Stroke - WB Flashcards
What is ABCD2 tool?
- Estimates the risk of stroke after a suspected transient ischemic attack (TIA)
- Includes factors such as age, BP, clinical features of TIA, duration and history of diabetes
CHAD2DS2VASc score
- Score for AF stroke risk
- Score of 2 or more = anticoagulate
HASBLED score
- Estimates major risk of bleeding for patients on anticoagulants for AF within 1yr
- Weighs up risk vs benefit
NIHSS score
Severity of stroke. Includes:
* Alertness
* Ability to answer age and current month
* Can blink eyes and squeeze hands
* Visual field defect?
* Facial palsy?
* Motor of arms and legs
* Ataxia
* Sensation changes
Key questions to answer when assessing ?stroke patient
- Is it a stroke?
- What caused it?
- Complications? Any likely?
- Treatment needed and when?
- How well is outcome likely to be?
- When can they safely leave acute care?
What causes stroke symptoms?
- Dysfunction of neurovascular unit - relationship between neurones, glial cells and endothelial lumens
- Hypoperfusion –> reduced ATP –> no energy for cell for membrane transport –> no AP’s
Stroke syndrome features
- Sudden onset
- Focal
- Predominantly negative - loss of function
- Fit into vascular territory
What suggests stroke is NOT the cause?
- Isolated presentation feature (eg vertigo)
- Migration - of symptoms, slow
- Sterotyping - repeated episodes previously of same thing over weeks (could be intracranial stenosis or capsular warning syndrome though)
Unknown cause of stroke name
Cryptogenic
Typical cause of PACS presentation
Embolisation from cardiac emboli (eg in AF, valvular heart disease, HF, endocarditis)
Large vessel emboli typical cause
Carotid atheroma emboli
Peripheral vascular disease
LACS typical cause
Fibrinolytic necrosis if hypertensive/diabetic (endothelial damage and blockage)
TOAST criteria
Classification of ischaemic stroke causes
Classification of haemorrhagic strokes
- Central/deep vs lobar
- Central/deep are typically primary due to HTN
- Lobar tend to be secondary - inc vascular anomalies, mass, cerebral amyloid angiopathy
Complications/likely complications of stroke
- Premature death - often due to post stroke complications
- Recurrent stroke and extension of stroke - extension due to loss of ischaemic penumbra (still viable but then dies), recurrent due to not addressing cause/RF
- Raised ICP - haematoma expansion, malignant oedema, haemorrhagic transformation, hydrocephalus
- Infections - aspiration pneumonia, UTI
- Immbolity complications - VTE, constipation, pressure sores
- Mood and cognitive function - affect rehab
- Post stroke pain/fatigue - spasticity, neuropathic pain, poor sleep, brain damage
- Spasticity, contractures, secondary epilepsy
Preventing post-stroke complications
- Routine NEWS
- Observations
- Mood
- Bowel and urine function
- Reviewing stroke impairments
- Sleep
- Legs/calves review ?DVT
- Monitoring bloods
Contents of stroke bundle
- Admit to stroke unit
- Revascularisation
- Optimise physiology (surveillance, prevention, early intervention of complications and nutrition support)
- Secondary prevention
- Rehab and reablement
How well will a patient recover?
- Prognosis can be derived from NIHSS and OCSP class
- Functional prognosis best informed by recovery trajectory - will continue until a patient reaches functional plateau
Functional plateau groups
- Early, high functioning plateau - extreme version of this is TIA/minor stroke, excellent functional prognosis
- Early, low functioning plateau - TACS with no meaningful improvement as time passes, poor proognisis
- Delayed and medium functioning plateau - define recovery in most moderate strokes, benefit from change at sustained rehab efforts until plateau occurs
driving post stroke
- 4 week restriction for cars
- 1 year for HGV licenses
- Residual VF defects are seperate requierments
- If persistent/residual disbaility - refer to regional driving assessment centres to allow car modifcation and allow resumption
When is decompresisve hemicraniectomy done?
- Malignant oedema in under 60s
- Can be considered if biologically fit and older than this
- Neurosurgical units manage
IC haemorrhage main concern
- Raised ICP
- Can be from haematoma expansion or hydrocephalus
- Blood pressure control and correct clotting abnormalities necessary
- Evac haematoma and ventricular drains can be used
Investigations prior to anticoagulation for AF, thrombophilis, venous sinus thrombosis
- ECG
- MRV/CTV
- 24hr BP
- Echo
- Thrombophilia screen
Carotid endarterectomy - when?
*
- Management of symptomatic carotid disease - after TIA with good recovery of more than 50% lumen reduction (NASCET) on carotid USS
- Need good BP control <130/80, high dose statin, DAPT before surgery
- = plaque stabilisation
Left atrial appendage closure - when?
- Option for secondary prevention of stroke in those with AF who cannot have anticoagulation
NG/PEG feeding for stroke patients - when?
- Temporary measure for when unsafe swallow currently
- Assess swallow with flexible endoscopic evaluation of swallowing (FEES) and video fluroscopy
- Not to be used to prolong suffering at end of life
Palliation options post stroke
- Address pain
- Mouth care
- Tube and IV feeding not appropriate - feed orally for pleasure (feed at risk)
ASPECT score
- Alberta stroke program early CT score
- 10 point CT scan score used in patients with MCA stroke
- Segmental assessment of MCA territory is made, 1 point deducted from initial score of 10 for every region involved - 0 = diffuse involvement
- Used in revasculiration for patient selection and outcome prediction
Modified rankin scale
- Global disability used to assess baseline function, evaluate outcomes and treatment impact after interventions
- 0-6
- 0 = no symptoms
- 6 = dead
ROSIER scale
Differentiate between stroke and stroke mimic in hopsital
Stroke mimic - 3 types
- Visible on brain imaging (MS, subdural haematoma, SOL etc)
- Distinct non-stroke syndrome features - BPPV, vestibular neuronitis, syncope syndrome, transient global amnesia (sudden temp loss of short term memory)
- Specialist assessment often needed - migraine with aura, focal seizures, functional syndrome (EEG and MRI needed)
What is apparent neurological deficit?
- Neurological dysfunction in patients with chronic stroke but good recovery
- Residual areas of scar tissue at site of previous damage
- Symptoms can return due to underperfomance of glial tissue in scenarios (eg in infections, low BP, low glucose, fatigue)
- Correction of underlying stressor –> return to baseline
Features of early stroke on CT scan
- Effacement of ventricles
- Loss of grey/white matter differentiation
- Increased density of relevent BV - clotted blood
Hypertensive ICH location
- DEEP
- Eg in basal ganglia/cerebellum
