Weakness

Question 1

You are the IMT1 on call overnight on the acute take. You have been asked to see a 84 year old male patient in A&E who has been brought in urgently by the ambulance crew with a history of new right sided weakness and slurred speech.

He has a past medical history of hypertension, benign prostatic hypertrophy and gout.

He usually lives at home with his partner and is independent.

His observations on arrival are as follows:

Temp 36.6, RR 18, saturations 96% on air, HR 104, BP 182/87

How would you initially assess and manage this patient?

Answer 1

I would first check if it is safe to approach the patient and use any appropriate PPE

Establish timeline, if pt is meeting criteria as per local stroke guidelines, I would put out an emergency call to ensure timely specialist review and investigations within the essential time window

A
* Ensure patent airway
* If any concern, I would call for senior / anaesthetic help asap
* If alert with no signs of compromise, I’d move on to assess B

B
- Continuous SpO2 monitor
- Assess RR
- Examine trachea and chest expansion
- Percuss and auscultate the lungs

C
- HR, BP, CRT
- 12 lead ECG
- 2 x large bore IV access
- Bloods - FBC, U&E, INR, LFTs, Coagulation Screen, VBG, potentially blood cultures if infection suspected
- Fluid status and oedema

D
- Glucose
- Pupils, GCS
- Focused neuro exam to determine the presence of any focal neurological signs
- This could be initially with a FAST screen or by completing the NIHSS score
- Evidence of head trauma

E
- Temperature
- Expose for a full examination
- Look for any signs of trauma

Having completed my initial assessment, I would go back to re-assess A/B/C and review any investigations that were available
* Review patient’s notes
* Collateral history
* Establish **social history **when later considering escalation status

NIHSS = NIH Stroke Scale

Question 2

What is your differential diagnosis?

Answer 2

1. Ischaemic stroke
2. Haemorrhagic stroke / intracranial bleed
3. Space occupying lesion
4. Dissection (aortic/carotid)
5. CNS infection
6. Delirium / infection / other stroke mimics

Pointers to bleeding (unreliable!): meningism, severe headache, coma. Pointers to ischaemia: carotid bruit, AF, past TIA, IHD

Question 3

What would be your initial investigations?

Include any Ixs that would form part of your initial A-E assessment

Answer 3

Bedside
- 12-lead ECG, monitor BP

Bloods
- VBG, FBC, U&E, Bone profile
- LFTs, INR, Coagulation screen

Imaging
- Urgent CT head to exclude intracranial bleed
- Aortic/carotid ultrasound may be appropriate if dissection considered
- Echo - thrombi, patent foramen ovale, AF

Question 4

CT head shows no acute intracranial bleed but has been reported as showing early changes suggestive of an acute left MCA infarct

Answer 4

• Escalate to seniors and local specialist stroke team for discussion or transfer to the local hyper acute stroke unit

Rx
- Loading dose of Aspirin 300 mg if not yet given
- If within 4.5h and no CIs, consider thrombolysis under specialist guidance
- If within 6h, mechanical thrombectomy should be considered

After
* Repeat ABC, consider supportive nutrition
* Blood pressure control usually not indicated in acute ischaemic stroke, but if plans for thrombolysis, should keep under 185/110mmHg
* Consider escalation status if significant deterioration
* Communicate with the patient and family

Question 5

The patient has an ECG and is found to be in AF

How would you like to manage this? Would anticoagulation be appropriate?

Answer 5

AF increases the risk of ischaemic stroke by approximately 5x, so reducing the risk is important in both paroxysmal and permanent AF

ChA2DS2-VASc and ORBIT scores to assess pt’s stroke and bleeding risk

Anticoagulation usually delayed in the acute phase of stroke by 1, 3, 5, 7 days, if really large, usually 10 days, depending on the size of the infarct, because of the risk of haemorrhagic transformation.
- In the meantime, continue aspirin 300mg OD for 2 weeks

Question 6

Can you describe any classification systems for ischaemic stroke?

Answer 6

The Bamford classification
* Total Anterior Circulation Stroke (TACS) - 3/3 features of weakness, hemianopia, cognitive
* Partial Anterior Circulation Stroke (PACS) - 2/3 features or higher cognitive dysfunction alone
* Posterior Circulation Syndrome (POCS) - posterior/cerebellar signs
* Lacunar Syndrome (LACS) - pure motor/sensory without higher cognitive dysfunction

The NIHSS can be used to quantify stroke severity

Question 7

What would you like to do to control blood pressure in this case?

Answer 7

In an acute ischaemic stroke, generally speaking anti-hypertensive treatment is not recommended

NICE: “Anti-hypertensive treatment in people with acute ischaemic stroke is recommended only if there is a hypertensive emergency”

• BP reduction to 185/110 or lower should be considered in people who are candidates for IV thrombolysis

In a haemorrhagic stroke, the guidance is to control BP more aggressively (even IV treatment) - under the care of a specialist
- Lower than 140mmHg, but magnitude of drop should not exceed 60mmHg