Stroke Care

Question 1

ACA (Anterior Cerebral Artery) Infarct
-clinical manifestation

Answer 1

Question 2

MCA (Middle cerebral artery) infarct
-clinical picture

Answer 2

Question 3

PCA (Posterior Cerebral Artery) Infarct
-clinical picture

Answer 3

• *Alexia** - inability to read written words
• *Agraphia** - inability to write words

Question 4

Penetrating vessels infarct
-clinical picture

Answer 4

Lacunar syndromes - sub cortical

Question 5

Vertebrobasilar infarct
-clinical picture

Answer 5

vertebrobasilar arterial system perfuses the medulla, cerebellum, pons, midbrain, thalamus, and occipital cortex.

Question 6

Internal carotid artery infarct
-clinical picture

Answer 6

Question 7

Internal carotid artery infarct
-clinical picture

Answer 7

Question 8

Investigations for intracerebral haemorrhage

Answer 8

Catheter angio - mainly younger patients, nil clear cause

Question 10

Blood Pressure Lowering in Stroke - ischaemic and haemorrhage

Answer 10

Blood pressure lowering in ischemic stroke

The precise timing and intensity of blood pressure lowering therapy after ischaemic stroke is uncertain, but most patients should have therapy started prior to discharge, and more intensive therapy may be beneficial.

• All stroke and TIA patients with BP >140/90mmHg should have long term blood pressure lowering therapy initiated or intensified. Benefits likely out-weight the risks in those with SBP 120-140mmHg.
• Most well-known trial is PROGRESS (Lancet 2001) –perindopril +/-indapamide –average follow-up 4 years, 10% vs 14% recurrent stroke (NNT=25). Also reduced major vascular events.
• Subsequent trials and meta-analyses confirmed stroke risk reduction essentially independent of agent, ~25% relative reduction; No strong preference between ACE-I, ARB, Ca Channel Antagonists, or thiazides. Avoid beta-blockers as first line agents unless the patient has concurrent ischaemic heart disease.
• Ideal long-term target not well established (<130mmHg may achieve greater benefit than <140mmHg).

Question 15

Swallowing Assessment in Acute Stroke

Answer 15

Question 16

Antithrombotic therapy in acute stroke

Answer 16

Question 17

Blood Pressure Management Principles in Acute Stroke

Answer 17

Blood pressure control in ischaemic stroke

• If giving tPA aim to keep BP < 180/105 with short acting agent that can be reversed if dropped too low
  
  • Ie. Labetalol, hydralazine
• If no tPA – patient can have higher BP may even go up to 220/120

Blood pressure control in ICH

• Aim for BP 140-160 (closer to 140) and not substantially lower than 140

Question 18

Indications for Surgery in ischaemic stroke

Answer 18

Question 19

Oxygen, Glycaemic and Fever Management in Acute stroke

Answer 19

Question 20

Management of ICH

Answer 20

Acute management

• Assess GCS and intubate if necessary!
• Blood pressure
  
  • Aim for BP 140-160 (closer to 140) and not substantially lower than 140
• Reverse warfarin!
• If on antiplatelet – DON’T given platelet infusion, can also cause harm
• Safe to recommence antiplatelet therapy after ICH event ~ 1 month post – decreased events in this population

IF spot sign positive – can consider to give transexamic acid

Question 21

Anticoagulation secondary prevention in ischaemic stroke

Answer 21

Question 22

Cholesterol lowering as secondary prevention in stroke

Answer 22

Question 26

Secondary Prevention in Stroke

Answer 26

Antiplatelet therapy

• Long term prevention
  
  • NO benefit of clopidogrel over aspirin
  • Clopidogrel + aspirin long term is harmful
• Short term prevention
  
  • Aspirin provides most benefit within 6 weeks
  • Aspirin + clopidogrel for 3 weeks provides added benefit compared with aspirin alone for TIA and minor strokes

Hypertension

• Wait 48-72 hours prior to lowering blood pressure
• Aim 120 to 140/80 to 90mmHg

Dyslipidaemia

• If patient has had an ICH pt should not be commenced, but if already on, can continue
• Treat stroke to target trial
• Lower LDL target is better outcomes! Give statin and ezetimibe
• No difference in ICH

​CEA recommendations

• Carotid endarectomy for patients with non-disabling carotid artery territory stroke or TIA with ipsilateral carotid stenosis measured at 70-99%
• Carotid endarterectomy can be considered in selected patients with symptomatic carotid stenosis of 50-69% (specifically males)
• Carotid endarterectomy should be performed as soon as possible after the ischaemic stroke or TIA – within 2 weeks, < 3 months at latest

Anticoagulation in AF

PFO closure

• PFO closure + anti-platelet therapy indicated for patients < 60 years with no other causes found apart from PFO who have associated atrial septal aneurysm or moderate to large right to left shunt + meta-analysis
• Increased risk of atrial fibrillation generally within first 1-1.5 months and most cases were transient

Question 28

Carotid Endarterectomy post stroke

Answer 28

The strongest evidence for carotid endarterectomy is within 2 weeks of an event (TIA or stroke, including retinal ischaemia) in the relevant territory and a carotid stenosis of 70-99%

• Most practical to image carotid circulation with CT angiogram (both intracranial and extracranial and provide posterior circulation information) during acute stroke imaging work-up (becoming more common than carotid Doppler)
• Crucial to be confident that the artery in question is the symptomatic vessel (e.g. not posterior circulation)
• Modest benefit for 50-69% stenosis (consider local surgical expertise and potential for more optimised medical therapy)
• No evidence for asymptomatic carotid surgery (or in the setting of non-stroke presentations –e.g. syncope)
• Carotid stenting often performed during acute thrombectomy –some emerging evidence for potential equipoise between endarterectomy and stenting in patients <70 years (see CREST trial and accompanying editorial, Brottet al, NEJM 2010; Davis & DonnanNEJM 2010)

Above evidence comes from meta-analysis/cochrane reviews of the ECST, NASCET and VACSP studies

Question 29

Thrombolysis
-time window

Answer 29

• Time window and potentially disabling deficit
• Time window for tPA (no large vessel occlusion)
  
  • 0 - 4.5 hours: CTB -> alteplase
  • 4.5 – 9 hours (or within 9 hours of mid point wake up): CTP/MRI perfusion à alteplase
  • Wake up =: MRI/DWI (markers to suggest <4.5 hours) –> alteplase

Question 30

Benefits of Stroke Units

Answer 30

Stroke Unit Care

• Proven to reduce morbidity and mortality for all stroke subtypes and severities
  
  • NNT for mortality = 33, dependency = 20 (Cochrane review)
• “black box” of interested, experienced team of practitioners in a defined location
• less complications: DVT, pneumonia, pressure areas
• At admission specify:
  
  • intermittent pneumatic compression for DVT prophylaxis
  • fast (including no oral meds) until ASSIST/Speech Therapy

Question 31

Endovascular Thrombectomy in Acute Stroke

Time window

Answer 31

• Main points
  
  • Consider in all patients with major vessel occlusion (ICA, M1, basilar, ?M2)
  • IV thrombolysis eligible or ineligible –give thrombolysis in parallel if eligible. (tenectaplase>alteplase)
  • Good premorbid function
  • No age or clinical severity limits
  • ICA/M1: <6hr broad criteria, 6-24hr if <70mL core
  • Basilar: time window ?24hr vs 9hr from onset of coma
  • CT perfusion to characterize irreversibly injured core/collaterals very helpful for prognosis
• Time window for thrombectomy (large vessel occlusion)
  
  • 0 – 4.5 hours: CTA + CTP -> thrombectomy + Tenecteplase/alteplase
  • 4.5 - 9 hours: large vessel occlusion and eligible for thrombectomy. But requires transfer with delays, then can give tPA if meets perfusion mismatch criteria. Otherwise move straight to thrombectomy if possible.
  • 4.5 – 24 hours: CTA + CTP -> thrombectomy

Question 40

Stenting recommendations in secondary stroke prevention

Answer 40

• IN selected patients with unfavourable anatomy, symptomatic re-stenosis after endarterectomy or previous radiotherapy, stenting may be reasonable
• In patients aged < 70 years old