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Y4 OPIC > 5 - Stroke Management > Flashcards

5 - Stroke Management Flashcards

1
Q

What are some stroke mimics?

A
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2
Q

What are typical stroke syndrome symptoms that differentiate a stroke from a stroke mimic?

A
  • Sudden onset
  • Focal
  • Predominantly negative
  • Vascular territory hypoperfusion can explain collection of symptoms

Therefore stroke mimic if any of: gradual onset, evolution of symptoms, non-focal, positive symptoms or not related to vascular territory, stereotyping

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3
Q

What is stereotyping in stroke medicine?

A

Episodic recurrence of neurological disturbance in an identical fashion with complete resolution in between

Predictor of stroke mimic

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4
Q

What is the NIHSS score and how do we interpret the score?

A

Predictive score of outcome in stroke. Used to assess stroke severity, decide on consideration for thrombolysis and estimate prognosis

Out of 42:

  • <4: good outcome
  • >22: high risk of cerebral haemorrhage with thrombolysis
  • 26 or more: CI for thrombolysis
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5
Q

What is the Rosier Scale?

A

Recognition of Stroke in the Emergency Room

Differentiate between stroke and stroke mimics

Score of 0 is unlikely but cannot be ruled out

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6
Q

What are the tools used to identify a stroke?

A
  • FAST: in community, if positive need to go to HASU urgent
  • NIHSS score
  • Rosier Scale
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7
Q

What is the ASPECTS score?

A

Alberta Stroke Programme Early CT Score

10 point CT scan score for patients with MCA stroke

1 point deducted for every region involved

Helps predict outcome and helps decide whether to do thrombolysis

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8
Q

What is the OCSP classification?

A

Oxford Community Stroke Project classification

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9
Q

What is the Modified Rankin Scale?

A

Used to look at level of global disability/dependence following stroke.

Used to assess baseline function and evaluate outcomes after interventions

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10
Q

What are CHADVASC and HASBLED scores?

A

Guide to anticoagulation with AF

Stroke risk and bleeding risk

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11
Q

What is a ABCD2 score and how is the score interpreted?

A

Stroke risk assessment following TIA

Helps to guide when to see a patient following a TIA

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12
Q

What TIA patients are at very high risk of stroke and need to be seen within 24 hours in TIA clinic?

A

Everyone with TIA should be seen within 24 hours, especially:

  • ABCD2 >4
  • Multiple TIAs (>2 in 7 days)
  • Patients in AF
  • On anticoagulation

Start all patients on aspirin 300mg if not CI

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13
Q

Once a patient is screened in the community with FAST and they are positive, what happens next?

A
  • If within thrombolysis time window urgent transfer to HASU
  • NIHSS score
  • Clinical assessment (see image)
  • Urgent Non-Contrast CT +/- CT Angio
  • Airway protection if reduced GCS and NBM for aspiration precaution
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14
Q

Why is an urgent CT head done in a suspected stroke?

A

Diffusion weighted MRI more sensitive for ischaemic stroke but quicker to do CT to rule out haemorrhage as this is CI for thrombolysis

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15
Q

What is the acute management if a patient has a CT and it is a haemorraghic stroke?

A

Biggest risk of death is raised ICP so:

  • NBM and airway support
  • Keep BP <140/90
  • Correct any clotting abnormalities e.g Vit K/PCC for Warfarin
  • Decompressive Hemicraniectomy
  • Suboccipital Craniotomy for posterior fossa bleed
  • Coil or clipping of aneurysm
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16
Q

Which patients with hameorraghic stroke should have a decompressive hemicraniectomy? (should be done within 48 hours of stroke)

A

Malignant oedema from MCA infarct

Can also do evacuation of haematoma and ventricular drains in some patients

17
Q

What is the acute management if a patient has a CT and it is an ischaemic stroke (haemorraghe ruled out)?

A
  • NBM and airway support
  • Revascularisation therapy (see next card)
  • Aspirin 300mg. If no intervention give straight away, if thrombolysis give 24 hours after, having CT head before to check no haemorrhage. Stay on this for 2 weeks then covert to Clopidogrel 75mg
  • Monitor for complications
18
Q

What are the revascularisation therapies used in ischaemic stroke and what criteria must be fulfilled for them?

A

Thrombolysis

  • IV Alteplase (Tissue Plasminogen Activator)
  • Within 4.5 hours since onset of symptoms
  • No CI

Mechanical Thrombectomy

  • Within 6 hours of symptoms if anterior circulation stroke
  • Within 12 hours of symptoms if posterior circulation stroke
  • Dependent on potential to salvage brain tissue according to CT perfusion or diffusion-weighted MRI.
19
Q

What are the revascularisation therapies used in ischaemic stroke and what criteria must be fulfilled for them?

A

Thrombolysis

  • IV Alteplase (Tissue Plasminogen Activator)
  • Within 4.5 hours since onset of symptoms
  • No CI

Mechanical Thrombectomy

  • Within 6 hours of symptoms if anterior circulation stroke
  • Within 12 hours of symptoms if posterior circulation stroke
  • Pt must have good baseline and lack of significant early infarction on initial CT scan or CT perfusion
  • Need CT angiography and ASPECTs score
20
Q

What are some contraindications for thrombolysis?

A
  • NIHSS <5 or 26 or more
  • >4 hours since symptom onset
  • Intracranial or GI bleeding
  • Neurosurgery or Head trauma in past 3/12
  • Active internal bleeding
  • Known intracranial aneurysm or neoplasm
21
Q

What are some investigations that may be done to locate the cause of a stroke?

A

Ischaemic stroke:

  • Carotid US and CT/MR angiography to look for stenosis
  • ECG and 24h tapes
  • Echocardiogram for cardio-embolic source
  • Vasculitis or thrombophilia screen in young patients

Haemorrhagic stroke:

  • Serum toxicology screen to look for cocaine

Further investigations

  • Serum glucose (all patients with stroke should be screened for diabetes with a fasting plasma glucose or OGTT)
  • Serum lipids
22
Q

After the acute management of stroke, what is some ongoing management that is put into place?

(NB card so memorise!!!)

A
  • Blood pressure control
  • Blood glucose control: maintain between 4-11 mmol/L
  • Anti-lipid therapy: statin 48 hours after the initiation of a stroke unless already established. Avoided in cerebral haemorrhage.
  • Anti-platelet/anti-coagulation: two weeks of aspirin 300 mg followed by clopidogrel 75 mg daily. Warfarin/DOAC may be appropriate (e.g. AF)
  • Carotid artery assessment: carotid dopplers or CT angiography. Carotid endarterectomy if anterior stroke and significant stenosis
  • Swallow and nutrition assessment: all patients. NBM if unsafe swallow, NG within 24 hrs SALT/dietician input essential.
  • Rehabilitation: referral to local stroke unit
  • Palliative care: early recognition and referral in those with suspected poor outcome.
23
Q

After the acute management of stroke, what is some ongoing management that is put into place?

A
  • Statin
  • Antiplatelet
  • BP control
  • Weight loss
  • Consider carotid endarctectomy
24
Q

If a patient has a stroke and AF but is contraindicated to having anticoagulants, what other secondary prevention measure can be put into place?

A

Left atrial appendage closure

25
Q

When are patients with a stroke given an NG or PEG tube?

A
  • If made NBM due to unsafe swallow given within 24 hours
  • If end of life avoid as meaningful gains, doesn’t improve QoL or extend life
26
Q

If a patient has a stroke and the prognosis is poor, what is the recommended palliative options?

A
  • Address pain
  • Mouth and skin care
  • Control agitation
  • Communicate with family
  • Oral feed with risk of aspiration, avoid enteral feeding and IV hydration
27
Q

What might you see on CT with a stroke?

A

Ischaemic (due to fluid and electrolyte shifts as membrane transport stopped)

  • Effacement
  • Loss of grey/white matter differentiation
  • Increased density of relevant blood vessel

Haemorraghic

  • Increased attentuation
28
Q

How may the location of a haemorraghic stroke help you to discover the aetiology?

A

Deep (e.g basal ganglia/cerebellum)

  • Hypertensive

Peripheral

  • Tumour
  • Cerebral amyloid antipathy
  • AV malformation
29
Q

What is important to do before administering thrombolysis therapy?

A

GET CONSENT

Need to explain risks and benefits. If unable to get consent can do best interests form

30
Q

How is thrombolysis given and what are some side effects of alteplase?

A

Calculated by patient weight. 10% is given as a bolus over 1-2 minutes with the rest given as an infusion over 1 hour. Patients monitored neurologically and haemodynamically regulary (every 15 mins during infusion) with checks of pulse, BP, GCS, pupil reaction and ask about headache

  • Anaphylaxis
  • Intracranial or Extracranial haemorrhage

Stop infusion and repeat scan if concern

Y4 OPIC (14 decks)

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