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OPIC > Stroke - passmed > Flashcards

Stroke - passmed Flashcards

1
Q

Management of stroke - general points

A
  • Manage blood glucose, hydration, O2 and temperature
  • Blood pressure - do not lower in acute phase unless complications (hypertensive encephalopathy or considered for thrombolysis)
  • BP control should be considered if present within 6 hrs and systolic BP >150
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2
Q

AF rules in stroke

A
  • Anticoags not started until brain imaging excludes haemorrhage
  • Usually not until 14 days have passed from onset of ischaemic stroke
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3
Q

Cholesterol rules stroke

A
  • If more than 3.5mmol/L commence on statin
  • Many delay treatment until after at least 48hrs due to risk of haemorrhagic transformation
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4
Q

Thrombolysis rules stroke

A
  • Alteplase or tenecteplase
  • Administer 4.5hrs of symptoms
  • Exclude haemorrhage first
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5
Q

Broadened criteria for thrombolysis

A

Consider if:
* Treatment can be started between 4.5 and 9hours of known onset or within 9hrs from midpoint of sleep AND
* They have evidence from CT/MR perfusion or MRI (DWI-FLAIR) of salvagable brain tissue
* Irrespective of large artery and require mechanical thrombectomy

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6
Q

Blood pressure rules prior to thrombolysis

A

Lower to 185/110 before thrombolysis

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7
Q

Contraindications of thrombolysis

A
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8
Q

Thrombectomy functionl status requirment

A
  • Pre-stroke functional status of less than 3 on modified Rankin scale (2 or less)
  • Score more than 5 on NIHSS (6 or more)
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9
Q

Timeline for thrombectomy

A
  • Within 6 hours of onset
  • With IV thrombolysis if within 4.5hrs
  • To people who have acute ischaemic stroke and confirmed proximal anterior circulation on CTA or MRA
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10
Q

Extended criteria for thrombectomy

A
  • Last known to be well within 6-24hrs (inc wake up strokes)
  • If have confirmed occlusion of PAC demonstrted by CTA or MRA AND
  • potential to salvage brain tissue as shown by CT perfusion of DWI MRI (showing limited infarct core volume)
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11
Q

When to CONSIDER thrombectomy

A
  • Well up to 24hrs before (inc wake up strokes)
  • Ischaemic stroke confirmed of proximal posterior circulation (basilar or PCA) demonstrated by CTA or MRA AND
  • Potential to salvage brain tissue as shown by CT perfusion or diffusion weighted MRI (showing limited infarct core volume)
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12
Q

Secondary prevention post stroke

A
  • Clopidogrel
  • Aspirin only if clopidogrel contraindicated/not tolerated
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13
Q

When is carotid endarterectomy offered?

A
  • Stroke/TIA in carotid territory and not severely disabled
  • Should be considered if stenosis is >50% on affected side (according to NASCET)
  • Perform ASAP within 7 days
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14
Q

Oxford stroke classification - types

A
  • TACI
  • PACI
  • LACI
  • POCI
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15
Q

TACI/PACI

A

Total:
* Unilateral hemiparesis and/or hemisensory loss of face, arm and leg
* Homonymous hemianopia
* Higher cognitive dysfunction - eg dysphasia
* Involves middle and anterior cerebral arteries

PACI:
* Only 2 of the above
* Usuallly upper/lower division of middle cerebral artery

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16
Q

LACI

A
  • Involves perforator arteries of internal capsule, thalamus and basal ganglia

Presents with one of:
* Unilateral weakness (and/or sensory deficit) of face and arm or arm and leg or all three
* Pure sensory stroke
* Ataxic hemiparesis

17
Q

POCI

A
  • Involves vertebrobasilar arteries

Presents with one of:
* Cerebellar/brainstem syndromes
* Loss of consciousness
* Isolated homonymous hemianopia

18
Q

What is lateral medullary syndrome?

A
  • Posterior inferior cerebellar artery affected
  • AKA Wallenbergs
  • Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, CN palsy/Horners
  • Contralateral limb sensory loss
19
Q

Webers syndrome

A
  • Midbrain stroke
  • Ipsilateral CN III palsy
  • Contralateral weakness
20
Q

Patients who have suffered haemorrhagic stroke are more likely to have:

A
  • Decreased level of consciousness
  • Headache
  • Nausea and vomitting
  • Seizures
21
Q

Imaging for stroke - initial and then future

A
  • CT head - no contrast - check for haemorrhage
  • MRI (DWI) can be considered if CT inconclusive - better at detecting acute ischaemia
  • CTA/MRA if considering thrombectomy
22
Q

Bloods for ?stroke

A
  • FBC
  • Coagulation profile
  • U&E
  • LFT
  • Fasting lipids
  • Glucose

Rule out mimics - hypoglycaemia, electrolyte disturbances
Assess risk factors - dyslipidaemia, diabetes
Evaluate contraindications for thrombolysis eg coagulopathy

23
Q

Further investigations to identify underlying cause of stroke

A
  • Echo - TTE ot TOE - identify AF, patent foramen ovale, valvular heart disease, LV thrombus
  • Carotid dopper US - carotid stenosis/occlusion if anterior circulation stroke
  • 24hrs ECG - detect paroxysmal AF
  • Cerebral angiography - if?cerebral vasculitis, arterial dissection or venous sinus thrombosis and non-invasive imaging modalities are inconclusive
24
Q

Stroke mimics

A
  • Migraine + aura - gradual, escalate over mins-hours, +photophobia/phonophobia or nausea, history of migraine
  • Bells palsy - does not spare forehead, can also have hyperacusis or altered taste ant 2/3 tongue
  • Hypoglycaemia - rapid onset, resolve once glucose corrected, can have sweating, palps, tremor (adrenaline release)
25
Q

Neurological complications of stroke

A
  • Hemiparesis/hemiplegia
  • Aphasia
  • Dysphagia –> aspiration pneumonia
  • Cognitive impairment - dementia, memory, attention, spatial awareness, executive function
26
Q

Physical complications of stroke

A
  • Falls - muscle weakness, balance problems, altered spatial awareness
  • Pain - thalamic lesions
  • Incontinence - urinary and faecal, bladder training programmes and continence promotion stategies can benefit
27
Q

Vascular complications of stroke

A
  • VTE - immbolity
  • CV - MI, HF, arrhythmias
28
Q

Psychological complications of stroke

A
  • Depression/anxiety
  • Emotional lability - rapid, exaggerated changes in mood –> distress
29
Q

Infection complications stroke

A
  • Pneumonia - aspiration due to dysphagia
  • UTI - catheter/retention
30
Q

Driving rules post stroke/TIA

A
  • Stroke/TIA = one month off driving, may not need to inform DVLA if no residual neurological deficit
  • If drive lorry/bus - must not drive for 1 year, notify DVLA
  • Multiple TIAs over short period of time - 3 months off driving, inform DVLA
31
Q
A

OPIC (17 decks)

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