin
– Aspirin plus MR dipyridamole if clopidogrel not tolerated
– MR dipyridamole if aspirin and clopidogrel not tolerated
what would you give as an anticoagulant?
– in AF if CHA2DS2-VASC score of 2 or 1 if they are a man they need to be a anticoagulated
– Warfarin or DOAC (apixaban, rivaroxaban, dabigatran)
– Usually most patients DOAC the benefits outweigh the risks so you would use that first line but some patients warfarin may be the better choice (can be reversed with vitamin K, so this might be better for patients who are more at risk of bleeding)
– Need regular blood tests on warfarin – elderly usually prefer this
what would you give as antihypertensive?
– Reduce risk of further ischaemic / haemorrhagic stroke in both hypertensive and previously normotensive patients
– Start after 2 weeks or sooner if discharged from hospital
– Follow NICE guidance for hypertension
• Aim for BP less than 130mmHg systolic
what would you give as a statin?
atorvastatin
– Lipid lowering reduces risk of ischaemic stroke
• High intensity statin e.g. atorvastatin 20 – 80mg
– Avoid in haemorrhagic stroke unless patient has CV risk requiring treatment
what would you do for swallowing difficulties?
– NG / PEG feeding may be needed
– Thickened fluids and / or puree diet (SALT)
– Review all medication
– Necessary medication in appropriate formulation
what would you give a patient for dry mouth?
– Artificial saliva and good oral hygiene / mouthcare
what would you give for sialorrhoea?
this is excessive salvia production
– Oral glycopyrronium / atropine eye drops (in mouth) / hyoscine patch – these are for excessive salvia production
what do you do for patients if they have depression?
– Screen all patients for depression (30% experience)
– Treat as per NICE (i.e. SSRI first line)
what happens if a patient has seizures?
– Common problem (up to 67% late onset seizures post ischaemic stroke)
– Give prophylactic antiepileptic drugs if recurrent seizures diagnosed as epilepsy
– As per epliepsy lecture
what do you give for a patient who is struggling with spasticity?
– Skeletal muscle relaxants – baclofen, tizanidine
– Botulinum toxin recommended by RCP stroke guidelines
