Stroke Medicine Flashcards
Oxford classification for stroke
Cortical inc speech/language disturbance, LOC, vision changes
TACS = 2x cortical symptoms, 1x motor/sensory symptom
Circle of willis
Examples of stroke mimics
- Hypoglycaemia
- Seizure
- Migraine with aura
- Bells palsy/Ramsay hunt syndrome
- Space occupying lesion
- Functional syndrome - diagnosis of exclusion
Grouping of stroke mimics - how identifiable they are
- Group 1 - readily identifiable on brain imaging
- Group 2 - syndromically distinguishable from stroke syndrome on clinical grounds after medical assessment
- Group 3 - exclusion of stroke syndrome requires specialist stroke assessment including brain imaging
Management of BPPV
- Diagnose - Dix-hallpike
- Treat - Epley, Brandt-Daroff exercises for home
What does positive head thrust test mean?
- Means something wrong with vestibular system
- Eg vestibular neuronitis
What is transient global amnesia?
- Can’t recall events during period of time
- Remain functional during episode eg can make a cup of tea
- Become repetitive - so seem confused
Hemiplagic migraine history
- Gradual onset of symptoms
- Headache associated
- Progression of symptoms
- eg blurred vision, then 20 mins later pins and needles migrating from fingers upwards, associated speech problems
Possible stroke mimics - others
- Venous infarcts - gradual onset, middle aged women, feel unwell, cna get motor/sensory disturbance
- Small cortical strokes - peripheral nerve lesions?
- Limb shaking TIA - ?seizure
- Occipital strokes - present with confusion, delirium, visual field defect
- Vestibular dysfunction
Causes of stroke - most common
- Atherosclerotic plaque –> thrombus –> embolus
Potential inv for ?stroke
- ECG - AF
- 24hr tape/more prolonged - AF
- Echo - if suspect LV thrombus/emboli or PFO (esp in young)
- Carotid US ?atherosclerosis (if more than 50% on relavant side –> carotid endarterectomy)
- Thrombophilia screen
- Angiography
patent foramen ovale
What is NIHSS?
- Domains that measure symptoms
- Assess severity of stroke in A&E
- 11 domains out of 42 - larger score = larger stroke, above 20 is very large
If less than 6 - considered mild - may not qualify for thrombectomy
Thrombectomy criteria
FINISH
Score more than 6 on NIHSS
Main management points for stroke - broad
- blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits
- blood pressure should not be lowered in the acute phase of ischaemic stroke unless there are complications
- blood pressure control should be considered for patients who present with an acute ischaemic stroke, if they present within 6 hours and have a systolic blood pressure > 150 mmHg (lecture said <130/80)
- aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
- atrial fibrillation - anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke
- if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation
Criteria for thrombolysis - tenecteplase (one off, alteplase is infusion so more difficult)
- Administered within 4.5 hours of onset of stroke symptoms
- Haemorrhage has been definitively excluded - via imaging
OR
* Treatment can be started between 4.5 and 9 hours of known onset, or within 9 hours of the midpoint of sleep when they have woken with symptoms, AND
* They have evidence from CT/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue
