The vascular system and stroke - Stroke Flashcards
What is the definition of stroke (Warlow et al,1996)
Stroke is a clinical syndrome characterised by rapidly developing clinical symptoms/or signs of focal neurological deficit lasting more than 24 hours and thought to be of vascular origin
What are the presenting problems of stroke?
- Unilateral weakness - sudden, progress rapidly and follows a hemipelgic pattern
- Speech distrubance - dysphasia and dysarthia
- Visual deficit
- Visuo-spatial dysfunction
- Ataxia
- Headache
- Seizure
- Coma
List some non-modfiable risk factors of stroke
- Age
- Gender (male > demale except of extreme age)
- Race (Afro-caribbean > asian > european)
- Previous vascular event
- Stroke
- Vasculitis e.g., GCA
- DVT
List some modifiable risk factors of stroke
- Cigarette smoking
- High blood pressure
- High cholesterol
- Excessive alcohol intake
- Heart disease - atrial fibrillation
- Diabetes mellitus
- Infective endocarditis
- Oestrogen-containing drug (contraceptive pill)
What drugs are you most intrested in when it comes to the DH of a patient with a suspected stoke?
- Anticoagulants (more at risk of bleeding)
- Antiplatelets
- Anti-epileptics
- Insulin and other diabetic medications
Describe the examinations involved and findings to look out for when diagnosing a stroke in a patient
General - HR, BP, O2 saturations, temperature, blood glucose, conscious level, facial symmetry
Skin - Xanthelasma, rash, pressure injury
Eyes - Arcus seniles, diabetic retinopathy, hypertensive retinopathy, rentinal emboli
Cardiovascular - heart rhythm, BP, carotid bruits (narrowing of carotid artery’s can cause bruits increasing likelihood of strokes), jugular venous pulse
Respiration - aspiration pneumonia, pulmonary oedema/infection, oxygen saturation
Abdominal - palpable bladder (some with stroke get into urinary retention)
Cranial nerves - neck stiffness, visual fields, nerve palsy
Speech - check comprehension to identify receptive dysphagia
PNS
Motor system - muscle bulk, abnormal posture and movements, tone, strength, including pronator drift, co-ordination, tendon and plantar reflexes
Sensory system - touch sensation, cortical sensory function: sensory inattention or neglect, joint position sense
Gait if possible - ataxic, non-weight bearing, hemiparetic gait pattern
Name the two pathological classifications of stroke and state the percentage of stroke that is due to each
Ischaemic (cerebral infarction) - 85%
Haemorrhagic (primary intracerebal haemorrhage) - 15%^
a) Small vessel disease is an aetiology of stroke. What is small vessel disease?
b) Name 3 conditions that it is secondary to
c) What would you see on a CT scan?
a) Occlusion of small perforating arteries
b) Secondary to hypertension/diabetes/diabetes mellitus
c) Small infarcts in sub cortical white matter/ basal ganglion/thalamus/internal capsule. This is known as “lacunes” or “lacunar infarcts
a) Describe the role of the CHA₂DS₂-VASc score
b) Name the components of the CHA₂DS₂-VASc score including what each component scores
a) Calculates stroke risk for patients with atrial fibrillation
b)
What is the most appropriate scoring scale to aid in triage in the emergency department when suspecting a stroke?
ROSIER - Designed for recognising stroke in the acute setting of the emergency department
Describe the role of the NIH Stroke Scale/Score (NIHSS)
It is a clinical assessment that is used to evaluate and document stroke severity.
What are the two most common primary causes of haemorrhage stroke?
Amyloid angiopathy (deposit of amyloid protein in the blood vessels of the brain reduces the elasticity of the artery and makes it more prone to cracking and leaking)
Hypertension (if you have hypertension for long periods of time, the arteries lose their elasticity and become more rigid and prone to cracking and leaking which make cause cerebral haemorrhage in the brain)
Explain 3 secondary causes of haemorrhage strokes
Arteriovenous malformation (AVM) - this is where you have a direct connection between an artery and vein without a capillary bed, which puts the venous and arterial system at high pressure. Veins are not designed to withstand the pressure, so they are prone to leaking and cracking
Aneurysms - aneurysms are weakness in blood vessels which cause them to expand and sometimes they can burst and cause a haemorrhage
Coagulopathy - most commonly due to anticoagulants e.g., Warafin, heparin, rivaroxaban (DOAC). Can also be due to liver problems and sepsis
What is the name of the clinical classification used for ischaemic (infarct) strokes?
Bamford (Oxford) classification
Name the four different classifications of the Bamford (Oxford) classification
Total anterior circulation syndrome (TACS)
Partial anterior circulation syndrome (PACS)
Lacunar syndrome (LACS)
Posterior circulation stroke (POCS)
a) What are the signs of a total anterior circulation syndrome (TACS)
b) What is the most common cause?
a) All of the following:
- Contralateral motor or sensory loss
- High cortical dysfunction (dysphagia, neglect, aphasia etc)
- Contralateral homonymous hemianopia
b) Middle cerebral artery occlusion (embolism from heart or major vessels)
a) What are the signs of a partial anterior circulation syndrome (PACS)
b) What is the most common cause?
a) 2 of the following:
- Contralateral motor or sensory loss
- High cortical dysfunction (dysphagia, neglect, aphasia etc)
- Contralateral homonymous hemianopia
OR high cortical function only
b) Occlusion of a branch of the middle cerebral artery or anterior cerebral artery (embolism from heart of major vessels)
a) What are the signs of a lacunar syndrome (LACS)
b) What is the most common cause?
a) Contralateral pure motor or sensory loss only
- No cortical/higher cerebral dysfunction or hemianopia
b) Thrombotic occlusion of small perforating arteries (Thrombosis in situ)
a) What are the signs of a posterior circulation stroke (POCS)
b) What is the most common cause?
a) - Isolated/cortical hemianopia
- Nystagmus
- Vertigo
- Diplopia (double vision)
- Dysarthria & dysphagia
- Hemiparesis
- Hemisensory loss
- Brain stem signs/cranial nerve syndrome
- Respiratory failure
- Coma and death
- Cerebellar (locked in) syndrome
b) Occlusion in vertebral basilar or posterior cerebral artery territory (Cardiac embolism or thrombosis in situ)
Wallenberg syndrome, also known as lateral medullary syndrome due to its location, is a type of POCS that presents with a constellation of features. Name 6 features of this.
DANVAH
-Dysphagia & dysarthria
- Ataxia (ipsilateral)
- Nystagmus (ipsilateral)
- Vertigo
- Anaesthesia (ipsilateral facial numbness and contralateral pain loss on the body)
- Horner’s syndrome (Ipsilateral)
+ Diplopia
a) What artery is occluded in Wallenberg’s syndrome?
b) Where is the lesion/infarct in Wallenberg’s syndrome found in the brain?
a) Occlusion of the posterior inferior cerebellar artery
b) Lateral medulla
Which stroke system affects the brain stem?
Weber’s syndrome/medial midbrain syndrome
a) What is the intracerebellar haemorrhage stroke (ICH) score?
b) What are the components of the ICH score?
c) Explain the relationship between the infraentorial origin and mortality
d) What is the relationship between the ICH score and mortality
a) It is the cerebral haemorrhage score for prognosis
b) Glasgow component score (GCS), ICH volume (size of the bleed), Infraentorial origin of ICH, age
c) If the bleed is in the back of the brain the risk is higher (higher mortality) because there is less space there for swelling
d) The higher the ICH score the higher the mortality
Define transient ischaemic attack (TIA)
Neurological signs that are consistent with a stroke that lasts for less than 24 hours
What is the diagnostic investigation for a stroke?
CT head
Describe the investigations that can be undertaken to diagnose a stroke in a patient
Bloods - FBC, U+E, LFTS, bone, clotting, blood sugar, cholesterol +/- ESR, haemophilia screen, vasculitis screen
ECG (look for AF as it a massive risk factor of strokes)
CT head (diagnostic)
CXR (signs of aspiration pneumonia)
+/- perfusion scan (if onset is unknown), MRI
Carotid doppler/CT angiogram
Echocardiography + 24-hour tape +/- prolonged monitoring
Describe the management of a patient who presented early with a TIA (< 1 week ago)
- Immediate aspirin 300mg (or Clopidogrel 300mg loading then 75mg OD)
- Specialist assessment within 24-hour symptom onset
- Secondary prevention as soon as the diagnosis is confirmed e.g., Statin
- Carotid duplex scanning in anterior circulation events - carotid endarterectomy if significant stenosis (> 50%)
Do you see damage on a CT and MRI if a patient has a TIA?
No damage on CT. May be seen on some MRI
a) What is the ABCD2 score?
b) What are the components of it?
c) What are the NICE guidelines about the ABCD2 score?
a) The risk of stroke during the 7 days after a TIA
b) A - Age > 59
B - Blood pressure >/= 140/80
C - Clinical presentation: unilateral weakness, speech disturbance, other
D - Duration
D - Diabetes
c) NICE guidelines say to see everyone within 24 hours of honest no matter the ABCD2 score
List 10 ‘stroke mimics’
- Migraine
- Metastatic cerebral tumours
- Abscess
- Subarachnoid
- Extradural and subdural haematoma
- Encephalitis
- Cerebral vein thrombosis
- Epilepsy and Todd’s palsy
- Multiple sclerosis
- Myasthenia gravis (rare long-term condition that causes muscle weakness)
- Bell’s palsy
- Functional symptoms
- Hypoglycaemia
- Hypothermia
- Sepsis
- Old strokes who are unwell
- Dementia
- Drug toxicity
- Transient global amnesia (an episode of confusion that comes on suddenly in a person who is otherwise alert.)
Describe the differences in clinical features of stroke and stroke mimics
a) What type of stroke is this?
Haemorrhagic stroke - white (hyper-attenuation) on CT is blood
What is the darkness surrounding the hypoattenuation area on this CT scan
Oedema
Describe the 7 R’s of the management of stroke
Recognise - Symptom recognition, call 999
React - Transfer to hospital with Acute Stroke Unit
Respond - Brain imaging and medical assessment
Reveal - Confirm diagnosis, assess for thrombolysis drugs
Rx/Reperfusion - Thrombolysis diagnosis, assess for thrombolysis drugs
Rehabilitation - Stroke team assessment and treatment
Reintegration - Patient support groups, family, community
Name 2 pre-hospital screening test for stroke/TIA
FAST (Facial, Arms, Speech, Time)
MASS
Describe the management of a TIA presenting late (> 1 week ago)
- Specialist assessment ASAP
- MRI imaging (T2) mode of choice to exclude haemorrhage
- Immediate initiation of clopidogrel
- Secondary prevention as soon as the diagnosis is confirmed
a) When should brain imaging in a suspected acute stroke be done?
b) What are the indications for brain imaging?
c) Why is early scanning important?
a) Immediate (next slot or within 1 hour)
b)
- Indications for thrombolysis
- Been taking anticoagulant therapy
- A known bleeding tendency
- A depress level of consciousness (GCS < 13)
- Unexplained progressive or fluctuating symptoms
- Papilledema, neck stiffness or fever
- Severe headache at onset of stroke
c) To rule out haemorrhage or other mimics
Describe the differences seen on a early CT scan of an acute ischaemic stroke vs acute haemorrhage
Early CT scan after an acute ischaemic stroke can be normal or show only subtle changes (darkness for infarct)
Early CT scan after an acute haemorrhage will show changes in almost all changes (white for bleeding)
a) What is thrombolysis?
b) Describe the mechanism of thrombolysis
c) What is the window for thrombolysis
d) What drug is commonly used in thrombolysis of an ischaemic stroke and how is given?
a) Treatment to dissolve clots in blood vessels using synthetic tissue plasminogen activators
b) Enzymically activates plasminogen to give plasmin which digests fibrin & fibrinogen, lysing the clot
c) <4.5 hours
d) Alteplase bolus followed by an infusion
What are the indications for thrombolysis?
- Symptom onset <4.5 hours
- Definite weakness and/or dysphagia regardless of severity
- Age 18+ years
- GCS <8
Name 8 absolute contraindications of thrombolysis?
- History or evidence of hemorrhagic stroke (at any point)
- History or evidence of intracerebral/subarachnoid haemorrhage (at any point)
- Active internal bleeding
- Neurosurgery last 3 months
- Sensory symptoms only-
-Seizure with residual neurologic impairment - Rapidly resolving symptoms
- Unkown time of onset of symptoms
- CT shows hypodensity > 1/3rd hemisphere (eASPECTS score)
- INR >/= 1.7 and aPTT > 35 or NOACs
- Platelets <100x109
- BP > 180/110 mmHg
a) Name 4 features of unsafe swallowing
b) Describe the management of this if a stroke patient suspected of stroke presents with these features
a) Symptoms when drinking water:
- Drooling
- Dyspnoea
- ‘wet’ voice
- >2 seconds to initiate swallow
- Coughing during or within 1 minute of swallowing
b) Nil by mouth with IV fluids and salt assessment
a) What is a thrombectomy?
b) What is the window of opportunity for thrombectomy?
a) Mechanical clot retrieval
b) Window is 6 hours. In some cases thrombectomy can be performed within 24h. It is not used 24 hours after the onset of symptoms
a) What is prescribed to acute ischaemic stroke patients, where ICH is excluded?
b) What should be added for those age 70+, or reporting dyspepsia?
c) What should you prescribe aspirin allergic/intolerant patients?
d) What must you consider in those already on aspirin or considered high risk?
a) Aspirin 300mg for 14 days and then 75mg clopidogrel indefinitely
b) PPI
c) An alternative anti-platelet
d) Dual anti platelet (Asp + Clopi) for up to 4 weeks
a) What is prescribed to acute ischaemic stroke patients, where ICH is excluded?
b) What should be added for those age 70+, or reporting dyspepsia?
c) What should you prescribe aspirin allergic/intolerant patients?
d) What must you consider for those on aspirin already?
a) Aspirin 300mg for 14 days and then clopidogrel indefinitely
b) PPI
c) An alternative antiplatelet e.g., clopidogrel
d) Consider dual antiplatelet (aspirin + clopidogrel) for 2-3 weeks
Describe the treatment of ischaemic stroke patients with AF/paroxysmal atrial fibrillation
Stop anticoagulation. Give 300mg aspirin (14 days) and then clopidogrel. Anticoagulate with warfarin or DOAC (usually 5-14 days after index event - must take off aspirin before anticoagulation)
If you cannot anticoagulant a stroke patient with AF with DOAC. What should be offered?
Vitamin K antagonist
Describe the management of VTE prophylaxis/treatment post-stroke
- NO anti-embolism stocks
- LMWH should considered if ICH excluded, low risk of bleeding, major restriction of mobility present, previous VTE
- Consider indwelling pleural catheter if started within 3 days of event, continue for 30 days or till mobile and patient/relatives agree after risks and advantages explained
- Patients with DVT or PE should receive anticoagulant treatment if no contraindications
- Patients with intracerebral haemorrhage and symptomatic DVT or PE should receive treatment with vena cava filter
Should post-stroke patients receive anti-embolism stockings as VTE prophylaxis/treatment?
NO
When can you consider giving LMWH as VTE prophylaxis/treatment post-stroke?
Consider if ICH excluded, risk of bleeding is low, major restriction of mobility present and previous VTE
What is the management of VTE prophylaxis/treatment post-stroke in patients with ischaemic stroke with symptomatic DVT or PE?
They should receive anticoagulant if no contraindications
What is the management of VTE prophylaxis/treatment post-stroke in patients with intracerebral haemorrhage with symptomatic DVT or PE
Patients should receive treatment with vena cava filter
Describe the management of intracerebral haemorrhage (ICH)
- Monitor conscious level in neurosurgical or stroke unit, if deteriorates refer immediately for brain imaging when necessary
- If primary ICH and on warfarin, stop warfarin and use a combination of Prothrombin complex concentrate and IV vitamin K to reverse INR to normal
- if secondary ICH to DOAC then consider specific reversal agent (if available)
- Good BP control immediately using IV labetolol. Must achieve a BP < 140mmHg (ONLY try and lower when SBP > 140 mmHg as lowering BP could worsen outcome by reducing cerebral perfusion)
- Consider surgical intervention if hydrocephalus/brain stem compression develops (cerebellar haemorrhage) e.g, VP shunt
in what cases of haemorrages is surgical intervention generally not for?
- Small deep haemorrhages
- Lobar haemorrhage unless hydrocephalus or rapid neurological deterioration
- Large haemorrhage and significant prior comorbidities before stroke
- Supranterorial haemorrhage with GCS , 8 unless due to hydrocephalus
Describe the maintenance of homeostasis post-stroke
- Fluids used routinely
- Supplemental 02, only if SATS < 95%
- Maintain blood sugar glucose between 4-15 mmol/l
- Blood pressure should NOT be actively treated initially as a routine unless > 200/120 mmHg or considered for thrombolysis
- Consider BP reduction <185/110 mmHg in candidates for thrombolysis
- Pyrexia should be investigated, and antipyretics considered to lower temeprature
- Lipid lowering NOT recommended in acute phase
Blood pressure should NOT be actively treated initially as a routine post- stroke, unless in certain situations. Name 2 excecptions
- If bp is >200/120
- if considered for thrombolysis
Describe the role of the nutrition and swallow assessment in stroke patients
- Must be complete on all patients
- Nil by mouth if unsafe swallow and consider nasogastric (NG) tube within 24 hours. SALT/dietician input essential.
Once patients have had a stroke they require a period of adjustment and rehabilitation. This is essential and central to stroke care. It involves the multidisciplinary team. Name 8 members of the multidisciplinary team
Doctors
Nurses
Speech and language (SALT)
Dieticians
Physiotherapy
Occupational therapy
Social services
Optometry and ophthalmology
Psychology
Orthotics
Patients often need rehabilitation after discharge from acute ward. What are the options offered to patients?
- Home based stroke early supported discharge
- Stroke in-patient rehabilitation
a) What is malignant MCA syndrome?
b) What intervention can be considered in malignant MCA syndrome?
c) In what circumstances can this take place?
a) Term used to describe rapid neurological deterioration due to cerebral oedema following middle cerebral artery (MCA) territory stroke.
b) Decompressive hemicraniectomy
c) - Patient must be referred within 24 hours of symptoms and treated within a maximum of 48 hours
- Signs on CT of an infarct of at least 50% of the MCA territory (with or without additional infarct in the territory of ACA or PCA on the same side)
Describe the role of anticoagulation for treatment if acute ischaemic stroke if patient in sinus rhythm
Anticoagulation has no routine role
Describe the treatment for carotid/vertebral dissection
Thrombolyse if appropriate, long-term anticoagulants or antiplatelets
Describe the treatment for venous stroke caused by venous sinus thrombosis (including those with secondary cerebral haemorrhages)
Should be given full-dose anticoagulation treatment
Describe the secondary prevention of stroke
- Blood pressure control: acute control with haemorrhage or peri-thrombolysis. Subsequent treatment if hypertensive emergency, otherwise gradual and cautious introduction of agents.
- Blood glucose control: maintain glucose between 4-11 mmol/L. Optimise diabetic control
- Anti-lipid/cholesterol therapy: commence on statin 48 hours after the initiation of a stroke unless already established (80mg atorvastatin) Avoided in cerebral haemorrhage.
- Anti-platelet/anti-coagulation: 2 weeks of aspirin 300 mg followed by clopidogrel 75 mg daily.
- Warfarin/direct-acting oral anticoagulant may be appropriate (e.g. AF)
- Carotid artery assessment: carotid dopplers or CT angiography. Consider carotid endarterectomy if anterior stroke and significant stenosis (ECST - 70-99% / NASCET - 50-99%).
- Offer smoking cessation support
What must you advise stroke patients when it comes to driving?
Cars and motorcycles: stop driving one month. Only inform DVLA if ongoing symptoms after one month
Larger vehicles (e.g. buses, lorries): stop driving, inform the DVLA
Must stop driving for 3 months if there is multiple events
Name 6 early complications of stroke
- Haemorrhagic transformation of ischaemic stroke
- Cerebral oedema
- Seizures
- Infection (e.g. aspiration pneumonia)
- Cardiac arrhythmias
- Venous thromboembolism
- Death
Name 7 late complications of stroke
- Mobility & sensory issues
- Bladder & bowel dysfunction
- Pain
- Fatigue
- Cognitive problems
- Visual problems
- Emotional and psychological issues
- Issues with swallowing, hydration and nutrition
What are the indications for Warfarin after a TIA?
Patient’s with a cardiac source of emboli e.g. atrial fibrillation
How soon should a patient be referred to specialist treatment after a TIA?
Patients should be referred within 24 hours
A gentleman presents with word finding difficulties, visual loss on the right-hand side and right sided numbness. What kind of stroke would you classify him as having using the Bamford (Oxford) classification?
TACS – all of the following: motor or sensory; cortical (dysphagia, neglect etc); homonymous hemianopia
If onset time is known and less than 4.5 hours, what kind of scan would you do for a stroke and what treatments would be potentially possible
CT head and thrombolysis (with alteplase)
If onset is not known of a stroke (e.g., wake up stroke) then what other kind of scan could you do to enable treatment
CT perfusion (characterise the cerebral circulation and areas of ischaemia better)
What are the risks of the treatment of thrombolysis?
Subarachnoid/intracerebral/subdural haemorrhage
What are the benefits of thrombolysis?
Dissolves the clot – saves penumbra, increases chance of going back to normal
If a stroke was haemorrhagic, what risk factors would you look for?
On antiplatelets, anticoagulants, hypertension, drugs (e.g., cocaine), amyloid angiopathy
a) What is the initial treatment of all ischaemic strokes after 4.5 hours?
b) What does this change to at 2 weeks?
a) 300mg aspirin
b) 75mg Clopidogrel
What must you do before you give aspirin to a patient who has been thrombolysed?
The patient must have a repeat CT scan
What is amaurosis fugax?
It means ‘transient darkening’ and describes a temporal loss of vision through one eye. This is usually due to temporary disturbance of the blood flow to the back of the eye
What are the indications of an endarterectomy?
- Severe carotid artery stenosis of 70-99% of the lumen diameter
- Symptoms in the same vascular territory
A patient has had transient weakness in the left upper limb in the last 5 weeks, each lasting approximately 20 minutes. A carotid doppler reveals 75% stenosis in the left carotid artery and 45% stenosis in the right carotid artery. Is endarterectomy indicated?
The patients symptoms are on the left meaning it is in the right vascular territory but the stenosis on the right is 45% and not 70-99% so not meeting the threshold for an endarterectomy
In which patients does mechanical thrombectomy provide the most benefit to?
Patients with proximal MCA or internal carotid artery thrombus
a) Describe the presentation of locked in syndrome
b) What lesion site causes this?
a) Complete loss of movement, preserved consciousness and ocular movements, often only vertical gaze
b) Basilar artery occlusion
a) Where is the dominant hemisphere of language for right handed people?
b) Where is the dominant hemisphere of language for left handed people?
a) Left hemisphere
a) 50% left hemisphere and 50% right hemisphere
Explain the symptoms of a MCA stroke in a right-handed patient?
- Left hemisphere is the dominant hemisphere for language and main speech areas in right handed patients
- Therefore symptoms are aphasia
A 70 years old male admitted with left hemiplegia, left hemianopia and left sided sensory loss and inattention. What is the diagnosis according to the Bamford classification?
TACS
A 85 years old female admitted with isolated receptive dysphasia. What is the diagnosis according to the Bamford classification?
PACS
A 70 years old male admitted with left sided weakness. On examination he had left facial weakness, grade 0 UL and grade 0 LL & No sensory or visual abnormality. What is the diagnosis according to the Bamford classification?
LACS
A 75 years old man attended A & E with visual problem. On examination he had isolated left homonymous hemianopia. What is the diagnosis according to the Bamford classification?
POCS
Describe what you would see on a CT scan of an early infarction (<6 hours)
- Loss of grey and white matter differentiation
- Loss of sulcal pattern
- Loss of definition of basal ganglion
- Dense MCA/BA sign
Describe what you would see on a CT scan of an established infarction (days-weeks)
- Looks darker
- If cortical –> wedge shaped
- If lacunar –> black holes,<1cm,BG/subcortical
A 57 years old, previously fit & healthy, developed left hemiplegia at 10:15. He had CT at 11:40 which was normal. Treatment?
Thrombolysis/Thrombectomy
A 86 years old male woke up with dense R hemiplegia, dysphasia and hemianopia. CT confirmed a Left MCA infarct. Treatment?
Prevention of complications
A 71 years old male, hypertensive recovered from left PACS ( right hemiparesis). His examination is unremarkable. Treatment?
Secondary prevention
Describe the factors involved to avoid secondary prevention
- Stroke unit
- Hydration
- Swallowing assessment
- Nutrition
- Temperature control
- Blood glucose monitoring Oxygen
- DVT prophylaxis
What is the sign of a post infarct cerebral oedema?
Deterioration in GCS
Describe the management of post infarct cerebral oedema
- Dexamethasone
- Mannitol - more beneficial
- Surgery
Mr SK who is 75 years old, has suffered from recent stroke from which he has made good recovery. He had a TIA 6 months ago.
On examination his pulse is 100 irregularly and BP is 154/94.
Cholesterol 6.3
ECG AF
CXR normal
ECHO normal
HbA1C 42 (normal)
No significant past medical history
Calculate the CHA2DS2Vasc score
Score = 4
What type of stroke is this?
Lacunar stroke/infart
78 years old gentlemen, smoker, hypertensive, T2DM seen in TIA clinic with expressive dysphasia lasted for 1 hour with complete resolution. He is right handed. He was already on Aspirin 75 mg.
BP 160/96
HbA1c 88
Chol 5.8
He was in SR. CTCA showed stenosis of 85% in Right ICA and 45% left ICA
Describe the management
- Can change aspirin to clopidogrel or aspirin + clopidogrel
- Anti hypertensives
- Statins
- Smoking cessation
- Diabetes control
Will not refer for carotid endarterectomy because left cerebral hemisphere is affected but ICA in left is 45% which does not meet the criteria (70-99%)
78 years old gentlemen, smoker, hypertensive, T2DM seen in TIA clinic with expressive dysphasia lasted for 1 hour with complete resolution. He is right handed. He was already on Aspirin 75 mg.
BP 160/96
HbA1c 88
Chol 5.8
He was in SR. CTCA showed stenosis of 85% in Right ICA and 45% left ICA
Describe the management
- Can change aspirin to clopidogrel or aspirin + clopidogrel
- Anti hypertensives
- Statins
- Smoking cessation
- Diabetes control
Will not refer for carotid endarterectomy because left cerebral hemisphere is affected but ICA in left is 45% which does not meet the criteria (70-99%)
If a young patient has a stroke, what investigations will you order?
- Vasculitis screen
- Haemophilia screen
- Serum toxicology screen can also be considered (sympathomimetic drugs e.g. cocaine are a strong risk factor for haemorrhagic stroke).
- Echocardiography
- 24-hour tape
How are strokes and epileptical events differentiated clinically?
Strokes tend to result in negative neurological symptoms (loss of function) and obey vascular territories. Epileptical events tend to present with positive neurological symptoms (tingling) and do not obey vascular territories.
