Lecture 1- Assessment and management of acute stroke Flashcards Preview

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1

define stroke

is ‘a clinical syndrome consisting of rapidly developing clinical signs of focal disturbance of cerebral function lasting greater than 24 hours (or leading to death) with no apparent cause other than that of vascular origin’.

 

- focal disturbance of cerebral dysfunction

- vascular origin

2

types of stroke

  • Ischaemic stroke – occlusion of a an intracerebral vessel (85% of all strokes)
  • Intracerebral Haemorrhage – bleeding into the brain parenchyma (10 to15%)
  • TIA – Transient occlusion of an intracerebral vessel

3

stroke pathway starts

pre-hospital

  • Patient rings for 999
  • Priority 1 call for ambulance
  • Paramedic assessment
    • Call BATPHONE and pre-alert the hospital

4

2) Hospital will pre-alert stroke team

 

  • Specialist stroke nurse
  • Junior doc
  • Registrar/consultant
  • Physician associate
  • Stroke team meet in A and E

5

 

2) Hospital will pre-alert stroke team

  • Specialist stroke nurse
  • Junior doc
  • Registrar/consultant
  • Physician associate
    • Stroke team meet in A and E

  • Focussed history and exam
  • Initial investigations
    • Bloods and IV access
    • ECG
  • Transported to CT (priority)
  • Images looked at straight away to make decision about immediate treament e..g thrombolysis/thrombectomy (may start giving it straight away)
  • Then more straight to Stroke unit

6

3) Life after hyperacute stroke unit (HASU)

 

 

Stay on HASU for 24-48hrs (until medically stable) then…

  • Discharge home
  • Discharge home with intensive therapy at home
  • Further in patient stay on stroke ward
  • Transfer to rehab unit

7

oxford classification of stroke

TACS

PACS

POCS

LACS

8

TACS

total anterior criculation stroke

  • proximal occlusion (ICA or proximal MCA)
    • large infarct in superiffical and deep territories
  • presentation 3/3
    • higher cerebral dysfunction
    • homonymous hemianopia
    • contralateral motor +/- sensory deficit

9

PACS

partial anterior circulation stroke

  • occlusion of MCA BRANCH
  • presentation 2/3
    • higher cerebral dysfunction
    • homonymous hemianopia
    • ipsilateral motor +/- sensory deficit
  • OR
    • higher cerebral dysfunction alone
    • or monoparesis

10

Monoparesis

Monoparesis muscle weakness that affects one limb, such as a leg or an arm. Paraparesis. Paraparesis is muscle weakness that affects both legs.

11

LACS

lacunar stroke

  • lenticulostriate arteries (off the mCA)
    • basal ganglia/pomns
  • presentation
    • pure motor or pure sensory
    • ataxic hempiparesis 

12

Hemiparesis

, or unilateral paresis, is weakness of one entire side of the body 

13

POCS

posterior circulation stroke

  • posterior vessel occlusion (PCA or branche sof basilar/vertebral)
  • presentation
    • cranial nerve paly
    • crossed signs
    • cerebellasr signs

14

NIHSS

National Institutes of Health Stroke Scale,

a tool used by healthcare providers to objectively quantify the impairment caused by a stroke.

15

maximum scofre on the NIHSS

42- severe stroke

16

CT used to exclude

haemorrhagic stroke (would show up as white - blood)

17

Ischaemic vis TIA vs versus ICH

 

  • Ischaemic and TIA (symptoms <24hrs) caused by blockage of coronary vessel
  • Intracranial haemorrhage caused by bleeding into the brain parenchyma

18

Summary of the Stroke Pathway

 

  • Time is brain!
  • CT needed urgently to rule out bleeding
  • Consider reperfusion therapy ASAP
  • Transfer straight to stroke unit for multidisciplinary specialist input
  • The acute hospital stay is only the beginning (for many patients)

19

Reperfusion

Opening up the blocked vessel in ischaemic stroke to reperfuse the ischaemic brain

  • Thrombolysis = clot busting
    • Alteplase
  • Thrombectomy = mechanically removed clot

20

thrombolysis 

tPA - alteplase activates plasminogen --> plasmin--> fibrin degradation 

21

indications for thrombolysis

  • Clinical diagnosis of acute ischaemic stroke causing one or more of an NIH score ≥ 4, aphasia, binocular visual field deficit, a swallowing deficit.
  • Imaging appearances consistent with ischaemic stroke
  • Symptom-onset within 4.5 hours prior to initiation of thrombolysis treatment
  • The old benefit as much as the young
  • No contraindications (think bleeding risk)
    • E.g. bleeding tendincies which could make them more likely to

22

thrombolysis continued

  • Opens up blocked vessels
  • Improves independence
  • Main complications- haemorrhage

     

    ONLY THROMBOLYSE WITHIN 4.5H- GIVE AS EARLY AS POSSIBLE- neurones are very vulnerable to ischaemia

23

Hyperacute care

 

 

  • Reperfusion
    • Thrombolysis
    • Thrombectomy
  • Prompt admission to stroke unit
  • Prompt secondary prevention
  • Early MD care
  • Maintaining homeostasis
    • Hydration
    • Nutrition
    • Oxygenation
    • Normoglycaemia
    • Preventing complications
    • Reperfusion
      • Thrombolysis
      • Thrombectomy
    • Prompt admission to stroke unit
    • Prompt secondary prevention
    • Early MD care
    • Maintaining homeostasis
      • Hydration
      • Nutrition
      • Oxygenation
      • Normoglycaemia
      • Preventing complications

24

Thrombectomy

 

  • Other way of opening up blood vessels
  • Mechanical

25

Acute ischaemic stroke- not all about tPA

 

Early secondary prevention works

  • Aspirin
  • Initiate statin
  • Control BP
  • Anticoagulated if in AF
    • Timing depends on stroke severity
    • DOAC now used 1st line
    • No role for antiplatelet
  • Carotid surgery

26

NO ROLE for ......... in stroke

antiplatelets 

27

What are Hyperacute Stroke Units (HASU)?

 

  • Dysphagia screening (nursing staff)
  • Monitoring of neurological status and GCS Cardiac monitoring
  • Early assessment by OT/Physio
  • Early mobilisation and discharge planning
  • SLT for detailed swallowing assessment and where communication is impaired
  • Continence assessment
  • Nurses: insert NG tubes and monitor
  • Dietitian: monitor intake, prescribe NG regimes
  • Emotional and psychological support and education (Stroke Association/ Neuro-psychology)

28

beneftis of stroke units versus conventional wards

29

Why do Stroke Units work?

 

  • Prevention of and early recognition and treatment of complications
  • Early initiation of secondary prevention strategies
  • MDT working
  • Co-ordinated and organised in-patient care with weekly MDT meetings
  • Programmes of education and training for staff, patients, carers
  • Involvement of carers in rehabilitation Staff interest and expertise

30

Acute management of intracerebral haemorrhage