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
Mx for confirmed ischaemic stroke within 4.5 hours and thrombolysis not contradicted
1) SUPPORT
a) assess GCS
b) monitor glucose - 4-11mmol/L
c) monitor BP ang give give anti-hypertensive treatment only if there is a hypertensive emergency
- Hypertensive encephalopathy
- Hypertensive nephropathy
- Hypertensive cardiac failure/myocardial infarction
- Aortic dissection
- Pre-eclampsia/eclampsia.
Consider reducing blood pressure to 185/110 mmHg or lower in people who are candidates for intravenous thrombolysis
First line IV labetalol, nicardipine and clevidipine
d) give oxygen only if sats less than 93
e) hydration - Isotonic saline
f) temp
g) ICP
Repeat the CT head immediately if you suspect elevated ICP, which may present as:
- A reducing level of consciousness
- Severe headache
- Nausea/vomiting
- A sudden increase in blood pressure.
h) seizures
- levetiracetam and sodium valproate are commonly used.
2) IV alteplase
- Treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms
AND
Intracranial haemorrhage has been excluded using appropriate imaging techniques
CONSIDERED IN ALL PATIENT GROUPS
3) thrombectomy LOOK LATER
4) antiplatelet agent - 300mg aspirin
5) VTE prophylaxis plus early mobilisation
when do you immediately refer to a neurosurgeon
1) with large middle cerebral artery territory infarcts and those with large infarctions affecting the cerebellum. These types of stroke have a very high mortality if urgent neurosurgical intervention is delayed.
— Patients with large middle cerebral artery territory infarcts (at risk of malignant middle cerebral artery syndrome) may need decompressive hemicraniectomy (neurosurgical removal of part of the skull to reduce intracerebral pressure).
— Patients with large infarctions affecting the cerebellum may need ventriculostomy (placement of an external ventricular drain) or posterior fossa craniectomy
2) uncontrolled or recurrent seizures or status epilepticus
why is it important to refer anyone with large infarctions or MCA
at risk of developing oedema and elevated intracranial pressure. If left unchecked, the oedema compromises blood flow and causes brain herniation, which is frequently fatal.
contradictions to thrombolysis with alteplase
Exclude hypoglycaemia and hyperglycaemia before giving thrombolysis; hypoglycaemia is a stroke mimic and hyperglycaemia is associated with intracerebral bleeding and worse clinical outcomes
ABSOLUTE
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
Relative
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
dose of alteplase
0.9 mg/kg intravenously (maximum 90 mg/dose); give 10% of the total dose by intravenous bolus initially, then give the remainder of the dose by intravenous infusion over 60 minutes
when to consider mechanical thrombectomy
A pre-stroke functional status <3 on the modified Rankin scale (mRS), and
A score >5 on the National Institutes of Health Stroke Scale (NIHSS).
1) 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
– confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
2) Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
- - confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
– if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
Consider thrombectomy together with intravenous thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes):
– who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and
– if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
what antiplatelet is offered and when
Offer an antiplatelet agent as soon as possible but certainly within 24 hours (unless contraindicated) to any patient presenting with acute stroke who has had intracerebral haemorrhage excluded by imaging
- Aspirin orally (for those with no dysphagia), or
- Aspirin rectally or by enteral tube (for those with dysphagia).
ALLERGIC give clopidegrol
give PPI if anyone had dyspepsia
Continue aspirin daily until 2 weeks after the onset of stroke symptoms, then start definitive long-term antithrombotic treatment
what VTE prophylaxis is one
Give intermittent pneumatic compression within 3 days of admission for the prevention of deep vein thrombosis and pulmonary embolism
Help the patient to sit out of bed, stand, or walk as soon as their clinical condition permits, as part of an active management programme in a specialist stroke unit
When do we start statin therapy
if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin.
safe to start statins after 48 hours
high intensity statin therapy
subtypes of ischaemic stroke
Thrombotic stroke
- thrombosis from large vessels e.g. carotid
Embolic stroke
- usually a blood clot but fat, air or clumps of bacteria may act as an embolus
- atrial fibrillation is an important cause of emboli forming in the heart
Cerebral hemisphere infarcts may have the following symptoms
- contralateral hemiplegia: initially flaccid then spastic
- contralateral sensory loss
- homonymous hemianopia
- dysphasia
brainstem infarction
may result in more severe symptoms including quadriplegia and lock-in-syndrome
lacunar infarcts
- small infarcts around the basal ganglia, internal capsule, thalamus and pons
- this may result in pure motor, pure sensory, mixed motor and sensory signs or ataxia
what Sx are more common is haemorrhagic stroke
- decrease in the level of consciousness: seen in up to 50% of patients with a haemorrhagic stroke
- headache is also much more common in haemorrhagic stroke
- nausea and vomiting is also common
- seizures occur in up to 25% of patients
what is FAST
Face - ‘Has their face fallen on one side? Can they smile?’
Arms - ‘Can they raise both arms and keep them there?’
Speech - ‘Is their speech slurred?’
Time - ‘Time to call 999 if you see any single one of these signs.’
Mx for haemorrhagic strokes
Anticoagulants (e.g. warfarin) and antithrombotic medications (e.g. clopidogrel) should be stopped to minimise further bleeding.
tools used for stroke
FAST
ROSIER
What is ROSIER
Exclude hypoglycaemia
Assessment
- Loss of consciousness or syncope - 1 point
- Seizure activity - 1 point
New, acute onset of: • asymmetric facial weakness + 1 point • asymmetric arm weakness + 1 point • asymmetric leg weakness + 1 point • speech disturbance + 1 point • visual field defect + 1 point
when to arrange a follow up
arrange a follow up at 6 months
east annually to review health, social care needs (such as access to benefits, community participation, housing and return to work), ongoing risk factors, and secondary prevention.
Arrange review of carers of people with stroke at 6 months and then annually to assess their health and social care needs.
lifestyle measures for stroke
Encourage physical activity every day
Advise smokers to stop and non-smokers to avoid passive smoking
Eat at least five portions of fruit and vegetables (from a variety of sources) per day and two portions of oily fish per week.
Reduce intake of saturated fats.
Keep salt intake low
Alcohol intake should be limited to 14 units a week, spread over at least three days.
Advise against routine dietary supplementation
B vitamins or folate; vitamins A, C, or E; selenium; and calcium with or without vitamin D unless required for other medical conditions.
medications used in secindary prevention of stroke
1) ANTIPLATELET THERAPY
clopidegrol 75mg daily
ASPIRIN/CLOPIDEGROL CONTRADICTED
Modified-release dipyridamole 200 mg twice daily
Aspirin 75mg daily may be used if both clopidogrel and modified-release dipyridamole are contraindicated or cannot be tolerated.
2) LIPID MODIFICATION DRUG Tx
high intensity statin (such as atorvastatin 20–80mg daily) will be offered at diagnosis of ischaemic stroke or TIA by secondary care. The aim of statin therapy is to reduce non-HDL cholesterol by more than 40%.
needs to be acheived within 3 months
Fibrates, bile acid sequestrants, nicotinic acid and omega-3 fatty acid compounds should not be prescribed
When may dual therapy may be started
aspirin and clopidogrel may be initiated in secondary care for the first three months following ischaemic stroke or TIA due to severe symptomatic intracranial stenosis or for another condition such as acute coronary syndrome.
problems with hypovolaemia in stroke
can worsen the ischaemic penumbra, as well as increase risk of other complications such as infection, deep vein thrombosis, constipation and delirium
Conversely, over-hydration can also complicate matters by leading to cerebral oedema, cardiac failure and hyponatraemia, therefore it is important to regularly review fluid status in these patients
why shouldnt we lower bp too much
potentially compromise collateral blood flow to the affected region, and possibly hasten the time to complete and irreversible tissue infarction
disability is most commonly measured using
Barthel index (BI), an outcome measure for stroke
Describes 10 tasks, and is scored according to amount of time or assistance required by the patient for each given task
Tasks: feeding, moving from wheelchair to bed, personal toileting, getting on/off toilet, bathing, walking on level surface, ascending/descending stairs, dressing, controlling bowels and controlling bladder
The total score is from 0 to 100, with 0 being completely dependent, and 100 being completely independent
assess the functional status of a patient post stroke, and to monitor their improvement with ongoing rehabilitation to regain independence after the event
lesion in anterior cerebral artery
Contralateral hemiparesis and sensory loss, lower extremity > upper
lesion in middle cerebral artery
- Contralateral hemiparesis and sensory loss, upper extremity > lower
- Contralateral homonymous hemianopia
- Aphasia
lesion in posterior cerebral artery
- Contralateral homonymous hemianopia with macular sparing
- Visual agnosia
Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain) lesion
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome) lesion
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
Anterior inferior cerebellar artery (lateral pontine syndrome) lesion
Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness
Retinal/ophthalmic artery lesion
Amaurosis fugax
Basilar artery lesion
‘Locked-in’ syndrome
lacunar strokes
present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
strong association with hypertension
common sites include the basal ganglia, thalamus and internal capsule
what should a rehab plan iclude
basic demographics, including contact details and next of kin
diagnosis and relevant medical information
list of current medications, including allergies
standardised screening assessments (see screening and assessment)
the person’s rehabilitation goals
multidisciplinary progress notes
a key contact from the stroke rehabilitation team (including their contact details) to coordinate the person’s health and social care needs
discharge planning information (including accommodation needs, aids and adaptations)
joint health and social care plans, if developed
follow-up appointments
what is CHADVASC scores
AF stroke risk
what is HASBLED
score for major bleeding risk
what does vertical nystagmus mean
central cause of vertigo
