Stroke Rehabilitation

Question 1

What is a stroke?

Answer 1

Rapidly developing clinical symptoms and/or signs of loss of brain function with symptoms lasting >24hrs or leading to death with no other cause

Question 2

What are important things to note when taking the history of a stroke?

Answer 2

Time of onset, symptoms, how did they progress

Question 3

How common are stroke mimics?

Answer 3

1/3 of all stroke presentations are stroke mimics

Question 4

What are some examples of stroke mimics?

Answer 4

Seizure, sepsis, toxins, SOL, syncope, delirium, vestibular dysfunction, dementia

Question 5

What are the questions asked when generating a Rosier score?

Answer 5

Has there been loss of consciousness or syncope?
Has there been seizure activity?
New onset of = asymmetric facial weakness, asymmetric arm weakness, asymmetric leg weakness, speech disturbance, visual field defect

Question 6

How is the Rosier Score graded?

Answer 6

Scores range from -2 to +5
Score >0 is likely to be stroke
Score <= 0 has low likelihood of being stroke

Question 7

Is a stoke technically classed as a diagnosis?

Answer 7

No = it is an experience of persisting neurological complications of CV disease

Question 8

What are the types of stroke?

Answer 8

Infarct = atheroembolic, small vessel, cardioembolic
Haemorrhage = structural abnormality, hypertensive, amyloid angiopathy
Subarachnoid haemorrhage

Question 9

What is the limitation of using CT to image strokes?

Answer 9

Scans aren’t sensitive for blood after about 1 week

In hyperacute setting CT may appear normal

Question 10

What is the management of stroke patients?

Answer 10

Thrombolysis/thrombectomy and imaging
Swallow assessment, nutrition and hydration
Antiplatelets and DVT prevention
Stroke unit care

Question 11

What are some factors to consider when deciding whether to thrombolyse a patient?

Answer 11

Age, time since onset, previous intracerebral haemorrhage/infarct, atrophic changes, blood pressure, diabetes

Question 12

What are the benefits of brain imaging?

Answer 12

Establishes diagnosis and indicates therapeutic decisions

Facilitates clinical management, patient flow and information for patient

Question 13

How effective are stroke units in caring for patients?

Answer 13

Highly effective = for every 33 patients treated there is 1 extra survivor, for every 20 patients treated 1 extra patient is discharged back to their own home

Question 14

What investigations should be done before prescribing antiplatelets after a stroke?

Answer 14

Do a CT first to exclude a bleed

Question 15

What antiplatelet is prescribed after a stroke?

Answer 15

Aspirin 300mg prescribed ASAP = must wait 24hrs if patient was thrombolysed

Question 16

What is the purpose of prescribing antiplatelets after a stroke?

Answer 16

Aim is to reduce further infarct = risk highest early on

Question 17

Why are stroke patients at higher risk of DVT?

Answer 17

Due to immobility

Question 18

What are some options for DVT prophylaxis?

Answer 18

Heparin reduces risk but benefit outweighed by bleeding risk
TED stockings don’t give overall benefit
Intermittent pneumatic compression can reduce risk

Question 19

How is dysphagia screened for in stroke patients?

Answer 19

Initial swallow screen takes place

Question 20

How is dysphagia managed in patients with an abnormal swallow screen result?

Answer 20

Assessment by speech and language therapists

May need NG tube placement or textured diet and thickened fluids depending on swallow

Question 21

What is a transient ischaemic attack (TIA)?

Answer 21

Brief episode of neurologic dysfunction caused by focal brain or retinal ischaemia without evidence of acute infarction

Question 22

How long do symptoms of a TIA usually last for?

Answer 22

Typically last for <1 hour

Question 23

What is done as part of the rapid assessment at the rapid access neurovascular clinic?

Answer 23

History, carotid imaging, ECG, blood tests

Question 24

What immediate therapies are offered following diagnosis at the rapid access neurovascular clinic?

Answer 24

Medication, carotid endarterectomy

Question 25

How should intracerebral haemorrhage patients who present <6hrs onset with systolic BP >150 be treated?

Answer 25

Treat urgently = lower systolic BP to 140 for at least 7 days

Question 26

What are some associations of intracerebral haemorrhages?

Answer 26

15% associated with anticoagulation = worst outcomes associated with vitamin K antagonists (warfarin)

Question 27

What can reduce the incidence and improve outcomes of intracerebral haemorrhages?

Answer 27

DOAC = still worse outcomes than if not anticoagulated

Question 28

What is the mortality of intracerebral haemorrhages?

Answer 28

Mortality rate of 30-50%

Question 29

What is the immediate management of intracerebral haemorrhages?

Answer 29

Anticoagulation reversal

Question 30

How is warfarin reversed?

Answer 30

Vitamin K/Prothrombin complex

Question 31

What are some specific anticoagulation antidotes?

Answer 31

Idarucizumab = reverses direct thrombin inhibitors

Andexanet alpha = reverses direct factor Xa inhibitors

Question 32

What are some methods of anticoagulation reversal when specific antidotes aren’t available?

Answer 32

Prothrombin complex advised

May also use tranexamic acid or rFVIIa