STROKE & TIA Flashcards
What is a stroke?
A sudden onset of focal or global neurological deficit of presumed vascular aetiology lasting >24 hours or leading to death
What is a TIA?
a transient (less than 24 hours) neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction
Majority resolve within 1 hour
What is a brain attack?
A deficit that is still present when you assess but not yet at 24 hours duration
I.e. you dont know if its a stroke or TIA
Stroke epidemiology?
100,000 strokes every year in the UK
1.3 million people living with a stroke in the UK
A leading cause of death and disability - causes 38,000 deaths in the UK each year
Occurring at younger age now - over 1/3rd of strokes occur in adults 40-69
Non-modifiable risk factors for stroke?
Age - older
Gender - male
Race
FHx
Modifiable risk factors for stroke?
Hypertension
Diabetes
AF
Hyperlipidaemia
Smoking
Obesity
Other established cardiovascular diseases
Other medical conditions: migraine, SCD, haemophilia, hypercoagulable disorders, CKS, ehlers-danlos, Marfan syndrome, PCKD, OSA, vascular malformations
Meds e.g. anticoagulation
What % of strokes are ischaemic?
85%
What most commonly causes ischaemic strokes?
Thrombus - often as a complication of atherosclerosis
Embolus - often as a complication of atherosclerosis of carotid arteries or AF
Others: intracranial or extracranial vessels disease or hamatological conditions
What most commonly causes haemorrhagic strokes?
Intracerebral haemorrhage - commonly due to hypertension
Subarachnoid haemorrhage - most commonly rupture of intracranial saccular aneurysms. Others are AVMs, arterial dissections, anticoag use
Short-term complications of strokes?
Haemorrhagic transformation of ischaemic stroke.
Cerebral oedema.
Delirium.
Seizures.
Venous thromboembolism — pulmonary embolism has been associated with 13–25% of deaths in the early period following stroke.
Cardiac complications — e.g. MI, CHD, AF, and arrhythmias are common due to shared aetiology.
Infection — e.g. aspiration pneumonia, urinary tract infection, and cellulitis from infected pressure sores.
Long-term complications of stroke?
Most common:
Urinary incontinence, malnutrition, acute confusion, pain, chest infection, VTE
Mobility issues - hemiparesis, hemiplegia, ataxia, falls, spasticity, contractures
Sensory problems e.g. touch, pain, temp
Pain e.g. neuropathic, MSK
Fatigue
Dysphagia, dehydration and malnutrition
Sexual dysfunction
Increased risk of pressure sores due to reduced mobility
Visual problems e.g. nystagmus, altered acuity, hemianopia, diplopia
Cognitive problems
Difficulties with ADLs
Emotional and psychological
Communication problems e.g. aphasia, apraxia, dysarthria
Loss of income
Prognosis for stroke?
30 day mortality for ischaemic stroke is 12 per 100 and for haemorrhagic stroke its 31 per 100
1 in 7 people with acute stroke die in hospital
Ischaemic stroke in people with AF is associated with greater mortality and disability
Mortality rates in haemorrhagic stroke are higher than ischaemic stroke
Overall mortality at 6 months following subarachnoid haemorrhage is >25%
Risk of recurrent stroke within 90 days after first stroke is 5%. In 10 years its 40%
Factors associated with worse outcomes in haemorrhagic stroke?
Haemorrhage volume
Advanced age
Impaired consciousness at presentation
Rupture of haematoma into the ventricular system
Symptoms of a TIA?
Sudden onset, focal neurological deficit which has completely resolved within 24 hours
Unilateral weakness or sensory loss
Dysphasia
Ataxia, vertigo or loss of balance
Syncope
Sudden transient loss of vision in 1 eye, diplopia or homonymous hemianopia
CN defects
Symptoms of a stroke?
Confusion, altered level of consciousness and coma
Headache - either insidious onset and gradually increasing (intracranial haemorrhage) or sudden severe headache (subarachnoid headache)
Unilateral weakness or paralysis in face, arm or leg
Sensory loss - paraesthesia or numbness
Ataxia
Dysphasia
Dysarthria
Visual disturbances - homonymous hemianopia or diplopia
Gaze paresis
Photophobia
Dizziness, vertigo or loss of balance
Nausea and vomiting
CN deficit
Difficulty with fine motor coordination and gait
Neck or facial pain
Symptoms of acute vestibular syndrome (i.e. posterior circulation)?
acute, persistent, continuous vertigo or dizziness with nystagmus, nausea or vomiting, head motion intolerance, and new gait unsteadiness.
What are stroke mimics?
Metabolic - hypoglycaemia, hypoxia
CNS - old strokes, epilepsy, Todd’s paresis, migraine, mass lesion, MS, encephalitis, syncope
Functional neurological disorder
What is functional neurological disorder?
The name given for symptoms in the body which appear to be caused by problems in the nervous system but which are not caused by a physical neurological disorder
I.e. medically unexplained
Stroke chameleons?
Acute confusional state
Abnormal movements or seizures
PNS symptoms e.g. wrist drop
Acute vestibular syndrome
Atypical symptoms
Investigations for suspected stroke?
Non-contract CT head scan within 1 Hour!
FBC and ESR
Blood glucose
Total cholesterol
U&Es
ECG
Carotid imaging for anterior events
Selective tests - ECHO, vasculitis and thrombophilia screen, 24 hour ECG tape for paroxysmal AF
Regional blood supply to cerebrum?
Anterior cerebral arteries - anteromedial cerebrum
Middle cerebral arteries - lateral part of brain
Posterior cerebral arteries - medial and lateral posterior cerebrum
Bamford classification of stroke?
The following criteria should be assessed:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
TACS - all 3 of above criteria
PACS - 2 of the above criteria OR higher cerebral dysfunction alone
LACS - presents with 1 of the following: pure sensory stroke; pure motor stroke; sensory-motor stroke; ataxic hemiparesis
POCS - presents with 1 of the following: CN palsy and a contralateral motor/sensory deficit, bilateral motor/sensory deficit, conjugate eye movement disrder, cerebellar dysfunction, isolated homonymous hemianopia
Management of acute ischaemic stroke when pt presents within 4.5 hours of symptom onset?
Arrange immediate emergency admission to an acute stroke facility
300mg aspirin orally or rectally asap as soon as haemorrhagic stroke is ruled out (but within 24 hours) - use for 2 weeks then start long term anti thrombotic agent
Thrombolysis with alteplase within 4.5 hours of symptoms and once haemorrhage has definitely been excluded
Mechanical thrombectomy in some cases
Long term:
Clopidogrel
If AF or flutter consider additional anticoag
High intensity statin
Lifestyle changes
Who can be considered for thrombectomy?
Confirmed acute stroke….
- And confirmed occlusion of proximal anterior circulation on imaging = do it within 6 hours alongside IV thrombolysis if within 4.5 hours
- And confirmed occlusion of proximal anterior circulation on imaging + potential to salvage brain tissue = offer between 6-24 hours
- And confirmed occlusion of proximal posterior circulation on imaging (basilar or posterior cerebral artery) + potential to salvage brain tissue = offer asap with Iv thrombolysis if within 4.5 hours
Which ethnicity has a higher risk of intracranial haemorrhage as a cause for stroke?
Asian - accounts for up to 30% of all strokes in them compared to 10-15% in whole population
What is cerebral amyloid angiopathy?
a condition in which proteins called amyloid build up on the walls of the arteries in the brain. CAA causes bleeding into the brain (hemorrhagic stroke) and dementia
Management of acute ischaemic stroke when pt presents after 4.5 hours of symptom onset?
Arrange immediate emergency admission to an acute stroke facility
300mg aspirin orally or rectally asap as soon as haemorrhagic stroke is ruled out (but within 24 hours) - use for 2 weeks then start long term anti thrombotic agent
Mechanical thrombectomy in some cases
Long term:
Clopidogrel
If AF or flutter consider additional anticoag
High intensity statin
Lifestyle changes
Management of a haemorrhagic stroke?
Refer for neurosurgical assessment as surgical intervention may be required
Consider antihypertensives if they present within 6 hours of symptom onset and systolic bp is 150-220
Stop and reverse any anticoagulants
Long term:
Maintain bp
Avoid statins, anticoagulants and aspirin (if worries about risk of vascular events or AF then seek specialist advice)
Management of TIA?
300mg aspirin immediately (unless bleeding disorder, taking anticoagulant, takes low-dose aspirin regularly or aspirin is contraindicated)
Urgent carotid imaging - Carotid artery endarterectomy if suffered stroke/TIA in carotid territory and not severely disables and carotid stenosis >70%
Secondary prevention:
Antiplatelet therapy - clopidogrel
High intensity statin
How to avoid complications when managing strokes?
Dysphagia management - aspiration and nutrition
Early sitting out and mobilisation
Careful handling and positioning - so they dont get shoulder pain
Preventing pressure sores
Avoid urinary catheters if possible
DVT prevention after first 2 weeks e.g. compression stockings
Good environment - to help with mental health
Ethical issues with strokes?
Autonomy and restraint e.g. nasogastric tubes, use of DOLS
Capacity decisions e.g. dysphasia
Dignity
End of life decisions
Safegaurding and best interests
Secondary prevention after strokes?
Advice for lifestyle, driving, travel etc
Clopidogrel 75mg Od
(Some may have dual therapy with aspirin + clopidogrel)
Atorvastatin 20-80mg od
Antihypertensives with target <130/80 after first 2 weeks
If paroxysmal, persistant or permenant AF or flutter… after 14 days in disabling ischaemic strokes use warfarin or direct thrombin or factor Xa inhibitor (with 300mg daily aspirin in the interim)
Aim of statin therapy in secondary prevention of stroke?
To reduce non-HDL cholesterol by >40%
Advice on driving after stroke/TIA?
Single TIA or stroke - 4 weeks - dont need to notify DVLA
Multiple TIAs - 3 months and must notify DVLA
Typical sites of intracerebral haemorrhages?
Where end-penetrating arteries are e.g/ lenticulostriate arteries, thalamostriate arteries, parapontine arteries, cerebellar arteries
Clinical presentation of intracerebral haemorrhage?
A progressive headache with evolving neurological deficit over mins-hours
The initial deficit can be from mass effect
Clinical signs are dependant on anatomical site
Not unusual for a secondary ischaemic stroke from vasospasm
Could also cause focal onset seizures
