Stroke Flashcards
What is the definition of a stroke?
Clinical syndrome consisting of rapidly developing clinical signs of focal disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin
What is the onset of stroke like?
Sudden
What might carotid territory strokes look like?
Usually unilateral
Weakness of face, leg, arm
Amaurosis fugax
Impaired language
What might a posterior circulation stroke look like?
Dysarthria Dysphasia Diplopia Dizziness Ataxia Diplegia
What is an ischaemic stroke?
Interruption of cerebral blood supply
What might cause and ischaemic stroke?
Embolism
Thrombosis
Systemic hypoperfusion
What is the oxford classification of strokes?
Anterior circulation infarct - partial/total
Posterior circulation infarct
Lacunar infarction
What is an anterior circulation infarction and what are the symptoms?
Anterior and middle cerebral artery stroke
Contralateral weakness
Contralateral sensory loss/sensory inattention
Dysarthria
Dysphasia (receptive/expressive)
Homonymous hemianopia/visual inattention
Higher cortical dysfunction
What are the symptoms of a posterior circulation infarction?
CN palsies and contralateral motor/sensory deficit
Conjugate eye movement
Cerebellar dysfunction eg vertigo, nystagmus, ataxia, dysarthria
Isolated homonymous hemianopia
Bilateral events can cause reduced GCS
What is a lacunar infart?
Occlusion of deep penetrating arteries
Affects a small volume of subcortical white matter - no cortical features
Underlying process often small vessel disease
What are the lacunar syndromes?
Pure motor hemiparesis Ataxic hemiparesis Clumsy hand and dysarthria Pure hemisensory Mixed sensorimotor
What is the Bamford stroke classification of a total anterior circulation stroke?
All 3 of the following:
- Unilateral weakness (and/or sensory deficit) of the face, arm, and leg
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphasia, visuospatial disorder)
What is the Bamford stroke classification of a partial anterior circulation stroke?
2 of the following
- Unilateral weakness (and/or sensory deficit) of the face, arm, and leg
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphasia, visuospatial disorder)
What is the Bamford stroke classification for lacunar syndrome?
1 of the following
- Pure sensory stroke
- Pure motor stroke
- Sensori-motor stroke
- Ataxia hemiparesis
What is the Bamford stroke classification of a posterior circulation stroke?
1 of the following
- CN palsy and contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (eg gaze palsy)
- Cerebellar dysfunction (ataxia, nystagmus, vertigo)
- Isolated homonymous hemianopia or cortical blindness
How do you assess a stroke in A&E?
ABCDE assessment + bloods, BM
Brief Hx and examination (time of onset, RF, CI to thrombolysis)
BP
NIHSS - grade severity of stroke
What investigations should you do for a stroke?
Urgent CT head +/- CT angiography
How can you treat a stroke?
Thrombolysis +/- mechanical thrombectomy if indicated
OR
Aspirin 300mg
What should you do after someone has had a stroke?
Investigate the cause
Screen and prevent complications (dehydration, aspiration, VTEs, pressure sores, infection, depression)
Establish secondary prevention (lifestyle, medication, surgery)
Rehabilitation (physiotherapy, occupational therapy, SALT)
What is the medication for secondary prevention?
Aspirin 75mg for 3 weeks Clopidogrel 75mg for life Statin BP medication Ect
What surgery can be done for secondary prevention?
Stents in carotids
Carotid surgery
What is the NIHSS?
National Institutes of Health Stroke Scale
Grades and tracks severity of stroke
What does the NIHSS look at?
Level of consciousness Best gaze Visual symptoms Facial palsy severity Motor arm and leg symptoms Limb ataxia severity Sensory loss severity Best language Dysarthria severity Extinction and inattention
What are the pros of doing a CT in an acute stroke?
Quick
Readily available 24/7
Sensitive for haemorrhage
May see hyperdense vessels
What are the cons of doing a CT in acute stroke?
Cannot usually diagnose an infarct in acute phase
Less sensitive than MRI for picking up other abnormalities eg demyelination, mass lesions, microhaemorrahges and for lacunar and PCI
What is thrombolysis?
Breaking down an acute clot
What do you give in thrombolysis?
Alteplase - IV - tissue plasminogen activator
0.9mg/kg
When can you give thrombolysis?
Within 4.5 hours of symptom onset
What are the CI of thrombolysis?
Symptoms only minor or rapidly improving
Haemorrhage on imaging
Suspected SAH
Active bleed from any site
Recent GI/urinary tract haemorrhage within 21 days
Platelet count < 100,000/mm3
Recent treatment with heparin and APTT above normal
Recent treatment with warfarin and INR elevated
Recent major surgery or trauma within last 14 days
Recent post MI pericarditis
Neurosurgery, serious head trauma or previous stroke within 3 months
Hx of intracranial haemorrhage ever
Known arteriovenous malformation or aneurysm
Recent arterial puncture at non-compressible site
Recent LP
BP > 185/110
Abnormal BM
Suspected/known pregnancy
Active pancreatitis
Epileptic seizure at stroke onset
What care needs to be given post-thrombolysis?
More aggressive BP monitoring
Vigilance for complications
24 hr CT head
What is a mechanical thrombectomy?
Mechanical recanalisation of culprit vessel
Proximal stenosis
Can be used with thrombolysis
What is the time frame for anterior circulation stroke treatment with thrombectomy?
6 hours
What bloods should you do in stroke?
FBC ESR U&E Lipid profile LFT CRP Clotting screen Glucose and HbA1c
What investigations should you do after a stroke?
Bloods ECG Carotid doppler USS Echo MRI
What extra investigations should you do in a young person?
Bloods - HIV and vasculitis screen, thrombophilia screen, homocysteine
Cardiac investigations - 7 day holter recorder, implantable loop recorder, transcranial doppler, transoesophageal echo
Vascular imaging - CT/MRI angiography
What is a watershed stroke?
A stroke occurring due to lack of blood supply in areas that are supplied by 2 arteries
Who is involved in stroke care from the MDT?
Nurses Physio OT SALT Dieticians Orthoptics
What lifestyle changes can be made following a stroke?
Smoking cessation Drug and alcohol cessation Dietary modifications Exercise Driving advice
What medical treatment can be given post-stroke?
VTE assessment Hydration NG feeding +/- PEG Spasticity - physio/botox Monitor for infection Antiplatelets Anticoags Hypertension treatment Statins
What are the 5 aspects in the management of haemorrhagic strokes?
ABCDE
BP
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
What can reverse anticoagulation?
Warfarin - beriplex and vit K
Heparin - protamine
LMWH - protamine (only partially)
What can mimic stroke?
Seizures Tumours/abscess Migraine Metabolic - hypoglycaemia, hyponatraemia Functional Spinal cord/peripheral nerve/cranial nerve
