Stroke/TIA/Intracranial bleeds Flashcards
Anterior circulation stroke: common symptoms
Unilateral weakness
Speech disturbance
Amaurosis fugax
Posterior circulation stroke: common symptoms (5 Ds)
Dysarthria Dysphagia Diplopia Dizziness Difficulty walking (ataxia)/ Diplegia
Rapid assessment of stroke in community:
- If one out of what three things is present?
Facial weakness/droop
Arm weakness
Speech disturbance
Time: must be thrombolysed (alteplase) within 4.5 hours
Recognition of stroke in the emergency room (ROSIER)
a) 2 criteria making stroke less likely
b) 5 criteria making stroke more likely (FALSE)
Note: If score > 0 stroke is likely (if 0 or less, stroke is less likely but not excluded)
a) Has there been LOC or syncope Y (-1) N (0)
Has there been seizure activity Y (-1) N (0)
b) Is there a new onset of:
F (face) - Asymmetric facial weakness Y (+1) N (0)
A (arm) - Asymmetric arm weakness Y (+1) N (0)
L (leg) - Asymmetric leg weakness Y (+1) N (0)
S (speech) - Speech disturbance Y (+1) N (0)
E (eyes) - Visual field defect Y (+1) N (0)
TIA
a) Immediate management
(i. e. stroke symptoms that have resolved by the time the patient presents)
b) Investigations and further management
a) - Aspirin loading dose (300mg) with PPI (clopidogrel loading dose if intolerant to aspirin)
- Refer to TIA clinic within 24 hours (irrespective of ABCD score - not used anymore)
b) - If specialist assessment determines likely TIA, do an MRI scan to detect region of ischaemia (more sensitive than CT)
- Also do carotid doppler - if 50 - 99% stenosis, carotid endarterectomy
Carotid endarterectomy:
a) Indications
b) Alternative
a) - Symptomatic carotid stenosis (acute non-disabling stroke or TIA) with 50–99% stenosis on Carotid Doppler
b) Carotid stenting
Stroke mimics: HEMI
H: Hypoglycemia (and hyperglycemia/ other metabolic)
E: Epilepsy
M: Multiple sclerosis/ Migraine
I: Intracranial tumors / Infections (sepsis, meningitis, encephalitis and abscesses)
Also… functional!
And spinal/ isolated cranial nerve pathology.
Indications for antihypertensives in acute stroke
a) Ischaemic stroke
b) Haemorrhagic stroke
c) Prior to thrombolysis, BP must be below…?
a) Hypertensive emergency, i.e. BP > 180/110 plus end-organ damage, for example:
- Hypertensive encephalopathy
- Hypertensive nephropathy
- Hypertensive cardiac failure/myocardial infarction
- Aortic dissection
- Pre-eclampsia/eclampsia
b) - Present within 6 hours of symptom onset, and
- BP > 140/90
(not if GCS < 6, for surgery, or underlying structural cause like tumour, aneurysm or AVM)
c) Blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for thrombolysis.
Thrombolysis (alteplase)
a) Give to all stroke patients provided…? (2)
b) How long post-thrombolysis should patients be started on aspirin 300mg?
c) Alternative treatment?
d) Contraindications: HASH SLAP
a) Haemorrhage excluded (on CT or MRI, cannot be done clinically); within 4.5 hours of onset
b) After 48 hours
c) Thrombectomy
d) CIs:
- Haemorrhage on CT scan
- Arteriovenous malformation / Aneurysm
- Seizures/ Symptoms suggestive of SAH or neoplasm
- Hypertension (BP >220/130)
- Stroke in last 3/12 or Surgery/Serious trauma last 2/52
- Liver disease, varices or portal hypertension
- Anticoagulant therapy / PT > 15s / platelets < 100
- Pregnancy
Suspected acute stroke: immediate management
a) In all cases
b) If within 4.5 hours
c) If outside of 4.5 hour window
d) Other Ix
a) In all cases:
- Refer to specialist acute stroke unit
- Exclude haemorrhage (CT)
- Homeostatic measures (SpO2, glucose and BP stable)
- NBM until SALT assessment (+ IV fluids)
- NG tube for feeding if aspiration risk
b) If within 4.5 hours of onset: thrombolysis
c) If unlikely to receive thrombolysis within 4.5 hours: loading dose aspirin (300mg) daily for 2 weeks then switch to clopidogrel 75mg daily
d) - Bedside: ECG
- Bloods: FBC, U+E, CRP/ESR, LFTs, Ca2+, cholesterol, glucose, clotting (+ INR), etc.
- Imaging: CXR (?aspiration)
Thrombolysis: three month prognosis
- 30, 30, 20, 20 rule
At 3 months post-alteplase:
- 30% recover completely or near-completely
- 30% mild-moderate neuro deficit
- 20% mod-severe neuro deficit
- 20% dead
Stroke/TIA secondary prevention
a) 2 classes for all
b) 1 added class in most (if indicated)
c) 2 indications for anticoagulation over antiplatelets
d) Beta-blockers?
e) Surgical
f) Lifestyle advice - give 5
g) Other secondary/tertiary stroke rehab interventions
a) Statin and antiplatelet:
- Aspirin 300 mg for 2 weeks
- Then long-term clopidogrel 75 mg (or aspirin + dipyridamole)
b) Antihypertensive (according to HTN guidelines)
c) AF (if non-valvular, can use a NOAC) and risk factors for cardiac thromboembolism (e.g. prosthetic valves)
- Start AC after 2/52
d) Not routinely indicated (unless part of BP control)
e) Carotid endarterectomy or angioplasty/stenting
f) Smoking, alcohol, diet, exercise, weight
g) - SALT, dietitian, PT/OT, psychological, visual, auditory, social, symptom control
- Glucose control
CHA(2)DS(2)VASc score
Congestive heart failure Hypertension Age > 75 Diabetes Stroke/TIA/VTE history Vascular disease (e.g MI, PVD) Age > 65 Sex (female)
HAS-BLED score
Hypertension Abnormal liver/kidney function Stroke Bleeding disorder Labile INR Elderly (> 65) Drugs (antiplatelets, NSAIDs) and alcohol (>8 units/week)
Suspected SAH:
a) Initial investigation. Once confirmed, perform…?
b) If negative, but history suggests SAH - perform…?
c) Initial management
d) Antihypertensives used
e) To prevent vasospasm
f) To prevent rebleeding: two options
g) Indications for surgery
h) Possible ECG sign of SAH
a) CT without contrast; then perform cerebral angiography to identify aneurysm for clipping/coiling
b) LP after 12h - xanthochromia
c) A-E assessment, analgesia + antiemetics, antihypertensives, prevent vasospasm, prevent re-bleeding, neurosurgery if needed
d) Labetalol and sodium nitroprusside
e) Nimodipine
f) Clipping (via craniotomy) or coiling (endovascular)
g) Very reduced GCS, large haematoma that needs evacuating, obstructive hydrocephalus
h) Deep T wave inversion
Intracranial bleeds
a) Extradural - vessels?
b) Subdural - vessels? At-risk patient groups?
c) SDH - indications for surgery
d) Prevention: i) SDH, ii) EDH
e) ABC management of haematomas
f) EDH management
a) Middle meningeal (over temple)
b) Bridging veins. Infants, elderly, alcoholic, dementia, on anticoagulants)
c) Focal signs, deterioration, a large haematoma, raised intracranial pressure or midline shift
d) i) Fall prevention, avoiding over-anticoagulation,
ii) Helmets for motorcyclists, lower alcohol use, reduced traumatic sports (e.g. boxing)
e) A-E assessment:
A - stabilise airway, treat neck with care and consider C-spine injuries, if reduced GCS (<9) consider ETT
B - high-flow oxygen, consider pneumothorax if trauma, measure respiratory rate (Cushing triad)
C - assess for Cushing reflex, fluid resuscitation if necessary
D - assess pupils, AVPU and glucose levels
f) ABC, IV fluids, mannitol/hypertonic saline, conservative (if stable, fully conscious, small haematoma and improving). haematoma evacuation otherwise
Cerebral perfusion pressure (CPP) is equal to…?
CPP = MAP - ICP
Cushing reflex - explain in the context of raised ICP
- When MAP < ICP, a reflex called the “CNS ischemic response” is initiated by the hypothalamus in the brain.
- The hypothalamus activates the sympathetic nervous system, causing peripheral vasoconstriction and an increase in cardiac output, both increasing arterial BP
- When MAP > ICP, blood flow to the brain is restored
- The increased arterial BP caused by the CNS ischemic response stimulates baroreceptors in the carotid bodies
- This slows the HR, causing bradycardia
- Irregular respirations may also occur from reduced brainstem perfusion or coning
Signs of basilar skull fracture
Periorbital ecchymosis (Raccoon eyes) CSF rhinorrhoea CSF otorrhoea Haematotympanum Mastoid ecchymosis (Battle’s sign) CN VII (facial paralysis) and CN VIII palsy (hearing loss)
NG tube insertion
a) Main risk
b) To reduce this risk, take what precaution?
a) Misplacement in lungs
b) Test the pH of the aspirate before every use of the tube and after insertion. If there is no aspirate or pH > 4 a chest x-ray is required to confirm the position
Total anterior circulation stroke (TACS):
a) occlusion of…?
b) All 3 of what features? (HHH)
a) - ACA + MCA; or,
- Proximal MCA, affecting both cortical and deep perforating branches of the MCA
b) - Hemiparesis: unilateral weakness (and/or sensory deficit) of the face, arm and leg
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphasia, visuospatial disorder)
Partial anterior circulation stroke (PACS):
a) Occlusion of…?
b) 2 out of what 3 features?
a) - Cortical OR deep perforating MCA branches; or,
- ACA
b) - Unilateral weakness (and/or sensory deficit) of the face, arm and leg
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphasia, visuospatial disorder)
Posterior circulation stroke (POCS)
a) Occlusion of…?
b) An isolated ______ _______ or what 2 syndromes?
a) Vertebrobasilar branches (e.g. PCA)
b) Isolated homonymous hemianopia.
- Probably macular-sparing due to MCA supply
Brainstem syndrome.
- CN palsy and a contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar syndrome.
- dizziness, vertigo, nystagmus, ataxia, etc.
- other cerebellar signs - DANISH
Lacunar stroke (LACS):
a) Due to…?
b) One out of what 4 possible presentations?
c) May have what type of hemiplegia?
a) Subcortical stroke of the small penetrating artery occlusion (e.g. lenticulostriate arteries)
b) Pure sensory stroke
Pure motor stroke
Senori-motor stroke
Ataxic hemiparesis
c) Dense hemiplegia - upper and lower limbs affected equally, compared with:
- ACA stroke - affects LL > UL
- MCA stroke - affects UL/face > LL
Brainstem syndromes: the 4 rules of 4
a) 4 structures in the Midline (medial) beginning with M
b) 4 structures at the Side (lateral) beginning with S
c) 4 CNs in medulla, 4 in the pons, 4 above pons
d) 4 CNs in the midline, divisible by 12
a) Motor pathway (CST), Medial lemniscus, MLF, Motor nuclei (CNs 3, 4, 6, 12)
b) Spinothalamic, spinocerebellar, sensory nuclei (CN 5), sympathetic chain
c) CN I-IV (above pons), CN 5-8 (pons), CN 9-12 (medulla)
d) CN 3, 4, 6 and 12
Brainstem syndromes:
a) How to get longitudinal location of lesion
b) How to get latitudinal location of lesion
a) Whether it affects the 4 Ms (medial) or 4 Ss (side)
b) Which CNs are affected (midbrain, pons, medulla)
Intracranial venous thrombosis
a) Caused by what state?
b) Can present as what 3 syndromes?
c) Diagnosis via…?
d) Treatment
a) Prothrombotic (e.g. pregnancy, malignancy)
b) Stroke, SAH or isolated raised ICP
c) CT/MRI head
d) Anticoagulants - heparin then warfarin
Stroke vs epilepsy vs migraine features
- Stroke/TIA - negative symptoms (loss of function)
- Epilepsy - positive (gain of function)
- Migraine - can be positive or negative
Upper and lower limb involvement.
a) Acute MCA stroke
b) Acute ACA stroke
c) Acute lacunar/internal capsule stroke
d) Chronic hemiplegic appearance
a) Arms > legs
b) Legs > arms
c) Dense hemiplegia: arms and legs affected equally
d) Leg extended, arm flexed
Cerebellar stroke.
a) Presentation
a) Acute onset of vertigo, vomiting +/- occipital headache (haemorrhage)
- Other cerebellar signs (eg. multidirectional nystagmus)
Subdural haemorrhage.
a) At-risk groups
b) Presentation
c) Investigations
d) Management
e) Indications for surgery
a) Infants, elderly, alcoholics, anticoagulated
b) - Acute: after moderate-severe head injury; headache, raised ICP, etc.; may be LOC
- Chronic: usually few weeks after trivial trauma; slowly-progressive signs (e.g. headache, vomiting, weakness, dysarthria, confusion, drowsiness, etc.)
c) - Full neuro exam and neuro obs
- Bloods: FBC, CRP, clotting (INR if on warfarin), U+Es, LFTs,
- Imaging: CT head (non-contrast 1st line)
d) A-E: airway adjuncts (?GCS < 8), oxygen (?raised ICP - hyperventilate), IV access, etc.
- Treat any coagulopathy (eg. vit K/PTC)
- Raised ICP: oxygen, hyperventilate, head up, mannitol
- Call neurosurgeons if necessary - craniotomy and clot evacuation
e) Surgery indications.
- Focal signs
- Deterioration (esp GCS)
- Large haematoma
- Raised intracranial pressure
- Midline shift.
Extradural haemorrhage.
a) Risk factors
b) Presentation
c) Investigations
d) Management
a) - Head trauma around the temple - often associated with a temporal/parietal fracture
- Spontaneous
- Spinal EDH - may be caused by LP/epidural, etc.
b) - Head injury with LOC
- Followed by a lucid interval and then rapid deterioration
- Ass. Sx: headache, vomiting, weakness, skull fracture, C-spine injury, Cushing reflex, CN palsy/pupillary defect, seizures, reduced GCS
c) - Full neuro exam and neuro obs
- Bloods: FBC, clotting (INR in warfarin), U+Es, LFTs
- Imaging: CT head and CT C-spine
d) - A-E assessment: can deteriorate rapidly, need airway and C-spine support (ATLS), breathing (oxygen, hyper-ventilation), circulation (IV access, fluids, b
- Correct any coagulopathy
- Raised ICP - raised head, oxygen, hyperventilate, mannitol/ hypertonic saline, call neurosurgeons
- Neurosurgery - Burr holes, etc.
Stroke rehab.
SALT.
- assessment (should be done on admission also)
- food modification if needed
- prevent aspiration pneumonia
- speech and communication therapies and aids
PT.
- early high-intensity mobilisation
- within 24 hours of symptom onset;
- focus on sitting, standing and walking, etc.
OT/orthotics
- aids
- electrical stimulation devices
- ankle/foot orthoses
Psychological.
- memory
- depression/ anxiety
Sensory.
- hemi-spatial neglect - help with awareness; inform DVLA if reduced fields
- visual, auditory and other sensory rehab
- aids (eg. glasses, hearing aids)
Social.
- Care needed?
- financial support
- help returning to work
Medication.
- analgesia
- anti-spasticity
- anti-depressants
Pathophysiology of stroke
- Thrombotic
- Embolic
- Haemorrhagic
- Venous thrombosis
- Cerebral hypoperfusion (eg. secondary to sepsis)
Alteplase prescription.
a) Route
b) Dose
a) IV
b) 900 mcg/kg
- 10% as bolus
- Then as IV infusion over 1 hour
