Stroke, TIA and Dysphagia Flashcards
In what situation should imaging be used over pH testing to confirm placement of a feeding tube?
In neonates
What does SAH stand for in the context of haemorrhagic stroke management?
Subarachnoid haemorrhage
What is the evidence supporting the use of antiplatelets in ischaemic stroke management?
Multiple trials demonstrated reduced ischaemic events
What fluid should drugs not be added to, due to the potential for drug interactions? What fluid can be used for administration of medicines?
Grapefruit juice
Fruit juice or other fluids
When adding medication to soft food, how much food should be used? What other risks are there of adding medication to feeds?
Added to the first mouthful of food
Potential physical changes to characteristics and stability of the medication and risk of microbiological contamination of the feed
Why must medication never be added to feeds?
Feed rate would alter drug dosage
What type of injections are not suitable for enteral administration?
High polyethylene glycol content
What should you do if the tube becomes blocked?
Tube flushing using warm water
Why shouldn’t drugs be mixed together during preparation when using enteral tubes? What is the recommended practice when administering several medications via enteral tube? When should medications NOT be administered through enteral tubes?
Drugs are more likely to interact with each other
Administer separately
On free-drainage
What type of medication can sometimes help with gastric motility?
Prokinetics (metoclopramide, domperidone)
What can inhibit absorption of medications administered via enteral tubes?
GI motility
What can result in partial or no absorption of the drug if an enteral tube terminating in the jejunum is used? What process is impaired if the acid environment of the stomach is required for drug dissolution?
The acid environment of the stomach is bypassed altogether
Absorption
How many people are estimated to be living in the UK post stroke? How many people in the UK are expected to experience a first or repeat stroke each year?
1.2 million
140,000
Approximately how many people per 100,000 in the UK are affected by a first-ever stroke each year?
230
What percentage of strokes are attributed to cerebral infarction? What percentage of strokes are due to cerebral haemorrhage? What percentage of strokes that are cerebral hemorrhages are due to primary hemorrhage? What percentage of strokes that are cerebral hemorrhages are due to subarachnoid hemorrhage (SAH)?
85%
15%
10%
5%
What is the approximate incidence of first-ever TIA in the UK per 100,000 people per year?
50
By what percentage have stroke mortality rates in the UK decreased from 1990 to 2010? Despite the decrease in mortality rates, stroke remains the ______ highest cause of mortality in the UK.
46%
4th
What percentage of all deaths in the UK are caused by stroke? What percentage of patients die from their first stroke?
7%
11%
What is the most likely cause of death if not the first stroke? Approximately how many people with acute stroke die in the hospital?
Repeat stroke or complications
1 in 7
How much higher are mortality rates in haemorrhagic stroke compared to ischaemic stroke?
35-40%
What is the overall survival rate following subarachnoid haemorrhage (SAH)? What percentage of people with SAH die before reaching the hospital?
About 70%
10-15%
What percentage of people admitted to a neurosurgical unit with a confirmed aneurysm survive? What is the risk of recurrent stroke at 1 year post initial stroke? What is the risk of recurrent stroke at 5 years post initial stroke?
85%
11.1%
26.4%
What is the risk of recurrent stroke at 10 years post initial stroke? What percentage of further vascular events occur within 3 months of an initial event?
39.2%
Up to 25%
Of the vascular events that occur within 3 months of an initial event, how many occur within four days? What percentage of recurrent strokes are fatal?
Half
18%
What is TIAs associated with?
High risk of stroke
What is the risk of stroke within the first 2 days after a TIA? What is the risk of stroke within 7 days after a TIA? What is the risk of stroke within 30 days after a TIA? What is the risk of stroke within 90 days after a TIA?
3.9-5%
5.5-8%
7.5-12%
9.2-17%
What percentage of people are unable to live independently at 3 to 6 months after a haemorrhagic stroke? What percentage of people have difficulty with basic self-care at 6 months post-stroke? What percentage of people have difficulty with autonomy and societal roles at 4 years post-stroke?
70-80%
40%
>30%
Approximately what percentage of people have long-term altered arm function after a stroke? What percentage of people develop joint contracture on the affected side within the first year of stroke with hemiparesis? What percentage of people experience falls within 6 months of discharge from secondary care after a stroke?
40%
~60%
Up to 70%
What are the non-modifiable risk factors for stroke?
Age
Gender
Ethnicity
What are the modifiable risk factors for stroke?
- Hypertension
- Diabetes Mellitus
- Atrial Fibrillation
- Cholesterol
- Smoking
- Obesity
- Low physical activity
- Alcohol Intake
- Stress
What are the common symptoms of stroke?
- Rapid onset
- Slurred speech
- Facial droop
- Unilateral weakness
- Confusion
- Difficulty speaking or understanding others
- Loss of co-ordination or balance
- Visual disturbance
- Hearing loss
What is the duration of symptoms in TIA?
Symptoms resolve within 24 hours
What type of headache can haemorrhagic strokes sometimes cause?
‘Thunderclap’ headache
What does the area the infarct is occuring in impact?
Symptoms
Which artery provides blood to most of the outer brain? What is the brain’s blood supply also know as? Which artery provides blood to the frontal inner portion of the brain?
Middle cerebral artery
‘Circle of Willis’
Anterior cerebral artery
Which artery provides blood to the back inner portion of the brain? Which artery supplies the brain stem?
Posterior cerebral artery
Basilar artery
What can be potentially discerned from symptoms and areas of brain to which they relate?
Culprit vessel
What are the types of stroke?
TIA
Ischaemic stroke
Haemorrhagic stroke
How long lived are most TIAs? What is TIA a transient episode of? What is not evident in TIA?
Most <20 mins per attack
Neurological dysfunction caused by focal ischaemia
Acute infarction
Historically how was TIA diagnosed?
Resolution of symptoms within 24 hours
What is TIA? What is the approximate incidence of first-ever TIA in the UK per 100,000 people per year?
Transient episodes of neurological dysfunction caused by focal ischemia
50
What focal neurological deficits may be included in TIA?
- Unilateral weakness or sensory loss
- Dysphasia
- Ataxia, vertigo, or incoordination
- Syncope
- Sudden transient loss of vision in one eye
- Homonymous hemianopia
- Cranial nerve defects
What is the function of the Optic nerve? What is the function of the Olfactory nerve? What is the function of the Oculomotor nerve?
Visual acuity
Smell
Opening of eyelids, eye movement
What is the function of the Trochlear nerve? What is the function of the Trigeminal nerve? What is the function of the Abducens nerve?
Eye movement (downward/medial)
Facial sensation, chewing movements
Eye movement (lateral)
What is the function of the Facial nerve? What is the function of the Auditory (vestibuIocochlear) nerve? What is the function of the Glossopharyngeal nerve?
Facial muscle movement and eyelid closing
Hearing and balance
Taste on posterior third of tongue
What is the function of the Vagus nerve? What is the function of the Accessory nerve? What is the function of the Hypoglossal nerve?
Uvula and swallowing
Shoulder shrug
Tongue movement
What are the classifications of stroke?
Ischaemic (85%)
- Large artery thrombosis due to atherosclerosis
- Small penetrating artery thrombosis (lacunar stroke)
- Cardioembolic
- Cryptogenic (Unknown culprit vessel)
- Other
Heamorrhagic (15%)
- Intracranial Heamorrhage (10%)
- Subarachnoid Heamorrhage (5%)
= Intracranial Aneurysm (4.25%)
= Non- Aneurysm (0.5%)
= Other vascular abnormalities (0.25%)
How does ischaemic stroke occur? What can ischaemic stroke be secondary to?
Thrombus or embolus occluding arteries
Atherosclerosis or clotting elsewhere
Where does intracerebral haemorrhage occur? What is intracerebral haemorrhage most commonly due to?
Within brain parenchyma or ventricular system
Hypertension
Where does subarachnoid haemorrhage occur? What is subarachnoid haemorrhage most commonly due to?
Bleed into the subarachnoid space
Cerebral blood vessel aneurysm or vascular malformation
What are the steps for rapid stroke recognition?
Rule out ‘Stroke Mimics’
FAST
ROSIER score
All suspected strokes should be admitted directly to a specialist unit
What conditions should you rule out as ‘Stroke Mimics’?
- Hypoglycaemia – blood glucose
- Syncope - ECG
- Sepsis – Sepsis 6 screen
- Severe migraine
- Space occupying lesions – R/O through imagining
What does checking facial movements assess in stroke recognition? What does checking arm movements assess in stroke recognition? What does checking speech assess in stroke recognition?
Function of cranial nerves
Motor control
Understanding and output
What is the overall goal of stroke therapy? What factors help these goals?
Minimise injury and maximise recovery
- Rapid recognition and reaction
- Restore perfusion
- Recover
What is the phrase “Time is brain” referring to in stroke?
1.9 million brain cells die every minute
What is the immediate initial management for a suspected TIA?
STAT Aspirin 300mg Aspirin
When should patients with a TIA Crescendo be urgently referred?
Within 24 hours of symptom onset
When is imaging not required for TIA?
Unless clinical picture suggests other intracranial pathology
What secondary prevention is offered once TIA diagnosis is confirmed?
Antiplatelets
- 1st Line: Clopidogrel 75mg OD
- 2nd Line: Aspirin 75mg OD with Dipyridamole MR 200mg BD
- If either 2nd line agents C/I use other as single antiplatelet therapy
Lipid modification
- High intensity statin to reduce non-HDL by >40%
- Atorvastatin 20-80mg OD (usual starting dose 40mg OD)
Optimisation of co-morbidities
What are the investigations used to diagnose acute stroke?
- Computed Tomography (CT): exclude differential diagnosis
- Magnetic Resonance Imaging (MRI)
- Cerebral Angiography: identify responsible blood vessel
- Electrocardiogram (ECG): underlying heart conditions
- Echocardiogram: blood clot from heart
- Carotid Duplex Ultrasound Scan: carotid artery stenosis
- Heart monitors, blood work and many more tests
What initial treatments are given for ischaemic stroke?
Imagining
Thrombolysis
Bloods
Initial treatment
Secondary prevention
Why is imaging required in ischaemic stroke?
Need to rule out ICH pre-thrombolysis or thrombectomy
What are the advantages of CT scan?
Quick
Readily available
Less expensive
Use with implanted devices
What is the preferred investigation to exclude haemorrhage and diagnose ischaemic stroke?
CT scan
What are the advantages of MRI?
Show ischaemic changes over days, weeks and months,
Differentiates between old and new ischaemia
Less radiation
What is the preferred investigation for confirmation of TIA?
MRI
How does Alteplase work? What does Alteplase aim to do?
Activates plasmin production degrading fibrin clots
Reduce the impact of ischaemia by restoring blood flow
When should Alteplase be administered? What needs to be excluded before Alteplase can be administered?
Within 4.5 hours of symptom onset
ICH
What is the initial dose of Atorvastatin given to patients post-stroke? How soon after the onset of stroke symptoms should Atorvastatin be started?
Atorvastatin 40mg OD
48 hours
What is the target range for blood glucose in stroke patients?
4-11 mmol/L
How should haemorrhagic stroke be treated initially?
- Stop antiplatelet/anticoagulant therapy and treat symptomatically
- Treat surgically with a craniotomy or hemicraniectomy
- Stop bleeding with Vitamin K, prothrombin complex concentrate (PCC), tranexamic acid
- Reduce BP: systolic target 130-140mmHg at least 7 days
- Ventricular drain if hydrocephalus
- Statin if indicated by CVD risk score
- SAH: nimodipine 60mg every 4 hours
What is the systolic blood pressure target for haemorrhagic stroke management?
130-140mmHg
How often should Nimodipine be administered in SAH?
Every 4 hours
Which types of acute intracerebral haemorrhages rarely require surgical intervention?
- Small deep haemorrhages
- Lobar haemorrhage without either hydrocephalus or rapid neurological deterioration
- Large haemorrhage and significant comorbidities before the stroke
- Low Glasgow Coma score of below 8 unless this is because of hydrocephalus
- Posterior fossa haemorrhage.
What are the criteria for decompressive hemicraniectomy following a stroke?
- Within 48 hours of symptom onset
- Clinical deficit suggest infarction in the territory of the middle cerebral artery
- Decreased level of consciousness
- Signs on CT of an infarct of at least 50% of the middle cerebral artery territory
Within what time frame should decompressive hemicraniectomy be performed after symptom onset? What percentage of the middle cerebral artery territory needs to be affected for hemicraniectomy consideration?
Within 48 hours
At least 50%
Within how many hours of symptom onset should rapid blood pressure lowering be offered? What is the recommended course of action if a patient presents with a systolic blood pressure greater than 220 mmHg? How long should the target systolic blood pressure be maintained for after treatment initiation?
Within 6 hours
Rapidly decrease
At least 7 days
What are the potential consequences of lowering blood pressure too aggressively in haemorrhagic stroke?
Tissue hypoxia
What are some common complications following a stroke?
- Aphasia and dysarthria
- Dysphagia
- Emotionalism
- Dyspraxia
- Impaired Cognition
- Depression
- Anxiety
What areas should be considered when supporting stroke rehabilitation via MDT?
- Nutrition
- Mobilisation
- Adaption
- Consider calcium and vitamin D deficiency
- Manage pain (Neuropathic, Musculoskeletal)
- Manage generalised or diffuse spasticity
- Assess for depression and anxiety
What percentage range of stroke patients experience swallowing difficulties?
40-78%
What are the potential consequences of dysphagia in stroke patients?
Aspiration, pneumonia and malnutrition
Within what time frame should stroke patients be screened for swallow difficulties?
Within 4 hours
What should be considered to facilitate nutritional and medication requirements in dysphagic stroke patients?
NG tubes
What factors should be considered when dealing with dysphagia?
Adsorption
Interactions
Feeding
Size and solubility
Timings
Alternatives
What are the different types of feeding tubes and their insertion points?
- Nasogastric (NG) - inserted into the stomach via the nose.
- Nasojejunal (NJ) - inserted into the jejunum via the nose (may also have a gastric port).
- Percutaneous endoscopic gastrostomy (PEG) - inserted into the stomach via the abdominal wall.
- Percutaneous endoscopic jejunostomy (PEJ) - inserted into the jejunum via the abdominal wall.
- Percutaneous endoscopic gastro-jejunostomy (PEGJ) - inserted into the jejunum via the abdominal wall and through the stomach.
What type of water should be used to administer medicines via a tube that ends in the jejunum?
Sterile water
What potential issue can arise if a feeding tube extends beyond the drug’s main site of absorption?
Unpredictable drug absorption
Why is sterile water recommended for jejunal feeding tube medication administration?
The acid barrier in the stomach is by-passed
What risk is increased when sorbitol-containing liquids and hypertonic solutions are administered directly into the jejunum?
Diarrhoea
Why is there an increased risk of diarrhea when administering sorbitol directly into the jejunum?
The buffering effect of gastric contents is lost
What material has been found to be less likely to cause clotting of enteral feed solution?
Polyurethane tubes
What are the inner diameters of different French size tubes?
French Size 5: 1.10 mm
French Size 6: 1.37 mm
French Size 8: 1.96 mm
French Size 10: 2.54 mm
French Size 12: 2.67 mm
What is the importance of knowing the internal and external diameters of feeding tubes?
Considering particle size and solubility
What testing method is used to ensure correct placement of a feeding tube and prevent dislodgement?
pH testing
Why is pH testing preferred over imaging for routine tube position checks? What pH range is particularly important to distinguish during tube position checks?
Less exposure to radiation
pH 5-6 range
When should tube tip position be checked?
- Following initial insertion
- Before administering each feed
- Before giving medication
- At least once daily during continuous feeding
- Following episodes of coughing, vomiting, or retching
- Following evidence of tube displacement
What pH level indicates that feeding can commence after tube insertion? Why is a pH of this or below considered safe for commencing feeding?
pH 5.5
No evidence of pulmonary aspirates below this
What action should be taken if the pH of the tube aspirate is above 6? What medication might cause a patient to have gastric aspirates with a pH of 6 or above? What may be required to confirm placement if a patient’s pH is above 6 due to antacids?
Wait 1 hour and try again
PPIs
Imaging
Where can one find information regarding if de-ionised water is required for medication?
NEWT monograph
How long can water be kept for enteral use?
Not over 24 hours
What action is used to clean and dislodge potential blockages in enteral feeding tubes?
Push flush
What is the typical volume of flush used for enteral feeding tubes? Why is flushing important for medicine administration via enteral tubes?
10ml usually or 30ml for some medicines
Helps prevent interactions of medicine-medicine and medicine-feeds
What needs to be considered regarding flushes for fluid restricted patients? Why is flushing performed before aspiration from an enteral tube?
Fluid restrictions
Ensure remanent gastric acid not in tube
What is one consequence of bypassing the stomach with an enteral feeding tube?
Drugs directly delivered bypassing the stomach
