STROKE Flashcards
requirements of the oxford stroke criteria
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
TACI define
- involves middle and anterior cerebral arteries
- all 3 of the above criteria are present
posterior anterior circulation infarcts include
- involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
- 2 of the above criteria are present
lacunar infarcts define
- involves perforating arteries around the internal capsule, thalamus and basal ganglia
- presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
posterior circulation infarcts
- involves vertebrobasilar arteries
- presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
lateral medullary syndrome define
(posterior inferior cerebellar artery)
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
webers syndrome
ipsilateral III palsy
contralateral weakness
which arteries are affected in TACI
anterior and middle cerebral arteries
define stroke
sudden interruption in the vascular supply of the brain.
what are the two types of stroke
ischaemic
- more than 24 hours
- less than 24 hours - TIA
haemorrhagic
define iscahemic stroke
It is usually caused by blood clot in an artery, which blocks the flow of blood.
- 85%
- clot from atheroma
- embolus from AF
define heamorrhagic stroke
damaged or weakened artery may burst and bleed:
- An intracerebral haemorrhage occurs when the blood vessel bursts inside the brain. The blood then spills into the nearby brain tissue. This can cause the affected brain cells to lose their oxygen supply. They become damaged or die.
subarachnoid haemorrhage
what is TIA
causes symptoms similar to a stroke but the symptoms last for less than 24 hours. It is due to a temporary lack of blood to a part of the brain. In most cases, a TIA is caused by a tiny blood clot that becomes stuck in a small blood vessel (artery) in the brain. This blocks the blood flow and a part of the brain is starved of oxygen. The affected part of the brain is without oxygen for just a few minutes and soon recovers. This is because the blood clot either breaks up quickly or nearby blood vessels are able to compensate.
Symptoms of a stroke
sudden onset - more than 24 hours CANNOT BE EXPLAINED BY ANOTHER CONDITION SUCH AS HYPOGLYCAEMIA
Weakness of one side of the body
visual problems - HOMONYMOUS HEMIANOPIA double vision, visual field loss
speech such as dysphasia/dysarthria and communication difficulties.
swallowing difficulties- do a swallow test before they allowed to eat or drink
Problems with balance and co-ordination.
Confusion, altered level of consciousness and coma.
Difficulties with mental processes. For example, difficulty in learning, concentrating, remembering
Headache – sudden, severe and unusual headache which may be associated with neck stiffness. Sentinel headache(s) may occur in the preceding weeks.
Dizziness, vertigo or loss of balance — isolated dizziness is not usually a symptom of TIA.
Sensory loss – paraesthesia or numbness.
Inappropriate emotions.
tiredness
posterior circualation stroke symptoms
acute vestibular syndrome — acute persistent continuous vertigo or dizziness with nystagmus - nausea or vomiting - head motion intolerance - new gait unsteadiness.
risk factors of stroke
age hypertension smoking hyperlipidaemia diabetes mellitus
lifestyle
- Smoking.
- Alcohol misuse and drug abuse (for example cocaine, methamphetamine).
- Physical inactivity.
- Poor diet.
Established CVS disease
- Hypertension.
- Permanent and paroxysmal atrial fibrillation (AF)
- Infective endocarditis.
- Valvular disease.
- Carotid artery disease — atheroma and stenosis of the carotid arteries are commonly associated with stroke and TIA.
- Congestive heart failure.
- Congenital or structural heart disease including patent foramen ovale.
other factors
- Age — the risk of having a stroke doubles every decade after the age of 55.
- Gender — Men are more likely than women to have a stroke at younger age. In women, an increased risk of stroke has been associated with current use of oral contraceptives, migraine with aura, the immediate postpartum period, and pre-eclampsia.
- Hyperlipidemia.
- Diabetes mellitus.
- Sickle cell disease.
- Antiphospholipid syndrome and other hypercoaguable disorders.
- Chronic kidney disease.
Obstructive sleep apnoea - (OSA) —cardiovascular risk factors such as hypertension, diabetes, smoking, and obesity are common in people with OSA but it is also an independent risk factor for stroke.
complications in the early period of stroke
- Haemorrhagic transformation of ischaemic stroke.
- Cerebral oedema.
- Seizures.
- Venous thromboembolism — pulmonary embolism
- Cardiac complications — cardiac complications (myocardial ischemia, congestive heart failure, atrial fibrillation, and arrhythmias)
- Infection
- – aspiration pneumonia
- – urinary tract infection
- – cellulitis from infected pressure sores.
long term complications of stroke
mobility
- hemiparesis and hemiplegia
- ataxia
- falls
- spastcity and contractures
sensory
- loss or alteration in sensations such as touch, temperature, and pain.
urinary and faecal incontinence
- urinary incontinence increases skin of breakdown
pain
- neuropathic pain or central post-stroke pain
- MSK pain - prolonged immobility, abnormal posture or pre-existing conditions.
- Shoulder pain - shoulder subluxation, motor weakness and spasticity
fatigue
- ass w depression and anxiety
SEs of meds, disturbed sleep, or respiratory problems.
swallowing, hydration and nutrition
- dysphagia
- poor oral hygiene
- dehydration and malnutrtition
communication
- dysphasia
- dysarthria
sexual dysfunction
altered sensation, limited mobility
skin problems
- pressures sores due to reduced mobility
visual problems
- altered acuity, hemianopia, diplopia, nystagmus, and blurred vision.
Difficulties with activities of daily living (ADL)
- Physical and cognitive impairment following stroke can lead to difficulties with personal care, driving, work, leisure and independent living.
emotional and psych
- depression and anxiety
cognitive problems seen in long term stroke complications
Dyspraxia (difficulty in carrying out purposeful actions) can affect activities of daily living such as dressing.
Impairment of attention and concentration can restrict independence.
Impairment of executive function can lead to difficulty in planning and executing tasks, inhibiting inappropriate impulses, regulating emotional responses and predicting consequences of actions.
Problems with spatial awareness such as left-sided neglect or hemianopia.
Examination of stroke
- Airway, breathing and circulation (ABC).
- Vital signs including blood pressure, heart rate, oxygen saturation, and temperature.
- The cardiovascular system — look for signs of heart failure, arrhythmias (such as atrial fibrillation), murmurs, valvular heart disease, endocarditis.
- The neurological system — look for clinical signs of stroke or TIA such as unilateral weakness, visual or speech disturbance, ataxia, and nystagmus.
- – The Face Arm Speech Test (FAST test) can be used for rapid assessment — it is positive if one or more of new facial weakness (asymmetry such as the mouth or eye drooping), arm weakness, or speech difficulty (such as slurring or difficulty in finding names for commonplace objects) are present.
— Carry out fundoscopy to identify intraocular haemorrhage (present in one in seven people with aneurysmal SAH).
Ix for stroke
non-contrast CT head
check blood glucose to rule out hypoglycaemia as it is a stroke mimic
FBC
exclude anaemia/thrombocytopenia prior to possible initiation of thrombolysis, anticoagulants, or antithrombotics
U&Es
- exclude renal failure as it may contradict some stroke interventions
- exclude electrolyte disturbance ie hyponatraemia causes sudden onset neurological signs
ECG to exclude arrhythmia - AF/ischaemia
carotid doppler
prothrombin time and PTT with INR
when do you request a non-enhanced CT head
within 1 hour if any of the following apply:
- indications for thrombolysis or thrombectomy
- On anticoagulant treatment
- A known bleeding tendency
- A depressed level of consciousness (Glasgow Coma Scale score <13)
- Unexplained progressive or fluctuating symptoms
- Papilloedema, neck stiffness, or fever
- Severe headache at onset of stroke symptoms.
why is a non contrast CT head even done
Use to exclude intracranial haemorrhage which must be done before starting thrombolysis, and before reversing anticoagulation in anticoagulation-induced intracerebral haemorrhage
What would you even see in a non contrast CT head
In people without indications for immediate brain imaging, request scan as soon as possible and definitely within 24 hours of symptom onset
- hypoattenuation (darkness) of the brain parenchyma
- loss of grey matter-white matter differentiation, and sulcal effacement
- hyperattenuation (brightness) in an artery indicates clot within the vessel lumen
initial Mx of SUSPECTED ischaemic stroke
Manage any
1) airway
2) breathing
- consider endotracheal intubation
- – who are unable to protect their airway
- – GCS (/ 8
- give oxygen only if sats drop below 93%
- – target 94-96
- – at risk of hypercapnaeic failure aim for 88-92%
circulatory insufficiencies requiring urgent treatment
admit everyone with sus stroke to a stroke unit within 4 hours
- assess swallowing function before administering anything
- start nutrition support
