Focal neurological deficits due to blockage of blood supply to part of the brain Lasting less than 24hrs but in practice these are usually much less

Lifestyle modifcations Treatment of high cholesterol and HTN Surgical intervention for carotid artery disease Antiplatelets if appropriate

Sudden onset of focal neurological deficit Lasting more than 24hrs or with imaging evidence of brain damage (eg infarction shown by emboli, thrombosis or low blood flow or haemorrhage)

NIH stroke scale - used as clinical stroke assessment tool to evaluate and document neuroligcal status in acute stroke patients Measure stroke severity

Stroke medicine Flashcards by Ella Harris

What are TIAs?

Focal neurological deficits due to blockage of blood supply to part of the brain
Lasting less than 24hrs but in practice these are usually much less

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Risk assessment for TIA to predict short term risk of stroke?

ABCD2 - but NOT a diagnostic tool

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How is ABCD2 calculated?

Sum of points of 5 different factors inc:
* Age
* BP
* Clinical features
* Duration of symptoms
* Diabetes?

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Cut off score for ABCD2

Score of 4 or more = higher risk of stroke

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Management of high risk patients

Prioritised to be seen in TIA clinic or by a stroke physician ASAP
Aspirin 300mg daily if suspected TIA started immediatly

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Investigations for TIA

Bloods
Carotid doppler
CT or MRI

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Treatment for TIA

Lifestyle modifcations
Treatment of high cholesterol and HTN
Surgical intervention for carotid artery disease
Antiplatelets if appropriate

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What is crescendo TIA?

Two or more TIAs in a week - should be treated for high risk stroke

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Define stroke

Sudden onset of focal neurological deficit
Lasting more than 24hrs or with imaging evidence of brain damage (eg infarction shown by emboli, thrombosis or low blood flow or haemorrhage)

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Initial classification of stroke

Haemorrhage
Infarct (ischaemic)

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How do we identify vascular territory involved - classification?

Bamford classification and then with brain imaging

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How to classify underlying cause of infarcts?

TOAST classification

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Classifying underlying causes of bleeds on brain

Primary HTN
Cerebral amyloid angiopathy
Secondary - eg trauma

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Emergency treatment of stroke

Thrombolysis for ischaemic
Anticoagulation reversal or neurosurgical intervention for bleeds

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Types of strokes

TACS
PACS
LAC
POCS

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What us used to classify the symptoms associated with the types of strokes?

Bamford classification

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Worse stroke type prognosis

TACS - often leave pt with significant weakness

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Assessment tools used for rapid assessment of stroke

FAST:
* Face (facial drooping)
* Arm (weakness)
* Speech (slurred)
* Time (call 999)
ROSIER
* Rosier scale used to distinguish between stroke and stroke mimic. commonly used in A&E

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What is NIHSS?

NIH stroke scale - used as clinical stroke assessment tool to evaluate and document neuroligcal status in acute stroke patients
Measure stroke severity

15 items on NIHSS

Level of conc
Language
Neglect
Visual field loss
Extraocular movement
Motor strength
Ataxia
Dysarthria
Sensory loss

Pharmaceutical treatment for identified ischaemic stroke

Alteplase - thrombolysis

Timeframe to have alteplase

Within 4.5hrs of onset of stroke
Increases likelihood of being functionally independent
Does not increase 90 day risk of mortality

Where should stroke pts be cared for and why?

Organised stroke unit
Long term reduction in death dependency and need for institutional care

What should all people presenting with acute stroke who have had haemorrhage excluded by imaging be given?

Aspirin 300mg orally if not dysphagic
300mg rectally or by enteral tube if they are

How long should aspirin 300mg be continued for?

* 2 weeks after the onset of symptoms * Then long term antithrombolytic agent should be commenced

Restrictions after stroke and TIA

* Not permitted to drive for 1 month * After this time you can again as long as there is no permanent neurolgical problems * If recurrent TIAs cannot drive for 3 months - must be assessed by doctor prior to driving

How is carotid stenosis quantified?

* NASCET - north american symptomatic carotid endarterectomy trial criteria * ECST - european carotdi surgery trialists collaberative group criteria

NASCET scoring value to undergo assessment/intervention

50-99% carotid stenosis with stable neurologicla symptoms from stroke or TIA

ECST value to undergo assessment/surgery

70-99% carotid stenosis with stable neurological symptoms from stroke or TIA

What should those with 50-99% NASCET and 70-99% ECST have?

* Assessed and referred for carotid endarterectomy within 1 weeek of onset of stroke/TIA symptoms * Undergo surgery within a maximum of 2 weeks from onset of stroke/TIA symptoms * Fitness for surgery should be assessed and may be small risk of stroke during surgery

What are people with severe middle cerebral artery infarction at risk of?

* Malignant MCA syndrome * Therefore should be considered for decompressive hemicraniectomy if any deterioration in clinical condition eg decrease in conc

Timing for decompressive hemicraniectomy for malignant MCA syndrome risk

* Referred within 24hrs of onset of symptoms * Treated within max of 48hrs

Criteria for malignant MCA syndrome decompressive hemicraniectomy

* Under 60 * CT infarct of at least 50% MCA territory * NIHSS score above 15

Examples of stroke mimics

* Seizures * Space occupying lesions * Hemiplagic migraine * Multiple sclerosis * Sepsis in those with pre-existing neurologicla weakness

Risk scoring used to assess if suitable for anticoagulation

CHADS-VASC 2 score

When is CHADS-VASC 2 score used?

Determine if someone is suitable for anticoagulants if they are in atrial fibrillation and at risk of stroke

What is useful to use alongisde CHADS-VASC 2?

* ORBIT * HAS-BLED score * Both used to assess bleeding risk

Anticoagulation for afib stroke risk

* Warfarin * DOAC eg apixaban, rivaroxaban, edoxaban

HAS BLED components

CHAD VASC 2 components

Complex decisions made in stroke examples

* DNACRPS * Commencing enteral feeding eg NG or PEG

Indication for enteral feeding

* Poor swallow following large stroke * Without if these patients would aspirate

Decision for enteral feeding is baseed on...

* Patient and family preference * Quality of life expected with treatment

Risks of NG/PEG tube

Aspiration - still Some patients will never be able to tolerate oral intake again

When are NG tubes often inserted?

* Post stroke when swallowing is affected * Decision to proceed with PEG feeding is often complex decision making process involving family and MDT