Stroke/bleeds Flashcards
What is a stroke?
Cerebrovascular accident causing a decrease in focal neurological deficit
CVA are either:
Haemorrhage or ischaemia/infarction secondary to inadequate blood supply
What can the disruption of blood supply causing CVA be caused by?
Thrombus formation/embolus
Atherosclerosis
Vasculitis
Shock
What is TIA?
Transient neurological dysfunction secondary to ischaemia without infarction.
What is a crescendo TIA?
Where there are two or more TIAs within a week. This carries a high risk of developing in to a stroke.
What is the presentation of a stroke?
In neurology, suspect a vascular cause where there is a sudden onset of neurological symptoms.
Stoke symptoms are typically asymmetrical:
Sudden weakness of limbs
Sudden facial weakness
Sudden onset dysphasia (speech disturbance)
Sudden onset visual or sensory loss
What are the risk factors for stroke?
Cardiovascular disease such as angina, myocardial infarction and peripheral vascular disease Previous stroke or TIA Atrial fibrillation Carotid artery disease Hypertension Diabetes Smoking Vasculitis Thrombophilia Combined contraceptive pill
What is the tool used for identifying strokes in the community?
F – Face
A – Arm
S – Speech
T – Time (act fast and call 999)
What tool can be used to identify stroke in an emergency?
ROSIER
Anything above 0 means stroke is likely
How do you manage stroke?
Admit patients to a specialist stroke centre
Exclude hypoglycaemia
Immediate CT brain to exclude primary intracerebral haemorrhage
Aspirin 300mg stat (after the CT) and continued for 2 weeks
Thrombolysis with alteplase can be used after the CT brain scan has excluded an intracranial haemorrhage. Alteplase is a tissue plasminogen activator that rapidly breaks down clots and can reverse the effects of a stroke if given in time. It is given based on local protocols by an experienced physician. It needs to be given within a defined window of opportunity, for example 4.5 hours. Patients need monitoring for post thrombolysis complications such as intracranial or systemic haemorrhage. This includes using repeated CT scans of the brain.
Thrombectomy (mechanical removal of the clot) may be offered if an occlusion is confirmed on imaging, depending on the location and the time since the symptoms started. It is not used after 24 hours since the onset of symptoms.
Generally, blood pressure should not be lowered during a stroke because this risks reducing the perfusion to the brain.
How do you manage TIA?
ABCD2 used to be used however this is no longer recommended by NICE
Immediate treatment…
- give aspirin 300mg immediately
Unless
1) the patient has a bleeding disorder
2) the patient is already taking low dose aspirin regularly (continue current dose unless reviewed by specialist)
3) aspirin is contra-indicated
Further management
1) clopidogrel
(Aspirin and dipyridamole for those who can’t tolerate clopidogrel)
Carotid endarterectomy
Recommended if patient has had a stroke or TIA in the carotid territory and are not severely disabled
Should only be done if carotid stenosis is >70%
What are the specialist imaging that can be used in stroke?
The aim of imaging is to establish the vascular territory that is affected. It is guided by specialist assessment.
Diffusion-weighted MRI is the gold standard imaging technique. CT is an alternative.
Carotid ultrasound can be used to assess for carotid stenosis. Endarterectomy to remove plaques or carotid stenting to widen the lumen should be considered if there is carotid stenosis.
What can be used as secondary prevention of stroke?
Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily)
Atorvastatin 80mg should be started but not immediately
Carotid endarterectomy or stenting in patients with carotid artery disease
Treat modifiable risk factors such as hypertension and diabetes
What professionals are involved in stroke rehabilitation?
Nurses Speech and language (SALT) Dieticians Physiotherapy Occupational therapy Social services Optometry and ophthalmology Psychology Orthotics
Around 10-20% of strokes are caused by intracranial bleeds, what are the risk factors for intracranial bleeds?
Head injury Hypertension Aneurysms Ischaemic stroke can progress to haemorrhage Brain tumours Anticoagulants such as warfarin
What is the presentation of intracranial bleeds?
Sudden onset headache is a key feature. They can also present with:
Seizures Weakness Vomiting Reduced consciousness Other sudden onset neurological symptoms
What scale can be used to assess the level of consciousness?
The Glasgow Coma Scale (GCS) is a universal assessment tool for assessing the level of consciousness.
It is scored based on eyes, verbal response and motor response. The maximum score is 15/15, minimum is 3/15. When someone has a score of 8/15 or below then you need to consider securing their airway as there is a risk they are not able to maintaining it on their own.
Eyes
Spontaneous = 4 Speech = 3 Pain = 2 None = 1 Verbal response
Orientated = 5 Confused conversation = 4 Inappropriate words = 3 Incomprehensible sounds = 2 None = 1 Motor response
Obeys commands = 6 Localises pain = 5 Normal flexion = 4 Abnormal flexion = 3 Extends = 2 None = 1
What is subdural haemorrhage caused by?
Subdural haemorrhage is caused by rupture of the bridging veins in the outermost meningeal layer. They occur between the dura mater and arachnoid mater.
What does subdural haemorrhage look like on CT?
On a CT scan they have a crescent shape and are not limited by the cranial sutures (they can cross over the sutures).
When does subdural haemorrhage occur?
Subdural haemorrhages occur more frequently in elderly or alcoholic patients. These patients have more atrophy in their brains making vessels more likely to rupture.
What causes an extradural haemorrhage?
Extradural haemorrhage is usually caused by rupture of the middle meningeal artery in the temporo-parietal region. It can be associated with a fracture of the temporal bone. It occurs between the skull and dura mater.
What does an extradural haemorrhage look like on a CT?
On a CT scan they have a bi-convex shape and are limited by the cranial sutures (they can’t cross over the sutures).
Who does an extradural haemorrhage normally affect?
The typical history is a young patient with a traumatic head injury that has an ongoing headache. They have a period of improved neurological symptoms and consciousness followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents.
What is an intracerebral haemorrhage and how does it occur?
Intracerebral haemorrhage involves bleeding into the brain tissue. It presents similarly to an ischaemic stroke.
These can be anywhere in the brain tissue:
Lobar intracerebral haemorrhage Deep intracerebral haemorrhage Intraventricular haemorrhage Basal ganglia haemorrhage Cerebellar haemorrhage They can occur spontaneously or as the result of bleeding into an ischaemic infarct or tumour or rupture of an aneurysm.
What does a subarachnoid haemorrhage involve?
Subarachnoid haemorrhage involves bleeding in to the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane. This is usually the result of a ruptured cerebral aneurysm.
How does subarachnoid haemorrhage usually affect?
The typical history is a sudden onset occipital headache that occurs during strenuous activity such as weight lifting or sex. This occurs so suddenly and severely that it is known as a “thunderclap headache”.
Who do SAH usually affect?
They are particularly associated with cocaine and sickle cell anaemia.
What are the management of intracranial bleeds?
Immediate CT head to establish the diagnosis
Check FBC and clotting
Admit to a specialist stroke unit
Discuss with a specialist neurosurgical centre to consider surgical treatment
Consider intubation, ventilation and ICU care if they have reduced consciousness
Correct any clotting abnormality
Correct severe hypertension but avoid hypotension
What is a subarachnoid bleed?
Subarachnoid haemorrhage involves bleeding in to the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane. This is usually the result of a ruptured cerebral aneurysm.
Subarachnoid haemorrhage involves bleeding in to the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane. This is usually the result of a ruptured cerebral aneurysm.
Subarachnoid haemorrhage has a very high mortality and morbidity. It is very important not to miss the diagnosis and you need to have a low suspicion to trigger full investigations. It needs to be discussed with the neurosurgical unit with a view to surgical intervention.
