Week 9 - Stroke Flashcards
What are the risk factors for stroke
Non-Modifiable:
- Age
- risk doubles every year after 55
- Gender
- men = at higher risk
- female = more likely to die from stroke
- Family history
- Afro-caribbean
Modifiable:
- Smoking
- Hypertension
- Hyperlipidemia
- Diabetes
- Atrial fibrilation
What are the symtpoms of a stoke
- droopy face
- loosing power on one side
What are the 2 main types of stroke
NOTE: both are treated DIFFERENTLY
- Ischaemic
- blood supply is disrupted due clot or plaque
- MOST common - Haemorrhagic
- bleeding in the brain
Transiet Ischaemic Attack (TIA) - symptoms of stroke that resolve within 24hrs
- lasts 5-10 minutes
In stroke symptoms last 24hrs if not resolved immediately
What are the 2 causes of Ischaemic stroke
- Cerebal Thrombosis
- have fatty depsoits in vessel = clump together = athersclerosis plaque / clot
- clot blocks brain vessel
- Distal Embolism
- a clot somewhere else in body that travels to brain + lodges in vessel
What are the 2 causes of Haemorrhagic stroke
- Intracerebal
- rupture of small vessel in brain
- Subarachnoid
- rupture of intracranial aneurism in subarachnoid space (lining of brain)
How is the type of stroke diagnosed
- Rule out other possible causes
- e.g. seizeures, drug toxicity, brain tumour, migraine (with aura)
- CT Scan
- is quick procedure compared to MRI
- Ischaemic - diff. to spot, clinican has to use clinical knowledge
- Haemorrhagic - easier to spot / very visible (areas will appear very bright on scan)
- MRI Scan
- time-consuming - BP (cardiac events)
- ECG (clotting, renal)
- FBC and U&Es
- Blood glucose (undiagnosed diabetes)
- Inflammatory markers (infection, cancer)
What happens after diagnosis
- Patient transferred to hyper-acute stroke unit
- only stay here whilst medically unstable - Once stable patient moved to stroke rehab unit or general medical ward
NOTE: NO treatment is admintsered until CT scan back to confirm diagnosis
List the drugs used ACUTELY in IMMEDIATE ISCHAEMIC stroke treatment
Acute = done immediately after stroke diagnosis
- Thrombolysis
- DRUG USED: Altepase
Works best when: - given within 3hrs of symptom onset (can be given up to 4.5hrs)
- 2x as effective if given within 1.5hrs
- CAUTION: risk of bleeding
- CAUTION: >80 (complication of stroke ~ haemorrhagic transformation = bleeding)
- CONTRAINDICATION: atrial fibrilation
- DRUG USED: Altepase
- Thrombectomy
- surgery to remove clot
- NOT receieved by all patients
- Aspirin 300mg (anti-platelet)
- for 14 days
- given to ALL ischaemic patients
- IF patient THROMBOLYSED = wait 24hrs + another CT scan (no bleed) before initiating aspirin
List the drugs used ACUTELY in IMMEDIATE HAEMORRHAGIC stroke treatment
Acute = done immediately after stroke diagnosis
- Anticoagulants are STOPPED and REVERSED
- drugs stopped include: warfarin, aspirin, NSAIDS
- if on warfarin GIVEN Vitamin K (reverse)
- Analgesia for headache
- inc. paracetamol OR codeine
- Neurosurgical Intervention
- clipping or coiling ruptured aneurysm
NOTE for subarachnoid haemorrhage
- Give Nimodipine
- 60mg 6 x daily for 21 days
- MUST be strated within 4 days
- To minimise secondary cerebral ischaemia
How and when do we control BP for both types of strokes: Acute treatment
BP = blood pressure
Fluctuating (high) BP is common after acute stroke
- will resolve itself
- if need to control use IV routes (short-acting = can be removed from body quick)
Ischaemic:
- ONLY manage high BP if patient is eleigble for thrombolysis or hypertensive emergency
- BP for thrombolysis < 185/110 mmHg
- High BP CAUSE: brain detects lack of O2 = body sends more blood to brain
Haemorrhagic:
- AIM: 130-140 systolic for 7 days
- TREAT if:
- within 6hrs of symptoms >150mmHg systolic
- after 6hrs of >220mmHg
What other factors need to be monitored / assesed: Acute Treatment
- Ability to swallow (seen by SALT)
- may have to change formulations / route of administartion - FLuid balance is montored + fluids replaced if needed
- prevent dehydration / fluid overload - Monitor temp.
- can be high after stroke
- use paracetamol to reduce - Control blood glucose
- using IV insulin - DVT prophylaxis
- use intermittent pneumatic compression (a machine the expands + collapses around their leg)
How do we prevent further strokes: Long-term Management
4 things
For BOTH Ischaemic and Haemorrahgic:
1. Control hypertension
2. Control blood glucose
For Ischaemic:
1. Use antiplatelet (or anticoagualnt)
2. Control cholesterol
Why do we control hypertension: Long-term Management
BOTH Ischaemic and Haemorrahgic
↓ risk of further strokes in hypertensive AND non-hypertensive patients
START after 2 weeks (stroke occured)
- USE: Antihypertensives
- if >55 OR Afro-Caribbean = USE CCB or thiazide-diuretic
- if young patient = USE ACE inhibitor
- AIM: <130mmHg systolic
Why do we control blood glucose: Long-term Management
BOTH Ischaemic and Haemorrahgic
Controlled in both diabetic and non-diabetic pateints
Why is a long-term antiplatelet (or anticoagulant used)
Ischaemic ONLY
Started after finishing 2 weeks of 300mg Aspirin
- USE: Clopidogrel 75mg OR Aspirin 75mg
- Anticoagulant: Warafrin OR DOAC
- DOAC = apixaban, rivoroxaban (5mg BD)
- DOAC: monitor renal function, bleeding risk, adherance
