Strokes

Question 1

Risk Factors

Answer 1

Valvular disease/replacement, permanent AF, TIA Hx, HTN, carotid artery disease, DM, hyperlipidemia, phospholipid syndrome, CCF.

Question 2

Presentation

Answer 2

Weakness, sernsory less (unilateral), facial droop/weak, dysarthria, amaurosis fugax, dizziness, headache.

Symptoms present acutely, and follow focal neurology.

Question 3

Strokes Mimics

Answer 3

Hypoglycaemia, MS, seizure, intracranial bleed (extradural, subdural, subarach), migraines, hypercalc.

Question 4

Aetiology

Answer 4

AF, MI, valvulopathy, endocarditis.

Carotid bruit, PVD, cancer, pregnant, DVT.

Question 5

What is the aim of treatment?

Answer 5

You cannot save dead brain but you can save penumbra.

Question 6

Management for ischaemic stroke

Contraindic of medication and SE.

Indic of Thrombectomy.

Answer 6

If within 4.5 hours and not contraindicated, then alteplase. Indicated if NIHSS 4 or above.
SE - Bruising, bleeds from nose and gums.

Contra -
BP 185/110, INR>1.7, recent stroke (3 months), major surgery (3 months), pregnancy, seizure.

BP CONTROL.

If large vessel, then thrombectomy (MERCI surgery) within 6 hours. NIHSS>6. CTA must be done, massive deficits needed.

300mg aspirin

NIB until swallow assessment made

VTE with intermittent pneumatic compression.

1/3 benefit from drug, 1/10 makes full recovery.
1/100 worse outcome, 1/15 have ICH.

Question 7

Acute Management for haemorrhagic stroke.

Answer 7

Reverse coagulopathy, nimodipine 
Elevate head
Lower BP is above 150mmHg
Consider anticonvulsant.
CT head.

Question 8

Investigations?

Answer 8

Figure out aetiology - embolus has come from somewhere.

ECG, carotid doppler, echo for valvular disease
Bloods: FBC, UandE, LFT, CRP for baseline. Lipid profile, HbA1c, TFT, anti PL antibody.

Question 9

Long Term Management

Answer 9

Control RF: Smoking cessation, HTN control, statin is lipid, exercise, balanced diet.

Secondary prevention: 2 weeks 300mg aspirin once daily then switch to clopidogrel.