Stroke (Investigations and Management) Flashcards
It is difficult to establish between ischaemic and haemorrhagic stroke by clinical assessment alone. What is the definite way of distinguishing the two?
Neuroimaging
What is the first line investigation for suspected stroke?
Brain CT
What is the brain CT in suspected stroke used for?
To establish between ischaemic and haemorrhagic stroke and to identify any other intracranial pathology
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)
Though a CT is the first line investigation for a stroke, what imaging modality is more effective for visualising infarcts?
MRI
CT scans will rapidly visualise a haemorrhagic stroke and can also show other complications such as what?
Intraventricular extension of haemorrhage and mass effect
What colour will a haemorrhagic stroke appear on CT?
White
What colour will an ischaemic stroke appear on CT?
Dark (or possibly nothing at all)
At the time of a stroke, a CT scan is more sensitive for detecting what kind of stroke?
Haemorrhagic
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
Different types of ischaemic stroke will show different things on imaging. What type of ischaemic stroke will show a ‘fibrin dependent red thrombus’?
Cardioembolic
Different types of ischaemic stroke will show different things on imaging. What type of ischaemic stroke will show a ‘platelet dependent white thrombus’?
Atheroembolic
Different types of ischaemic stroke will show different things on imaging. What type of ischaemic stroke will show ‘atherosclerosis’?
Small vessel disease
Headache is more commonly a symptom of which type of stroke?
Haemorrhagic
Aneurysms where will always compress CNIII?
Posterior communicating artery
What clinical picture will emerge if CNIII is compressed?
3rd nerve palsy - down and out, ptosis, pupillary dilatation
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
What are some neurological symptoms which are not common presentations of stroke?
Blackouts, dizziness, pain, changes in vision
Which two investigations can be used to determine between an ischaemic or haemorrhagic stroke?
CT or MRI
What are three further investigations which may be done to determine the cause of an ischaemic stroke?
Carotid imaging, cerebral angiography, ECHO
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
