Stroke and TIA Flashcards
how are patients suspected of having a TIA risk stratified (in terms of risk of ST risk of stroke)?
ABCD2 criteria:
age 60 or older
BP 140/90 or higher
clinical-unlateral weakness (2), speech disturbance without weakness (1)
DM (1)
duration of symps-10-59mins (1), 1hr or more (2)
so score 0-7, if 4 or more then HIGH risk: need aspirin 300mg daily started immediately, spec assessment and investigation within 24hrs of symptom onset and measures for secondary prevention introduced as soon as diagnosis confirmed.
if AF automatically classes as high risk
as does crescendo TIAs-2 or more attacks in same week
and a TIA whilst on an anticoagulant
medical complications of strokes beyond the acute setting?
complications of immobility: pressure sores, VTE-use intermittent pneumatic compression for prophylaxis, infection-UTI, bronchopneumonia and atelectasis recurrent ischaemic stroke seizures intracranial complications-hydrocephalus neurological-balance, spasticity cognitive impairments-apraxia, visual agnosia, neglect, memory, planning visual impairment and hemianopia speech and communication problems-aphasia pain, neuropathic and MSK aspiration pneumonia metabolic upset, refeeding syndrome malnutrition, swallowing problems, dehydration incontinence-urinary and faecal iatrogenic-constipation disability depression
aspiration pneumonia most likely organisms?
viridans group strep-strep milleri subgroup
anaerobes e.g. peptostreptococcus
also strep pneumoniae, h.influenzae, stap aureus
need BS antibiotic cover
immediate management of TIA patient who is deemed high risk of having a stroke based on ABCD2 criteria?
r/f for specialist assessment within 24hr of onset of symptoms
start statin-simvastatin 40mg
if not taking AC or AP drug, give 300mg aspirin (licensed) or clopidogrel (only if aspirin hypersensitivity or not tolerated)-aiming to prevent strokes caused by atherosclerotic plaque rupture or embolisation
consider also PPI if high risk of GI ADRs
if taking AC drug, need immediate admission
if take low dose aspirin regularly then continue until r/v at specialist assessment
advise not to drive until advice given at specialist assessment, won’t be able to drive for 1 month
main aims of TIA clinic?
ensure TIA resolved
ensure has not recurred
search for reversible causes of future strokes that can be addressed e.g. smoking, HTN, high cholesterol, DM, AF
also rule out other differentials e.g. tumour, MS
define stroke
sudden onset focal neurological defecit attributable to vascular cause i.e. in a vascular territory
type of neurological symptoms resulting from a stroke?
negative symptoms-LOSS OF FUNCTION
key aspects to the hx in pt presenting with ?stroke?
- symptom onset-SUDDEN, and important for subsequent management-indications for thrombolysis within 4.5hr of symptom onset in terms of NNT, also want to know symptom progression
- associated symptoms-weakness, facial drooping, dysarthria, aphasia-higher cortical symptoms
- other symptoms to ask about to rule out differentials-headache, LOC, loss of continence-these make stroke UNLIKELY
- RFs-those for ischaemic and those for haemorrhagic stroke, AGE, BP, high cholesterol, IHD, DM, smoking, alcohol, cocaine and legal highs, AF, causes of AF-mitral stenosis, hyperthyroidism, valvular HD-AS, endocarditis, HIV-accelerated inflammatory atheroma formation, Hep B and C-leucoencephalopathy, personal hx, FH (under 60yrs), ACs, low PLT, PVD, sickle cell disease, antiphospholipid syndrome, AV malformations, pregnancy, OCP, venous sinus thrombosis-BACK PRESSURE.
features of antiphospholipid syndrome?
disease with a thrombotic tendency, most commonly primary but can occur secondary to SLE
assoc. with anti-cardiolipin and lupus anticoagulant Abs
CLOTS:
coagulation defect
livedo reticularis
obstetric (recurrent miscarriage)
thromboyctopenia
tx with low dose aspirin or warfarin if recurrent thromboses
biggest RF for stroke?
increasing age
assessment tools available for pt presenting with suspected stroke?
FAST
ROSIER-recognition of stroke in emergency room, commonly used in A+E
clinical stroke assessment tool that can be used in confirmed acute stroke?
NIHSS-national institute of health stroke scale: used to evaluate and document neurological status in acute stroke patients
measure of stroke severity
15 items which scores on levels of consciousness, language, neglect, visual-field loss, EO movement, motor strength, ataxia (loss of coordination of muscles), dysarthria and sensory loss.
score out of 42
if symptoms of stroke do not fit into 1 vascular territory, what does this suggest?
diagnosis by definition is NOT stroke
OR
cause of stroke is cardioembolic resulting in multifocal ischaemia
how are ischaemic strokes classified?
OCSP (oxfordshire community stroke project)/Bamford classification criteria: TACS-total anterior circulation stroke PACS-partial anterior circulation stroke LACS-lacunar circulation stroke POCS-posterior circulation stroke
presenting features of total anterior circulation infarcts?
contralateral hemiparesis
contralateral hemisensory loss
contralateral homonymous hemianopia
higher cortical dysfunction e.g. dysphasia (if dominant lobe affected), visio-spatial problems, perceptual problems e.g. neglect, asterognosis, dyspraxia.
presenting features of partial anterior circulation infarcts?
2 of the 3 criteria of TACIs-hemiparesis (OR) hemisensory disturbance and homonymous hemianopia
OR
presence of higher cortical dysfunction alone e.g. dysphasia
presenting features of lateral medullary syndrome (posterior inferior cerebellar artery)?
also known as wallenberg’s syndrome
ipsilateral ataxia, nystagmus, facial numbness, dysphagia, cranial nerve palsy e.g. horner’s
and
contralateral sensory loss-pain and temperature (lateral spinothalamic tract, decussates in SC)
may follow vertebral artery damage e.g. during chiropractics
initial treatment of patients with an ISCHAEMIC stroke?
admit patient to a specialist acute stroke unit
?if pt suitable for thrombolysis-pt presenting within 4.5hr of symptom onset, ruled out haemorrhagic stroke (with CT scan) and pt doesn’t have contraindications
THROMBOLYSIS-IV alteplase 900 micrograms/kg over 1 hour, initial 10% given by IV injection then rest by IV infusion
start aspirin 300mg OD and continue for 2 weeks, (start after 24 hrs post thrombolysis if this is given). Give PO, or PR or by enteral tube if pt dysphagic.
after 2 weeks (or earlier if pt an inpatient) can start LT definitive antithrombotic treatment: clopidogrel OR modified dipyridamole plus aspirin (if clopidogrel CI) OR modified dipyridamole monotherapy (if aspirin and clopidogrel CI)
if cardioembolic stroke need to give anticoagulant treatment e.g. warfarin (after 2 weeks), may start earlier if part. high risk pt
safe to start STATIN after 48hrs (delay due to risk of haemorrhagic transformation)
*thrombectomy-up to 7 hours post onset
contraindications to thrombolysis?
cannot confirm onset of stroke as within 4.5hrs
CT head shows acute intracranial bleed
previous intracranial bleed
intracranial neoplasm
seizure at stroke onset
stroke or serious head injury in preceding 3 months
major surgery or serious trauma within 2 weeks
GI or urinary tract bleed in preceding 3 wks
symptoms suggestive of SAH
AV malformation or aneurysm
LP in preceding wk
PLT less than 100
INR more than 1.7, conurrent AC treatment
glucose less than 2.7 or more than 22
positive preg test
rapidly improving neuro signs (suggesting TIA)
systolic BP more than 185 or diastolic more than 110 or continuous AHs IV (more than 2) to lower BP below this range
suspected acute pericarditis
secondary prevention following an ischaemic stroke?
- long term antiplatelet or anticoagulant therapy (latter if stroke was cardioembolic-AF)-clopidogrel recommended, if CI or no tolerated then modified dipyridamole plus aspirin, modified dipyridamole alone if both clopidogrel and aspirin CI or not tolerated.
- statin, started 48hrs post stroke-?atorvastatin 80mg-secondary prevention for anyone with established CVD, cerebrovasc disease or PVD.
- BP control
- diabetic control
- low alcohol intake
- regular exercise
- weight loss
- stop smoking
- SURGERY-carotid endarterectomy-recommended if stroke or TIA suffered in carotid territory and pt not severely disabled, artery stenosis more than 50%.
what name is given to the syndrome caused by a midbrain stroke producing ipsilateral 3rd nerve palsy with contralateral hemiplegia?
weber’s syndrome
LT management and monitoring required for patients following a stroke?
GP f/u within 6wks of d/c, then at 6mnths, then annually
annually check BP and lipid profile
arrange annual pre-winter influenza immunisations
what symptoms in the hx suggest a diagnosis that is NOT a stroke?
headache
LOC
incontinence acutely
stroke mimics?
SAH SDH venous infarcts SOL seizures (Todd's paresis-transient weakness post seziure) hemiplegic migraine abscesses hypoglycaemia-must check BMs MS functional hemiparesis sepsis in those with pre-existing neurological weakness
