Stroke Flashcards
What are the risk factors for strokes?
Smoking Adverse family history Diabetes Hypertension Atheroma Polycythaemia or hyper viscosity Vasculitis High alcohol intake Thrombophilia Oral contraceptive pill Male Low exercise Dietary Increased weight AF
What is the acute management for stroke
o Oxygen to hypoxic patients
o Blood glucose concentration should be maintained between 4 and 11 mmol/L
- Dysphagia is common post stroke, therefore a swallowing assessment needs to be performed bedside
- Refer to vascular surgery if carotid Doppler shows stenosis >50%.
What are the investigations for stroke?
Bloods: FBC, U+E, lipids, glucose, ESR, TFT, clotting, screen-consider antiphospholipid antibody in venous stroke
CT brain: to establish diagnosis (infarct/haemorrhage/space-occupying lesion)
MRI: Diffusion weighted image (DWI) sequence to confirm infarcts. Magnetic resonance angiography (MRA) to look for intracranial stenosis
ECG: AF, LVH, cardiac ischaemia
Carotid doppler: look for ipsilateral carotid stenosis
Echocardiogram: To exclude endocarditis or mural thrombus : “bubble” echocardiogram to look for patent foramen ovale
What is the hyperacute management for stroke?
- FAST (Face, Arm, Speech Test) or ROSIER (Recognition Of Stroke In Emergency Room) should be used to screen for stroke or TIA
- Patients should be admitted immediately to a specialist stroke unit
- Neuroimaging, normally a CT scan, should be performed immediately
- Thrombolysis using alteplase should be considered for patients with ischaemic stroke presenting within 4.5 hours of onset where no contraindications are identified
- Clopidogrel should be given as soon as possible in acute ischaemic stroke. A combination of aspirin and dipyridamole is an alternative to clopidogrel
- Patients with primary intracerebral haemorrhage who are taking warfarin should have this reversed using vitamin K and prothrombin complex concentrate
What is the epidemiology of strokes?
- 110,00 strokes in the UK each year and 50,000 TIAs
- Single biggest cause of severe adult disability- 3rd biggest cause of death
- 20-30% of patients die within a month of stroke
What is the Oxford classification of stroke?
• Total Anterior Circulation Stroke (TACS)- 20% of stroke o Higher dysfunction dysphasia, reduced consciousnesss, visuospatial neglect, asterognosis o Homonimous hemianopia o Motor/sensory deficit • Partial Anterior Circulation Stroke (PACS)- 35% of stroke o 2 out of 3 of TACS o Higher dysfunction alone • Lacunar Stroke (LACS)- 20% of stroke o Pure motor o Pure sensory o Sensorymotor o Ataxic hemiparesis o NONE OF THESE New dysphasia New visuospatial problem Proprioceptive sensory loss only No vertebrobasilar features • Posterior Circulation Stroke (POCS)- 25% of stroke o Cranial nerve palsy AND contralateral motor/sensory deficit o Bilateral motor or sensory deficit o Conjugate eye movement problems o Cerebellar dysfunction o Isolated homonymous hemianopia
What are the risk factors for an intracerebral haemorrhage?
o On anti-coagulation o Bleeding tendency o Depressed consciousness o Severe headache o Hypertension +++ o Vomiting o BM >11
What are the causes of intracerebral haemorrhage?
- Primary causes- BP or amyloid angiopathy
* Secondary- underlying lesion, coagulopathy
What is the management for intracerebral haemorrhage?
o Reverse anticoagulants
o Stop antiplatelet
o Potential rapid deterioration
o Roles of neurosurgery/ITU
What is the assessment for intracerebral haemorrhage?
Confirm history Exclude mimics: Migraine Space-occupying lesions Seizure Syncope Metabolic disturbance Peripheral neuropathy Cervical spine pathologies Transient global amnesia Psychiatric conditions Time on onset- important for thrombolysis
What are the areas that can be affected in cerebral haemorrhage?
o Motor o Speech o Vision o Sensation o Coordination o Conscious level o Memory
What are the indications for urgent scan?
RCP guidelines- all strokes to be scanned within 24hrs soon to be 12
Thrombolysis
On anti-coagulation
Bleeding tendency
Unexplained progressive/fluctuating symptoms
Depressed conscious level
Suspicion of SAH
What are the benefits of a head CT?
Early accessible Fast Sensitivity for bleeding High radiation burden Critical to exclude haemorrhage
What are the early signs of infants on head CT?
o Hyperdense MCA
o Loss of grey-white differentiation
o Sulcal effacement
o Loss of insular ribbon
What are the benefits of a brain MRI?
o Less accessible o Longer procedure o Contraindications o More detailed, better images o Define pathologies and arterial supplies
What are the blood and other investigations?
o FBC, U&E, LFT, TFT o Glucose o Lipids o Coagulation o ESR o Thrombophilia screen o Vasculitic screen • Look at ECG for AF, LVH or ischaemic changes • Look at Echo for valvular disease (SBE), mural thrombus, LVH & PFO
What are the indications for thrombolysis using Altepase (0.9mk/kg)?
o Up to 4.5 hours o Clear time of onset o Clinical symptoms and signs of acute stroke o Haemorrhage excluded o Age- no upper age limit
What are the contraindications for thrombolysis?
o Rapidly improving or minor stroke symptoms
o Stroke or serious head injury 3 months
o Major surgery, obstetrical delivery, external heart massage last 14 days,
o Seizure at onset of stroke
o Severe haemorrhage last 21 days
o Bleeding tendency
o History of central nervous damage- neoplasm, haemorrhage, aneurysm, spinal or intracranial surgery or haemorrhagic retinopathy
Known clotting disorder
Hypoglycaemia (<3) or hyperglycaemia (>20)
Bacterial endocarditis/pericarditis
Large hypodensity on CT scan >1/3 of MCA territory rule
IDA or thrombocytopenia
Acute pancreatitis, oesophageal varices, aortic aneurysm, active hepatitis, cirrhosis
Cancer with increased bleeding
Severe uncontrolled hypertension >185/110
When are anti-platelets used?
o Acute- Aspirin 300mg PO/PR for 2 weeks
o Stroke- Clopidogrel 75mg
o TIA- Clopidogrel 75mg
Which anti-coagulation is used?
Secondary prevention
o Heparin (UF/LMWH)- increases risks of bleeding
o Warfarin for AF
o CHAD2VASC score
o Anti-platelets for 2wks (risk of HTI), then switch with Clopidogrel
Which DVT prophylaxis is used?
o Bed bound or less active
o Enoxaparin- started on day 3 in ischaemic stroke
o TED stockings increases risk of skin complications
o Mechanical compression stockings have evidence for use in stroke
What are the complications of stroke?
- DVT
- Pulmonary embolism
- Aspiration and Hypostatic pneumonia
- Pressure sores
- Depression
- Seizure
- Incontinence
- Post stroke pain
What are the specific stroke pain syndromes?
o Headache- both haemorrhage or infarcts o Dissection o Back pain- bedbound o Low-tone- shoulder subluxation o High-tone- myalgia o Oedema o Constipation/retention o Associated conditions- IHD, gout, OA, VTE o Central post-stroke pain
What are the clinical signs of deterioration following thrombolysis?
Intracerebral haemorrhage Recurrent cerebral infarction Seizure Hypotension Sepsis Hypoglycaemia Cerebral oedema Systemic bleeding
What is the dose for alteplase?
0.9mg/kg weight
10% bolus and 90% over 1 hour
