Stroke & TIA Flashcards
What are the types of stroke?
Ischaemic 85%
Haemorrhagic 15%
What are the causes of a stroke?
Small vessel occlusion
Cardiac emboli: Endocarditis, MI, carotid dissection
Atherothromboembolism: Carotids
CNS bleed: AV malformation, HTN, trauma, aneurysm rupture, anticoagulation
How does a stroke present?
Dysphagia
C/L weakness/paralysis + sensory loss
I/L facial palsy (forehead sparing)
Homonymous hemianopia
What signs are specific to an ischaemic stroke?
50% flaccid initially
C/L sensory loss + hemiplegia, dysphagia, hemianopia
Basilar artery = Locked in syndrome
Lacunar = Ataxic hemiparesis & dysarthria, cognition INTACT
What signs are specific to a haemorrhage stroke?
Severe headache
N&V
↓GCS, ↓BP
Pontine haemorrhage = Locked in syndrome, Quadriplegia, B/L miosis (still reactive)
What Sx can help you deduce specifically where a quadranopia is?
Inferior quadranopia = Posterior stroke
Superior quadranopia = Temporal stroke
How is a stroke investigated?
Urgent CT/MRI (if no ‘immediate CT’ Sx then CT in <24hours)
Hyperdense MCA sign on CT: Appears in 90mins of ischaemia
Signs of cause: ECG, Pulse (AF)
Bloods: FBC, U&E, Coag, Glucose, Na+, Ca2+, Cholesterol
How is a stroke managed acutely?
Nil by mouth
ISCHAEMIC=
1) Aspirin 300mg: ASAP after haemorrhage excluded
1) Alternative- Clopidogrel
2) THROMBOLYSIS IN 4.5HOURS OF Sx: Alteplase 10% dose as bolus then rest over 60mins
WITHHOLD ASPIRIN FOR 24hours post-ALTEPLASE
Adjunct) Mechanical thromectomy
Decompressive hemicraniotomy = MCA infarct
Glucose: Maintain 5-15
HAEMORRHAGIC = Neurosurgery
If someone has greater deficit in their arms/face than their legs, where is the stroke?
Middle cerebral artery
If someone has greater deficit in their legs than their arms/face, where is the stroke?
Anterior cerebral artery
In terms of Sx how is a lacunar stroke in the thalamus & internal capsule described?
Internal capsule = Pure motor Sx
Thalamus = Pure sensory Sx
What scoring system can be used in A&E to recognise risk of someone having a stroke?
-NIHSS: Score severity
-ROSIER:
>1: Stroke likely
-score: Consider alt diagnosis
-LOC = -1
-Convulsive episode = -1
-Face weakness = 1
-Arm weakness = 1
-Leg weakness = 1
-Speech disturbance = 1
- Visual field defect = 1
What conditions can mimic a stroke?
Migraine Hypoglycaemia Seizure Brain tumour/ space-occupying lesion Sepsis Syncope CN7 palsy Toxic metabolic states
What are the indications for immediate head CT in a stroke?
- Tx by thrombolysis or early anticoagulation
- On an anticoagulant
- known bleeding tendency;
- GCS <13
- Unexplained progressive or fluctuating Sx
- Papilloedema, neck stiffness or fever
- Severe headache at onset of stroke Sx
What are the indications for thrombolysis?
Sx consistent w/stroke
Clear time of onset
Presents in <4.5hours
No CI
What are the contraindications to thrombolysis?
- Imaging: Haemorrhage, extensive small vessel disease, >1/3 MCA infarct
- > 4.5hours since onset
- Anticoagulated (NOAC except Dabigatran)
- Seizure post-stroke
- Stroke/Head injury in <3m
- Major surgery in <3m
- Platelets <100
- sBP consistently >185
How is a TIA different from a stroke?
Sx lasting <24hours
How is a haemorrhagic stroke treated acutely?
ALERT neurosurgery
Nimodipine
?Airway protection
Decompensating = Surgery
What is the the long-term management after a stroke?
Clopidogrel 75mg
Warfarin: AF
Statin: Cholesterol >3.5
HTN: Amlodipine/Labetalol
What follow-ups need to be done post-stroke?
SALT Assessment Carotid artery doppler <1week: ESSENTIAL if ant circulation stroke >50% occluded = vascular surgeons DVLA: CANNOT drive for 1month if residual loss inform DVLA who will arrange their own assessment
How do the results of carotid doppler correlate to treatment?
Asymptomatic + <70% = Aspirin/Clopidogrel
Asymptomatic + >70% = Aspirin/Clopidogrel +/- Carotid endarterectomy
I/L symptomatic >50% = Carotid endarterectomy
What stockings should be warn for VTE prophylaxis post-stroke?
Pneumatic stockings
What are the Sx of a cerebellar stroke?
POCS (POst Circulation Syndrome)
DANISH Sx
What territories does a TACS stroke affect?
Total Anterior Circulation Middle/Anterior cerebral artery ALL of: U/L weakness Homonymous Hemianopia Higher cortical dysfunction (Dysphasia, visuospatial)
What territories does a PACS stroke affect?
Partial Anterior Circulation Syndrome Middle/Anterior cerebral artery 2 of: U/L weakness Homonymous Hemianopia Higher cortical dysfunction (Dysphasia, visuospatial)
How is a TIA managed?
Aspirin 300mg STAT then OD for 2weeks
Reduce after to 75mg OD
Neuro: In <7d = 24hour referral, if >7d= 1w referral
What Score can be used to screen someone with a TIA for a potential stroke?
ABCD2
A: >60yo
B: BP >140/90
C: U/L weakness arm/face (2) OR Speech disturbance (1)
D: DM
D: Sx <10mins (0) OR 10-59 (1) OR >60 (2)
SCORE:
>6 = Admission
>4 or Crescendo = Neuro in 24hours
<4 = Neuro in 1 week
What type of aphasia does a lesion in Broca’s or Wernicke’s area lead to?
Broca’s = Expressive: Lesion at inferior frontal gyrus
Speech non-fluent/halting/ laboured, comprehension = normal
Wernicke’s = Receptive: Lesion at superior temporal gyrus
Sentences make no sense but fluent, comprehension = impaired
When should a CT be repeated in stroke?
24hours after thrombolysis (check for haemorrhagic transformation)
What are the DVLA rules for TIA?
CANNOT drive for 1month
