What are the broad classifications of stroke?
Ischaemic - 80%
Intracerebral haemorrhage - 15%
Subarachnoid haemorrhage - 5%
What are the classifications of ischaemic stroke (Oxford/Bamford classification)? AND PREVALENCES
TACI - total anterior circulation stroke (15%)
PACI - partial anterior circulation stroke (35%)
POCI - posterior circulation stroke (25%)
LACI - lacunar stroke (25%)
Define stroke and TIA
An acute neurological deficit lasting >24h and of vascular pathology
TIA = <24h, no permanent brain damage, big RF for stroke
Definition of total anterior circulation stroke
All three of these present:
- Higher cerebral dysfunction (e.g. dysphasia, visuospatial disorder)
- Homonymous hemianopia
- Ipsilateral motor/sensory defect
Definitions of PACS
Two of the three criteria of TACI
- Higher cerebral dysfunction (e.g. dysphasia, visuospatial disorder)
- Homonymous hemianopia
- Ipsilateral motor/sensory defect
Definition of POCI
Any one of these are present
- Cranial nerve palsy and a contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (e.g. horizontal gaze palsy)
- Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
- Isolated homonymous hemianopia
Definition of LACI
No loss of higher cerebral functions
Either a:
- Pure motor stroke
- Pure sensory stroke
- Pure sensorimotor
- Ataxic hemiparesis
What are some risk factors for ischaemic stroke? (10)
- Hypertension
- Hypercholesterolaemia
- Diabetes
- Previous stroke /TIA
- Smoking
- Alcohol excess
- Age
- Male
- AF
- Carotid disease
Investigations for ischaemic stroke
CT head Blood glucose Bloods CXR ECG
- Carotid duplex ultrasound/CTA
Then consider:
- Prolonged ECG
- Echo
- Atypical screen
What is thrombolysis?
Patient is given rTPA (alteplase)
Within 4.5h of symptom onset
Why does thrombolysis need to be given within 4.5h?
Penumbra theory
Penumbra is potentially salvageable tissue that is moderately ischaemic but may remain viable for a short period due to collateral circulation.
However, the collateral circulation doesn’t meet the needs of the area so cells will die if reperfusion doesn’t occur!!
Thrombectomy
May be used alongside or as an alternative to thrombolysis
<6h from symptom onset (longer in basilar occlusion
Management of ischaemic stroke
- (Thrombolysis, thrombectomy if possible)
- Aspirin, then Clopidogrel (after 2 weeks)
- IV fluids
- Atorvastatin
- Therapy
- Nutrition
- Long-term control of RFs (e.g. BP, lifestyle modifications)
What further management could be considered for Ischaemic stroke?
- Referral for carotid endarterectomy
- If in AF- consider anticoagulation at 2 weeks
- Left atrial appendage or PFO closure
What would be the indication for a carotid endarterectomy?
if >70% stenosis of ipsilateral ICA
What is the dosing and duration of Aspirin and Clopidogrel treatment following an ischaemic stroke?
Aspirin - 300mg OD for 2 weeks
THEN Clopidogrel 75mg OD
What are some risk factors for haemorrhagic stroke?
- Hypertension
- Cerebral amyloid angioplasty –> deposition of beta-amyloid in media and adventitia of cerebral arteries means they are more likely to tear
- Anticoagulation
- Arterio-venous malformation
- Mass
Investigations for a haemorrhagic stroke
- CT head
- Bloods (inc. INR and thrombin time if appropriate
- ECG
- CXR
Management of haemorrhagic stroke
- BP control
- Urgent reversal of anticoagulation and stop antiplatelets/anticoagulants
- IV fluids
- Therapy and management of complications
Name some stroke mimics (9)
- Hypoglycaemia
- Migraine
- Tumour
- Seizures/epilepsy
- Bell’s palsy
- Multiple sclerosis
- TIA
- Systemic infection
- Subdural haemorrhage
