Stroke Flashcards
Define stroke
A clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin
Define TIA
Duration less than 24 hours
Define ischemia
Interruption of blood supply
Define haemorrhage
Bleeding into brain
Symptoms of a stroke of the carotid artery
Weakness of:
- face
- leg
- arm
- impaired language
- amaurosis fugax
Symptoms of a stroke of the posterior circulation
- dysarthria (impaired speech)
- dysphagia
- diplopia
- dizziness
- ataxia
- diplegia (paralysis)
Treatment for a TIA
A: aspirin (300mg stat, 75mg daily (give with PPI if hx of dyspepsia)
B: Admit to acute stroke unit
C: Treat BP
D: Order CT
What score is used to identify risk of stroke after TIA?
ABCD2
What is the ABCD2 risk score?
Age: over 60 =1 BP SBP>140 or DBP>90 = 1 Clinical features: unilateral weakness = 2 Speech disturbance alone = 1 Duration of sx: >60 mins = 2 10-60 mins = 1 <10 mins = 0 Diabetes =1
what do the scores mean?
1-3 risk is 0.4%
4-5 risk is 12%
6 risk is 31%
When are you at a high risk of a TIA?
- ABCD2>/=4
- more than one TIA in last 7 days
- new arrhytmia
- known high grade ipsilateral carotid stenosis
If at high risk of TIA
300mg aspirin for 2 weeks then clopidogrel
- specialise assessment and ix within 24hrs of sx
Imaging after a TIA
MRI
Carotid doppler (look for significant stenosis of internal carotid)
24 hour ECG
Surgery for TIA
Carotid endarterectomy and carotid stenting when symptomatic carotid stenosis
Are ischaemic or haemorrhagic more common?
Ischaemic (85%)
Haemorrhagic (15%)
Acute iscaemic stroke has 3 main blood supplies
- Anterior circulation infarction (partial/total)
- Posterior circulation infarction
- Lacunar infarction
Sx of an anterior circulation infarction?
ANTERIOR AND MIDDLE ARTERIES
Contralateral weakness Contralateral sensory loss/sensory inattention Dysarthria Dysphasia (receptive, expressive) Homonymous Hemianopia/visual inattention Higher cortical dysfunction
Sx of a posterior circulation infarction?
Cranial nerve palsy and a contralateral motor/sensory deficit (‘crossed signs’)
Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia, dysarthria)
Isolated homonymous hemianopia
Bilateral events can cause reduced GCS
Sx of a lacunar circulation infarction?
Occlusion of deep penetrating arteries
Only affects a small volume of subcortical white matter (therefore do not present with cortical features e.g. dysphasia, apraxia, neglect, visual field loss)
Underlying process is often referred to as small vessel disease (arterial wall disorganisation, microatheroma, lipohyalinosis)
Lacunar syndromes: Pure motor hemiparesis Ataxic hemiparesis ‘Clumsy hand’ and dysarthria Pure hemisensory Mixed sensorimotor
If a ptx comes in with a stroke what is the pathway?
- ABCDE + bloods
- brief hx and ex
- BP
- Grade severity of stroke
- urgent CT head (+/- CT angiography)
- Thrombolysis (4 and a half hours) +/- mechanical thombectomy if indicated or aspirin 300mg
- Ix cause
- Screen and prevent complications (dehydration, aspirin, VTEs. pressure sores, infection)
- Establish 2ndry prevention
- rehab - physios, OT, SALTs
Example of thrombolyssis
Alteplase (tissue plasminogen activator)
Time limit for thrombolysis
4.5 hours
CIs for thrombolysis
- haemorrhagic stroke
- Suspected SAH
- recent GI/UT haemorrhafe in 3 weeks
- recent treatment with warfarin
- 14days post major surgery
- abnormal blood glucose
- pregnancy
- acute pancreatitis
3 post thrombolysis care
- More aggressive BP monitoring
- Vigilance for complications (bleeding)
- 24 hour CT to check for haemorhagic transformation
When would a mechanical thrombectomy be used?
- proximal stenosis
- 6 hour time frame
- limited resource
What ix would you do for a ?stroke?
Blood tests ECG Carotid doppler USS Echocardiogram MRI
Which blood tests would you do?
FBC – Hb and HCt (PRV/anaemia and hypo-oxygenation), MCV (haemoglobinopathies), WCC (intracranial infection, endocarditis), platelet count (high/low)
ESR (vasculitis/autoimmune disease)
U&Es (hydration status, guide drug treatment)
Lipid profile (hypercholesterolaemia/triglyceridaemia)
LFTs (can affect clotting, guides drug treatment)
CRP (infection – causative/associated)
Clotting screen (APTT, PT, Fibrinogen)
Glucose and HbA1C (hyper/hypoglycaemia – mimic/risk factor)
Why would you do an ECG?
MI, atrial fibrillation/flutter
When would you add a 72 hour tape to the ECG?
paroxysmal AF
Why would you do a cortid doppler USS
carotid stenosis
Why would you do a echocardiogram?
endocarditis/thrombus
Why would you do an MRI
confirm diagnosis, look for multiterritory infarcts – delayed CT head if MRI contra-indicated
In a young patient/atypical stroke what ix should you consider?
Bloods: - HIV and vasculitic screen - Thrombophilia screen - Homocysteine Cardiac investigations: - 7 day Holter recorder/implantable loop recorder - Transcranial dopplers - Transoesophageal echo Vascular imaging: - CT angiography - MR anigography
Role of nurses in stroke recovery
Analysing clinical status and progress; blood pressure management
Administration of medications
Nasogastric feeding
Preventing pressure sores
Role of physios in stroke recovery
Strength, balance, function
Preventing spasticity
Chest physiotherapy in infections and sputum clearance
Role of OTs in stroke recovery
Functional assessments and future needs planning
Cognitive and mood screening
Role of SALTs in stroke recovery
Swallowing impairment and prognosis
Communication rehabilitation in dysphasias
Other members of MDT for stroke
- dietician
- orthoptics
Lifestyle management after a stroke?
Smoking cessation
Drug and alcohol cessation
Dietary modifications
Exercise
Driving advice (one month after stroke/TIA)
Medical management to prevent complications
VTE assessment
- Intermittent pneumatic
compression devices
Hydration
NG feeding +/- PEG feeding
Spasticity
- Physiotherapy
- Botox
Monitoring for infection
Medical secondary prevention
Antiplatelets:
- Aspirin 300mg PO/PR for 2 weeks (small ARR) and clopidogrel lifelong
Anticoagulation:
- If in AF or evidence of pAF – may need to wait up to 2 weeks
- HASBLED and CHADSVASC scores
Hypertension:
- Acute: risk of hypoperfusion
- Chronic: long term blood pressure target of < 130/80 (higher if severe bilateral carotid stenosis)
Cholesterol:
- Statin therapy – aim 40% reduction in non-HDL cholesterol
Surgical management
Extracranial Carotid Stenosis:
- USS carotid dopplers +/- CTA/MRA
- Ipsilateral (symptomatic) carotid stenosis
Alternative: carotid artery stenting
Malignant MCA syndrome
- Decompressive hemicraniectomy
Posterior circulation infarct
- Risk of hydrocephalus
- EVD/posterior fossa decompression
Management of a haemorrhagic stroke
- ABCDE - monitored environment, regular neuro-observations (inc GCS and pupils)
- Blood pressure? (140-160 systolic acutely, <130/80 long term)
- Bleeding tendency? (coagulopathy/low platelets/medication-related)
- Underlying malformation? (tumour aneurysm, amyloid angiopathy, AV malformation, cavernoma)
- Need for neurosurgery? (useful for superficial clots, CSF obstruction causes hydrocephalus, posterior fossa decompression)
Anticoagulation options and their reversers
DOACs are LESS reversible*
Warfarin (Beriplex and Vitamin K)
Heparin (Protamine)
LMWH (partially reversed with protamine)
Apixaban/Rivaroxaban/Edoxaban (Beriplex is possibly effective)
Dabigatran (Idarucizumab)
Differentials for a stroke
Seizures
Tumours /Abscess
Migraine
Metabolic (e.g. hypoglycaemia, hyponatraemia)
Functional
Spinal cord/peripheral nerve/cranial nerve
