Assessment & Management Of Acute Stroke Flashcards
(24 cards)
How common are strokes?
1/4 ppl have a stroke
Third cause of death developed world
Commonest cause long term disability
25% under 65yrs
3% under 40yrs
What does FAST positive mean?
Face - face fallen on one side/ can’t smile
Arms - can’t raise both arms and keep up
Speech - slurred
Time - call 999 if one sign present
Steps in management of stroke
Ring 999
Paramedic ring hospital
Hospital ring stroke team - meet A&E - history (NIHSS) , cannula, bloods, ECG, immediate CT SCAN - decide on treatment (thromoblysis/ thrombectomy/ BP lowering/ surgery)
-> hyperacute stroke unit 24-48hrs, swallowing checked, observations 15mins, junior DR/ nurses/ consultant/ physiotherapy/ occupation therapy/ S<, nasogastric tube? ->
Home/ rehabilitation unit/ acute stroke ward
Questions to ask during initial assessment of a stroke
Vascular problem?
TIA (resolves <24hrs - transient occlusion intracebral vessel) or stroke
Intracebral haemorrhage or infarct (85% - occlusion intracerebral vessel)
Which part of brain
Which blood vessel
Aetiology
Oxford class
Severity
Can we give give clot busting treatment??
Define a stroke
Clinical syndrome
Rapidly developing clinical signs
Acute Focal/ global disturbance of cerebral function
> 24hrs (or leading death)
No apparent cause other than vascular
What is the NIHSS?
National institutes of health stroke scale
Quantifies the impairment caused by a stroke, good for measuring response to treatment
11 items
Score 0-42
1-4 minor stroke
5-15 moderate
16-20 moderate to severe
21-42 severe
Problems: underestimates servitude POCS, misses CN/ cerebellar signs
What are the different OCSPs, aetiology, how common and what is the mortality of each?
TACS (total anterior circulation stroke 20%) - 60% 1yr - proximal occlusion ICA/ MCA, large volume infarct superficial + deep
PACS (partial anterior circulation stroke 35%) - occlusion MCA branch, restricted infarct - mortality 16% 1 yr
LACS (lacunar stroke 20%) - single perforating artery basal ganglia/ pons - 11% 1yr
POCS (posterior circulation stroke 25%) - posterior vessel occlusion, PCA or branches basilar/ vertebral - 19% 1yr
What does the immediate CT scan show?
Normally normal in ischaemic strokes
Can see blood in haemorrhage
How can we reperfuse the brain?
Opening up blocked vessel in ischaemic stroke
Thrombolysis - clot busting (20% patients eligible)
Thrombectomy -mechanically removing clot (puncture femoral artery groin- pull out clot) number needed to treat 2.6, occlusion of large BVs e.g. ICA, MCA, basilar
When to give IV thrombolysis
Clinical diagnosis of acute ischaemic stroke causing 1+: NIH score _>4, aphasia, binocular visual field deficit, swallowing deficit
imaging appearance consistent with ischaemic stroke
Symptoms onset within 4.5hrs prior to initiation of treatment
No contraindications
1/3 improve
1/10 full recovery
1/14 IC haemorrhage
Quicker given less neurones die
E.g. tissue plasminogen activator - alteplase , eminase, retavase, streptase
What can be given as early stroke secondary prevention?
Aspirin/ clopidogrel
Statin first 2days
Control BP
Anticoagulation in AF - DOACs (direct oral anticoagulants)
Carotid surgery if needed
How to treat ICH strokes?
Reversal of coagulopathy
(Bleeding disorder)
BP lowering (IV labetolol, GTN)
Surgery to evacuate haematomma if: haemorrhage with hydrocephalus, lobar haemorrhage with Glasgow coma score 9-12, cerebellar haemorrhage
Management stroke unit
Specialist rehabilitation
Bloods - platelet count and clotting
Prevent high BP, hyperglycaemia, Hypoxia - exacerbate haematoma expansion
Intermittent pneumatic compression stockings - prevent venous thromboembolism
Causes of ischaemic stroke
Cardioembolism 30%
AF
MI
Prosthetic heart valves
Cardiac surgery
Cardio version
Infectious endocarditis
Atherothrombosis large vessels 15% , in issue intracerebral, embolism from atherosclerotic plaques extract real vessels (carotid, aortic arch, vertebral)
Lacunar 20%
Vasculitis
Thrombophilia
Carotid artery dissection
ICH 15% - hypertension, cerebral amyloid angiopathy, arteriole OJ’s malformation rupture, secondary ICH e.g. from tumours
What imaging modalities are useful in TIA, what would be expected to find?
MRI + diffusion weighted imaging to exclude other diagnoses
With acute ischaemia: bright white lesions with black holes on apparent diffusion coefficient map
What investigations should be performed with confirmed TiA?
ECG (AF!, IHD, LVH)
Bloods (glucose + lipid profiles)
Carotid USS (atherosclerotic plaque)
BP
Brain imaging (exclude other diagnosis and locate e.g. CT/ CT angiogram/ MRI)
Occlusion in situ = AF
Occlusion embolus = atherosclerotic disease (risk factors)
What percent of TiA patients go on to have a stroke?
20% within 90days
1/2 within 48hrs
Most common complications of a stroke
Pneumonia
DVT
Poor nutrition
Dehydration
Depression
Venous thromboembolism
Incontinence
Pressure sores
Seizures
Spasticity
Which types of strokes cause headaches and why?
ICH - blood irritant brain/ meninges + oedema around haematomma -> raised ICP (vomiting, v high BP)
POCS (ICH/ ischaemia) - acute inflammation & swelling posterior fossa -> block 4th ventricle -> obstructive hydrocephalus
Treatment for TIAs
Antiplatelets
Anticoagulants if AF
Carotid endarterectomy if >50% stenosis
BP control
Statins
Smoking cessation
When to give clot busting treatment
Clinical diagnosis of acute ischaemic stroke causing 1 or more:
- NIH score _>4
- aphasia
- binocular visual field deficit
- swallowing deficit
- unable walk or self care independently
- imaging appearances consistent IS (no bleed)
+ Symptom onset within 4.5hrs
+ No contraindications
Causes of haemorrhagic strokes
V high BP
Atherosclerotic damage to small BVs (esp MCA branches) -> aneurysm
Cerebral amyloid angiopathy
Arteriovenous malformations
Anticoagulants
Secondary ICH (bleeding from tumours)
What is dysphasia/ aphasia?
Language disorder
Expressive/ receptive/ mixed
Dysphasia - complete lack of bailout to understand speech
Aphasia - partial
Difficulty with: Speaking Understanding Writing Reading Numbers Gestures
What is dysarthria?
Speech disorder
Can understand but can’t produce
Weakness/ abnormal muscle tone of muscles involved articulation such as lips/ tongue
Poor articulation / slurred Poor respiration Poor phonation Poor resonance Poor prosody
Slow, effortful, quiet, hoarse, prosodically abnormal
May see face paralysis and drooling
Regions of the brain associated with dysphagia
Primary motor cortex
Brainstem
Thalamus Cerebellum Basal ganglia pyramidal tracts FrontL operculum Insula
