Stroke Investigation and Prevention Flashcards
What is a useful assessment tool in stroke?
ROSIER score
What is the ROSIER score?
Exclude hypoglycaemia then: LOC or syncope -1 point Seizure activity -1 point New, acute onset of: Asymmetrical facial weakness +1 Asymmetric arm weakness +1 Asymmetric leg weakness +1 Speech disturbance +1 Visual field defect +1
Stroke likely if > 0
What is primary prevention and secondary prevention?
Primary - before any strokes
Secondary - preventing further strokes
Whatis primary prevention in stroke?
Control risk factors: HTN DM Hyperlipidaemia Cardiac disease - AF, IHD, VHD Quit smoking Exercise
Lifelong anticoagulaation in AF and prosthetic heart valves
What is secondary prevention of stroke?
Control risk factors
Antiplatelet agents after stroke
- If no primary haemorrhage on CT give 2 weeks of aspirin 300mg then switch to long-term clopidogrel mono therapy.
If this is CI or not tolerated then give low dose aspirin plus slow release dipyridamole
Anticoagulation after stroke from AF:
Can be commenced 2 weeks after stroke
Offer a DOAC or warfarin following risk/benefits discussion
What tools can be used to asses stroke risk in AF patients?
CHA2DS2VASc
CCF HTN Age > 74 =2 or >65-74 =1 DM Previous Stroke/TIA/VTE Vascular disease Sex category
Offer anticoagulation in patients with a score of 2 or above
Take bleeding risk into account: using HAS-BLED score
If HAS-BLED>3 caution in using anticoagulants
What tool used to assess bleeding in AF?
History of bleeding, uncontrolled HTN
Alcohol abuse
Stroke Hx
Bleeding disorder
Labile INR
Elderly > 65
Drugs predisposed to bleeding
What are other cardiac sources of emboli?
AF Cardioversion Prosthetic valves Acute MI with large left ventricular wall abnormalities PFO Septal defects Cardiac surgery IE - septic emboli
What is the mechanism of action of aspirin? Clopidogrel
Dipyridamole?
Aspirin - inhibits COX1, suppressing prostaglandin and thromboxane A2 synthesis and therefore inhibiting platelet aggregation
Clopidogrel - inhibits palatela aggregation by modifying platelet ADP receptors preventing further strokes and MIs
Dipyridamole - increased cAMP and reduced thromboxane A2
what should you investigate for following a stroke?
HTN - look for retinopathy, nephropathy, cardiomegaly
Cardiac source of emboli - 24h ECG for AF
CXR may show enlarged LA
Echo may reveal mural thrombus due to aF or hypo kinetic segment fo cardiac muscle post-MI
IE
RHD
Carotid artery stenosis:
Carotid copper US ± CT/MRI angiography
Benefits/risks of neovascularisation should be individualised
Carotid endarterectomy
Hypoglycaemia, hyperglycaemia, dyslipidaemia, hyperhomocyteinaemia
Vasculitis - ESR, ANCA,
Prothrombotic states - thormbophilia, antiphospholipid syndrome
Hyperviscousity - polycythaemia, sickle-cell disease
Thrombocytopenia and other bleeding disorders
When should a carotid endoarterectomy be considered?
Patient has suffered stroke or TIA in the carotid territory and are not severely disabled
Should only be considered if carotid stenosis > 70%
