Stroke (Cerebrovascular disease) Flashcards
Background
Stroke is a focal neurological deficit due to the interruption of the blood supply to the brain.
Medical emergency sooner diagnosed = better.
Types:
2 main - ischaemic and haemorrhagic
- Ischaemic = thrombotic or embolic.
- Haemorrhagic = intracerebral haemorrhage OR subarachnoid haemorrhage
Memory trick:
MIS TIA IS HAEMORRHAGING
Signs and symptoms (same for all types)
Facial weakness.
Arm/leg weakness.
Slurred/Disturbed speech.
Visual defect.
Dizziness/fall.
Loss of consciousness.
Headache.
[BE-FAST]
B - Balance/Coordination
E - Eyes - any visual symptoms
F - FACE - droop on one side of the face? Can the person smile?
A - ARMS - raise both arms and keep them there?
S - SPEECH - Slurred?
T - TIME - call 999 – if displaying any of the signs
Risk factors
Modifiable risk factor
HTN
Smoking
AF
Hyperlipidaemia
Diabetes
Diet, alcohol intake and exercise
Stress and/or depression
High waist to hip ratio
High ratio of apolipoprotein B to apolipoprotein A1*
Non-modifiable risk factor
Age
Ethnicity
IHD/PVD
Genetic predisposition (family Hx)
Gender
Sickle cell disease
Diagnosis
investigation of choice:
CAT/CT scanning of the head. This takes only 5-10 minutes.
NEEDED TO ASSES WHICH TREATMENT TO DO AS ISACAHEMIC USES ANTIPLATALETS AND CAN INDUCE BLEEDING.
DRUGs memory trick
ASAP:
Anti platelets
Statins
Anticoagulants
PPIs
TIA - Transient ischaemic stroke/Minor IS
TIA - temporary disruption in the blood supply to the brain, leading to ischaemia. Caused by clot or other debris. Short lived (few mins to hrs)
Treatment
ASAP Aspirin 300mg ALT another antiplatelet.
- PPI if get dyspepsia associated with aspirin use OR for dual therapy to reduce risk of GI events (bleeding)
- If already on low dose A continue dont increase.
IF they present within 24hrs of TIA or Minor IS:
ASAP Aspirin as above +
if low bleeding risk -
dual antiplatelet therapy with
Clopidogrel + Aspirin THEN C alone.
Other dual option:
Ticagrelor + A THEN T or C alone.
DUAL ALT C alone.
Doses
Aspirin/Clopidogrel - 300mg OD ONCE THEN 75mg OD.
- in Dual- Clop is 21 days only.
Ticagrelor 180 mg OD ONCE THEN 90mg BD + aspirin for 30 days only.
NOTE: ACS is 12 months aspirin here it is 21 with clo, 30 with tica.
- Clo and Tico is continued ALONE after above days.
Ischaemic Stroke
Thrombotic IS commonly from atherosclerosis - narrowed blood vessels = reduced blood flow to area in this case the brain.
Damaged areas of an atherosclerotic plaque can cause a blood clot to form = blocking blood supply
Embolic IS = blood clots/debris from elsewhere in the body travel through circulatory system. Main cause is AF.
Treatment
INTIAL -
Alteplase or tenecteplase IF give within 4.5hrs of symptoms and intracranial strokes ruled out via imaging. THEN
Antiplatelet AFTER 24 hrs unless disabling.
Disabling IS start aspirin ASAP within 24 hrs then continue for 2 weeks.
Aspirin 300mg daily oral>rectal. ALT clopidogrel.
THEN
Clopidogrel 75mg daily (secondary prevention)
PPI if Hx of dyspepsia with aspirin or for continuous dual antiplatelet usage to reduce GI effects risk.
SURGERY OPTION: Give thrombectomy ASAP within 6hrs of symptoms with IV thrombolysis (above) If have acute IS and confirmed occlusion of proximal anterior circulation.
Anticoagulant not used if in sinus rhythm unless PT has DVT, PE or AF (warfarin or DOACs:
- Pt with mobility issue after stroke AVOID LMWH and Stockings for DVT prevention instead give Warfarin.
IF already on anticoagulant for prosthetic heart valve who had disabling IS and at good risk for haemorrhagic transformation STOP anticoagulant for 7 days and swap with aspirin 300mg.
HTN - only if severely hypertensive because it can cause reduced cerebral perfusion.
If needed , IV labetalol ALT IV GTN
LONG TERM (secondary prevention) MIS TIA IS
Lifestyle mods (weight loss, smoking cessation, alcohol reduction, Diet to reduce BP and cholesterol [Mediterranean]) 5 fruit & veg/day, 2 oily fish/week, reduced saturated fats, Keep low salt intake
**Antiplatelet - **
Clopidogrel monotherapy 75mg daily ALT aspirin 75mg daily + MR dipyridamole 200mg BD. IF C and A not tolerated - MR dipyridamole 200mg BD. IF C and D not tolerated Aspirin 75mg daily.
DUAL antiplatelet A + C (up to 90 days) or A + Ticagrelor (for 30days) for some (i.e. high risk of TIA or intracranial stenosis) THEN antiplatelet monotherapy.
PPI if Hx of dyspepsia with drugs.
Statin
if already taking continue if not should be started at least 48 hours after the stroke. Use high statin (atorvastatin 20-80mg daily [more common 80]). ALT cholesterol meds should NOT be used.
HTN
B blockers not used unless other co existing condition. can use thiazide-like diuretic, long-acting CCB, ACE I, or ARB.
Anticoagulants
Not routinely recommended except when AF or other indications (eg cardiac source of embolism, cerebral venous thrombosis or arterial dissection) are present. Don’t use if in sinus rhythm.
Drugs used will be adjusted dose warfarin or DOACs.
Pt with IS or TIA linked with AF/A -flutter should be reviewed for long-term anticoagulant
Haemorrhagic Stoke and long term
Haemorrhagic strokes are caused by a rupture of blood vessels that then causes a compression of brain tissue from an expanding haematoma (collection of blood outside blood vessels)
TREATMENT
Initial -
May need Surgery to remove haematoma.
HTN
DONT use rapid BP lowering drugs for ppl who:
- have an underlying structural cause,
- score on the Glasgow Coma Scale of <6,
- Going to have early neurosurgery to evacuate the haematoma, or
- Have a very large haematoma with a poor expected prognosis.
Offer treatment if presents within 6hrs of symptoms Systolic BP of 150 to 220. Aim for 130 to 139 BP sustained for 7 days
BEYOND 6 hrs then consider case by case basis.
Anticoagulants to be STOPPED and REVERSED. If immobile AVOID LMHW or stockings.
Reversal agents -
- prothrombin complex concentrate or IV VIT K = Warfarin.
- idarucizumab (Praxbind) = Dabigatran
- Andexanet alfa (Ondexxya) = Apixaban or Rivaroxaban
**Long term - **
AVOID STATINS for intracerebral - Can increase risk of haemorrhage but can be used in caution if risk outweighs.
Try AVOID anticoagulants and aspirin - seek specialist advise
Intracerebral stroke (a type of haemorrhagic stroke)
TREATMENT SAME AS Haemorrhagic Stoke
Anticoagulant therapy has, however, been used in patients with intracerebral haemorrhage who are symptomatic of DVT or PE BUT AVOID WHEN CAN
ALT IS placement of a caval filter
SAH stroke complication
Subarachnoid haemorrhage (SAH)
Main complications of a SAH is secondary cerebral ischaemia, which can cause death in those patients who survive the initial bleed.
Cause by cerebral vasospasm
Can be treated with CCB nimodipine
