Stroke medicine Flashcards
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
Risk assessment for TIA to predict short term risk of stroke?
ABCD2 - but NOT a diagnostic tool
How is ABCD2 calculated?
Sum of points of 5 different factors inc:
* Age
* BP
* Clinical features
* Duration of symptoms
* Diabetes?
Cut off score for ABCD2
Score of 4 or more = higher risk of stroke
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
Investigations for TIA
- Bloods
- Carotid doppler
- CT or MRI
Treatment for TIA
- Lifestyle modifcations
- Treatment of high cholesterol and HTN
- Surgical intervention for carotid artery disease
- Antiplatelets if appropriate
What is crescendo TIA?
Two or more TIAs in a week - should be treated for high risk stroke
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)
Initial classification of stroke
- Haemorrhage
- Infarct (ischaemic)
How do we identify vascular territory involved - classification?
- Bamford classification and then with brain imaging
How to classify underlying cause of infarcts?
TOAST classification
Classifying underlying causes of bleeds on brain
- Primary HTN
- Cerebral amyloid angiopathy
- Secondary - eg trauma
Emergency treatment of stroke
- Thrombolysis for ischaemic
- Anticoagulation reversal or neurosurgical intervention for bleeds
Types of strokes
- TACS
- PACS
- LAC
- POCS
What us used to classify the symptoms associated with the types of strokes?
Bamford classification
Worse stroke type prognosis
- TACS - often leave pt with significant weakness
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
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
