Stroke (Investigations and Management) Flashcards by Jane Keery

It is difficult to establish between ischaemic and haemorrhagic stroke by clinical assessment alone. What is the definite way of distinguishing the two?

Neuroimaging

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What is the first line investigation for suspected stroke?

Brain CT

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What is the brain CT in suspected stroke used for?

To establish between ischaemic and haemorrhagic stroke and to identify any other intracranial pathology

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What is important to be aware of, with regards to the initial CT scan, in ischaemic stroke?

The CT scan may be normal in the first few hours (especially in cases of POCS)

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Though a CT is the first line investigation for a stroke, what imaging modality is more effective for visualising infarcts?

MRI

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CT scans will rapidly visualise a haemorrhagic stroke and can also show other complications such as what?

Intraventricular extension of haemorrhage and mass effect

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What colour will a haemorrhagic stroke appear on CT?

White

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What colour will an ischaemic stroke appear on CT?

Dark (or possibly nothing at all)

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At the time of a stroke, a CT scan is more sensitive for detecting what kind of stroke?

Haemorrhagic

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What is important to be aware of, with regards to haemorrhagic stroke on CT?

After around 1 week, a CT scan is not sensitive to blood and the clot will look similar to a thrombus

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Different types of ischaemic stroke will show different things on imaging. What type of ischaemic stroke will show a ‘fibrin dependent red thrombus’?

Cardioembolic

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Different types of ischaemic stroke will show different things on imaging. What type of ischaemic stroke will show a ‘platelet dependent white thrombus’?

Atheroembolic

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Different types of ischaemic stroke will show different things on imaging. What type of ischaemic stroke will show ‘atherosclerosis’?

Small vessel disease

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Headache is more commonly a symptom of which type of stroke?

Haemorrhagic

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Aneurysms where will always compress CNIII?

Posterior communicating artery

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What clinical picture will emerge if CNIII is compressed?

3rd nerve palsy - down and out, ptosis, pupillary dilatation

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What is the best first management of a stroke?

Early referral to acute stroke services for assessment, evaluation of suitability for thrombolysis, investigation and management

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What are some neurological symptoms which are not common presentations of stroke?

Blackouts, dizziness, pain, changes in vision

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Which two investigations can be used to determine between an ischaemic or haemorrhagic stroke?

CT or MRI

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What are three further investigations which may be done to determine the cause of an ischaemic stroke?

Carotid imaging, cerebral angiography, ECHO

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How is carotid imaging for ischaemic stroke performed? Why is this done?

By US, CT or MR angiography to assess for atherosclerotic narrowing

Why is cerebral angiography performed for ischaemic stroke?

To assess for cerebral vascular stenosis

Why is an ECHO performed for ischaemic stroke?

To assess for valvular heart disease, congenital defects and possible thrombus/embolus sources

Why is an ECG performed on all stroke patients?

To arrhythmias, either as a mimic of stroke or as a cause of stroke

If an aneurysm or AVM is suspected as the cause of a haemorrhagic stroke, what investigation must be done?

MR/CT/digital subtraction cerebral angiography

What investigation is sometimes performed 6-8 after a haemorrhagic stroke? Why?

MRI- to determine if there was an underlying cause

What are the 1st line blood tests taken in stroke patients to ascertain risk factors and guide acute care?

Glucose, electrolytes and cholesterol

What are the 2nd line blood tests taken in stroke patients to assess for rare causes of stroke?

Thrombophilia screen, vasculitis screen, blood cultures

What is the 1st line acute management of stroke if necessary?

ABCDE

Following the CT scan, what is the best management of an ischaemic stroke?

Thrombolysis/thrombectomy

Within what timeframe must thrombolysis/thrombectomy be performed?

Within 3.5-4.5 hours of stroke onset

Following the CT scan, what medication is given to all patients with an ischaemic stroke?

300mg aspirin

In what case should you wait 24 hours before giving a stroke patient aspirin?

If they have been thrombolysed

Patients who have a stroke are at a high risk of what due to immobility? How is this managed?

DVT/PE - give LMWH

All patients who have had a stroke should get screened for what?

Should get a swallow screen

If a swallow screen is abnormal, what happens?

Patient should be assessed by SALT

Stroke patients should be nil by mouth until when?

They are assessed by SALT

If a patient has a poor swallow or cannot swallow at all, what are some management options?

Textured diet, thickened fluids or NG tube depending on how severe

How long is aspirin given for if a patient has had a stroke? What is it replaced with after this time?

2 weeks, and then it is replaced by clopidogrel for life

Which patients should receive warfarin anticoagulation following their 2 weeks of aspirin instead of clopidogrel (an anti-platelet)?

Those who have chronic non-valcular and non-rheumatic AF or another cardioembolic cause for their stroke

As well as SALT, what other AHP should assess stroke patients? What tool do they use?

Nutritionists using the MUST scoring

What is the treatment for intracerebral haemorrhagic stroke?

No specific medical treatment - stop any anti-coagulant or anti-platelet

When is surgery used for treatment of stroke?

All cases of haemorrhagic stroke should be discussed with a neurosurgeon - ruptured aneurysms or other arterial tears/ruptures may need clipping or endovascular intervention

Aside from anti-coagulants and anti-platelets, which other medications may be offered as secondary stroke prevention?

Statins and BP control

What advise is offered as secondary stroke prevention?

Stop smoking, improve diet and increase exercise

What happens in thrombolysis?

IV alteplase is given within 3.5 hours of the symptom onset

What is the major complication of thrombolysis?

Precipitation of acute haemorrhage in an ischaemic/infarcted area

What are some factors based around the onset of symptoms which would be contra-indications to thrombolysis?

Onset > 3.5 hours ago, seizure since onset, resuscitation required, minor/improving symptoms, significant co-morbid dependence

What are some factors based around recent medical history which would be contra-indications to thrombolysis?

Invasiveor surgical procedure in the last 3 weeks, pregnant or recent obstetric delivery

What are some bleeding disorders which are contra-indications to thrombolysis?

Previous intra-cranial haemorrhage, active bleeding, GI ulcer/bleeding, anticoagulation use, severe liver disease

What are some cranial disorders which would be contra-indications to thrombolysis?

Stroke in the past 3 months, structural cerebrovascular disease, major infarct/haemorrhage on CT

What are some cardiac disorders which would be contra-indications to thrombolysis?

Aortic dissection, severe hypertension > 220/130