Stroke complication, Tx, and prognosis

Question 1

List complications of stroke

Answer 1

Recurrent stroke or extension of stoke
Complications of immobility - VTE, constipation and bed sores
Raised ICP (haematoma expansion, malignant oedema, haemorrhagic transformation or hydrocephalus)
Infections (Chest -aspiration, or urinary tract - incomplete bladder emptying from either constipation or supine/bed bound posture)
Mood and other cognitive issues - can affect motivation and compliance with rehabilitation among other things
post-stroke fatigue - fatigue due to poor sleep, medications, or as an inherent result of brain cell damage
Post stroke pain - Pain due to spasticity, joint dislocation or central/neuropathic pain
Spasticity, contractures and secondary epilepsy

Question 2

How to manage acute stroke?

Answer 2

Ensure blood glucose, hydration, oxygen saturation and temperature are within normal limits
Feeding assessment and Mx
Aspirin 300mg orally/rectally - if haemorrhagic stroke has been excluded
If cholesterol >3.5mmol/L - start a statin (after at least 48 hours - risk of haemorrhagic transformation)

Question 3

Problem with hypovolaemia in stroke?

Answer 3

can worsen the ischaemic penumbra and increase risk of other complications such as infection, deep vein thrombosis, constipation and delirium

Question 4

What level should blood glucose be maintain

Answer 4

between 4 and 11 mmol/L in people with acute stroke

Question 5

How to control BP in acute stroke?

Answer 5

Only use antihypertensives post-ischaemic stroke if there is a hypertensive emergency (>220/120-130 mmHg) with either Hypertensive encephalopathy, Hypertensive nephropathy, Hypertensive cardiac failure/myocardial infarction, Aortic dissection, Pre-eclampsia/eclampsia

If Tx indicated – reduce BP by approx.. 15% in 1st 24-hrs after stroke using IV labetalol, nicardipine and clevidipine

If going for thrombolytic therapy for acute stroke – reduce BP to < 185/110mmHg. After thrombolytic therapy – maintain BP at 180/105mmHg for at least 24hrs after Tx.

Question 6

How to assessment and manage feeding post stroke

Answer 6

If concerns aboout swallowing - specialist assessment in 24hr preferably - not greater than 72hrs

If unsafe to swallow – NG tube feeding (within 24hrs of admission ideally) – unless they have had thrombolytic therapy

If NG tube not tolerated – nasal bridle tube/gastrostomy instead

Question 7

Describe the care bundle post stroke

Answer 7

Admission to stroke unit
Revascularisation therapy
Optimising physiology and surveillance, prevention and early intervention of complications 
Nutritional support
Secondary prevention 
Rehabilitation

Question 8

How does reperfusion therapy help?

Answer 8

improves chances of recovery by preserving neural tissue which will be the basis of future “neuroplasticity”.

Question 9

Thrombolysis indications?

Answer 9

<4.5hrs post stroke onset
Disabling impairments - NIHSS >4, dysphasia, inability to self care or mobilise independently, visual field defect, dysphagia

Question 10

Absolute CIs of thrombolysis?

Answer 10

Blood pressure >185/110 after two attempts to lower it
Stroke within the last 14 days
Trauma/surgery in last 14 days
On dabigatran with abnormal APTT or thrombin time >100 seconds
Active internal bleeding
Severe haematological abnormalities
INR>1.7 or APTT>40
On rivaroxaban/apixaban/edoxaban
On high dose LMWH
Platelet count <50 x 10^9/L
Arterial puncture at a non-compressible site or LP in last 7 days
Symptoms suggestive of SAH, even if CT normal
Infective endocarditis, pericarditis or presence of ventricular aneurysm related to recent MI
Childbirth within the previous 4 weeks
Acute pancreatitis
Severe liver disease, including hepatic failure, cirrhosis, portal hypertension, oesophageal varices and active hepatitis.

Question 11

Relative CIs of thrombolysis?

Answer 11

Pre-treatment scan showing evidence of infarction >4.5h (e.g. hypo-density on CT); mass effect / oedema; tumour, AVM or aneurysm; evidence of large infarct core on MR-DWI or CTA
Intra-cranial or intra-spinal surgery within last 2 months
Any non-neurosurgery (including minor surgery) within last 6 weeks
Stroke or head injury in last 6 weeks
History of GI or urinary tract bleed in last 6 weeks
Previous CNS bleeding, e.g. SDH
Glucose <2.7 or >22 mmol/L - relate to the possibility of a stroke mimic explaining all stroke impairments.
Seizure at stroke onset - relate to the possibility of a stroke mimic explaining all stroke impairments.
Possibility of pregnancy
Greater than 90-minute delay post scan
Symptoms that start during sleep
Severe pre-morbid dependency

Question 12

How to consent for thrombolysis

Answer 12

Ensure Patient understands risk of bleeding before alteplase is given

Question 13

How do you administer alteplase?

Answer 13

dose of alteplase is calculated by patient weight

10% is given as a bolus over 1-2 minutes with the rest given as an infusion over 1 hour.

Patients are monitored every 15 mins during infusion with checks of pulse, BP, GCS, pupil reaction and ask about headache etc, towards identification of either anaphylaxis or bleeding

Question 14

Thrombolysis complications?

Answer 14

Haemorrhage
- Extracerebral - Thin thready pulse, drop in BP, Malaena, Distended abdomen
- Intracerebral - Neurological decline, New headache, Rising BP, Nausea and Vomiting
Hypotension - more common with streptokinase
allergic reactions may occur with streptokinase
Also deterioration can be related to death of brain cells:
- Evolution of stroke causing rising ICP  Oedema or Hydrocephalus
- Seizure
- Infection
- Metabolic disturbance

Question 15

Alteplase MOA?

Answer 15

recombinant tissue plasminogen activator – requires first contact with fibrin first to start lying the clot - For large clots the sheer volume of the clot mean a significant fibrin load

Question 16

Mechnical thrombectomy indication?

Answer 16

Large vessel occlusion stroke
p
Pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS)
Within 6hrs of symptom onset

Question 17

When to offer thrombectomy and IV thrombolysis?

Answer 17

people who have acute ischaemic stroke and:
Confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

Question 18

Indication for Decompressive Hemicraniectomy?

Answer 18

management of malignant oedema in patients <60yo (or older if biologically fit)
• Refer to neurosurgical unit within 24hrs, and surgery completed within 48hrs

Question 19

Intervention for Intracerebral haemorrhage?

Answer 19

Raised intracranial pressure is main concern
Non-surgical Mx: BP control and correction of clotting abnormalities
Surgical Mx: Evacuation of haematoma and ventricular drains

Question 20

Carotid endarterectomy indication? How to optimise patient for surgery?

Answer 20

Mx of symptomatic carotid disease (after TIA or stroke with good recovery) of more than 50% (NASCET method) lumen reduction on carotid ultrasound or carotid stenosis > 70% according ECST** criteria

reduction of recurrent stroke is optimised by aggressive medical therapy
BP control [<130/80], high dose statin therapy, and dual antiplatelet therapy
Attempts to achieve plaque stabilisation

Question 21

Options for stroke secondary prevention in patients with AF in whom anticoag is CI?

Answer 21

Left atrial appendage close

Question 22

How to assess swallow?

Answer 22

Bedside assessments
Video fluoroscopy
Flexible endoscopic evaluation of swallowing (FEES)

Question 23

WHat is involved in stroke rehab?

Answer 23

• Mobility, ADL (activities of daily living), speech and cognitive therapy are the mainstays of stroke rehabilitation

Also managing spasticity (including orthotic prostheses and botulinum toxin therapy), and environmental modifications.

Question 24

2ndary prevention in ischaemic stroke?

Answer 24

1st line: Clopidogrel

Aspirin plus modified-release (MR) dipyridamole – of clopidogrel CI or not tolerated
MR dipyridamole alone only if aspirin or clopidogrel are contraindicated or not tolerated

Question 25

What does stroke rehab involve?

Answer 25

MENDS
MDT: physio, SALT, dietician, OT, specialist nurses, neurologist, family
Eating: Screen swallowing: refer to specialist - NG/PEG if unable to take oral nutrition;
Screen for malnutrition (MUST tool) - Supplements if necessary
Neurorehab: physio and speech therapy- Botulinum can help spasticity
DVT Prophylaxis
Sores: must be avoided @ all costs

Question 26

Grouping for mortality prognosis?

Answer 26

1. Unstable – these will require multiple assessment to evaluate efficacy of interventions in return patients to medical stability.
2. Stable but at high risk of stroke complications – these will particularly require efforts to prevent complications and close surveillance to ensure complications are picked early
3. Stable – standard attention; review could be left to the end of the ward round.

Question 27

How to determine function prognosis? groups of recovery trajectory and plateau?

Answer 27

best informed by the recovery trajectory (reflecting neuroplasticity at the site of neuronal damage). - Measured through success or failure in achieving recovery milestones

Early, high functioning plateau – the extreme version of this is a TIA or minor stroke, signifying excellent functional prognosis.

Early, low functioning plateau – the extreme version of this is a TACS with no meaningful improvement in function as time passes, signifying poor functional prognosis.

Delayed and medium functioning plateau – this will likely define recovery in most moderate strokes. These patients will benefit from a chance at sustained rehabilitation efforts until a functional plateau is achieved.

Question 28

Stroke impairments that reduce the chance of long-term independent living?

Answer 28

Dense hemiparesis, inattention, receptive dysphasia and cognitive dysfunction

Question 29

Driving restrictions after stroke?

Answer 29

4-week period of driving restriction applies for standard car licences and 1 year for HGV licences

Persisting impairments/disability is not an automatic disqualification from driving and consideration should be given to Regional Driving Assessment Centres referral which may prompt car modification and allow resumpt

Question 30

Define TIA? Mx?

Answer 30

SSymptoms last less than 24hrs

Immediate antithrombic therapy - give aspirin 300 mg immediately, unless contraindicated

If the patient has had more than 1 TIA (‘crescendo TIA’) or has a suspected cardioembolic source or severe carotid stenosis: discuss the need for admission or observation urgently with a stroke specialist
If the patient has had a suspected TIA in the last 7 days: Arrange urgent assessment (within 24 hours) by a specialist stroke physician

If the patient has had a suspected TIA which occurred more than a week previously: Refer for specialist assessment as soon as possible within 7 days

Question 31

How to manage patient with diabetes in stroke?

Answer 31

Sliding scale

Question 32

Most sensitive imaging for acute infarct?

Answer 32

Diffusion weighted MRI

Question 33

Imaging after thrombolysis? Age range for thrombolysis?

Answer 33

CT 24hrs post thrombolysis

18-80yrs

Question 34

Role of occupational therapy in stroke Mx?

Answer 34

Impairment: e.g. paralysed arm
Disability: e.g. inability to write
Handicap: e.g. can’t work as accountant
OT aims to minimise disability and abolish handicap

Question 35

One way to clarify cause of haemorrhagic stroke?

Answer 35

Interval imaging