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
