Flashcards in Neuro - Stroke/TIA Deck (17)
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1
As a quick exam to check for stroke/TIA, what (2) do you get patients to do?
Facial Droop: Have Patient Smile
Arm Drift: Close Eyes & Hold Out Both Arms
2
Emergency Rx for stroke (Code Stroke)
1. Urgent triage and high priority for stroke patient
2. Mobilise the stroke team
3. IV - glucose, routine biochemistry, FBE
4. ECG
5. Accurate clinical diagnosis – exclude mimics 6. Urgent CT
3
(4) Clinical features that help predict stroke
• exact time of onset
• patient could recall exactly what they were doing at symptom onset
• well in the last week
• definite focal symptoms or signs, worse NIHSS
4
(5) clinical features that help predict mimics of stroke
• known cognitive impairment
• lost consciousness or seizure at onset
• patient could still walk
• no lateralising symptoms
• confusion, non-vascular or no neurological signs
5
3 major stroke types
• Ischemic stroke (cerebral infarction)
• Intracerebral hemorrhage (ICH)
• Subarachnoid hemorrhage (SAH)
6
5 subtypes of ischaemic stroke
1. Large artery thromboembolism
2. Cardiogenic embolism (e.g. AF)
3. Small vessel (lacunar) infarction
4. Rarer causes
5. Unclassified or cryptogenic
7
2 subtypes of intracerebral haemorrhage
1. Deep hypertensive location
2. Lobar
8
3 subtypes of subarachnoid haemorrhage
1. Aneurysm
2. Arteriovenous malformation
3. Other
9
(4) Areas commonly affected in deep ICH
Putamen, thalamus, brainstem, cerebellum
• Usually due to hypertension and rupture of deep penetrating arteries
10
General area commonly affected in lobar ICH
- Causes?
Superficial
• Often secondary to amyloid angiopathy, tumour, arteriovenous malformation, aneurysm
11
Describe primary prevention of stroke
In those who have never had strokes before
• Main modifiable risk factors are smoking, hypertension, diabetes and obesity
• Encourage smoking cessation, weight loss, increased physical activity and a healthy diet
• Antihypertensive drugs reduce the risk of primary stroke by up to 40%
• There is NO clear indication for antiplatelet treatment in low risk, or intermediate risk (uncomplicated diabetes, hypertension or hypercholestrolaemia) of stroke
• In high risk of cardiovascular disease consider aspirin
12
What is dabigatran?
A Direct Thrombin Inhibitor (NOAC)
13
What is Rivaroxaban?
Factor Xa Inhibitors (NOAC)
14
What is Apixaban?
Factor Xa Inhibitors (NOAC)
15
How do you assess stroke risk in non-valvular AF?
CHADS2 score
(score 1 for each risk factor of heart failure, hypertension, age >75, and diabetes, score 2 for previous stroke of TIA).
• If score zero, can undertake a more comprehensive risk assessment e.g. VASc
• CHADS2 score of one or more recommends an oral anticoagulant
• Oral anticoagulants reduce the risk of stroke by about 60% in people with AF
16
Describe secondary prevention of stroke
In those who have had a previous stroke
• Blood pressure lowering
• Cholesterol and statins
• Antiplatelet therapy – which strategy?
• Atrial fibrillation and anticoagulation
• Carotid revascularization endarterectomy and stenting
Lowering blood pressure and cholesterol at any level equally effective in secondary stroke prevention
High-risk patients benefit from BP, cholesterol lowering regardless of baseline
Antiplatelet therapy routine if patient not anticoagulated
17
