STROKE 2

Question 1

Stroke is also referred to as cerebrovascular accident (CVA).

Cerebrovascular accidents are either 2 things …what?

Answer 1

• Ischaemia or infarction of brain tissue secondary to inadequate blood supply
• Intracranial haemorrhage

Question 2

what is a TIA?

crescendo TIA?

Answer 2

transient neurological dysfunction secondary to ischaemia without infarction that resolves within 24 hrs?

is where there are 2 or more TIAs within a week. This carries a high risk of developing in to a stroke.

Question 3

if theres a sudden onset of neurological symptoms what should u suspect as a cause?

Answer 3

vascular cause

Question 4

what are typical Stoke symptoms?

Answer 4

typically asymmetrical

1. Sudden weakness of limbs
2. Sudden facial weakness
3. Sudden onset dysphasia (speech disturbance)
4. Sudden onset visual or sensory loss

Question 5

what symptoms do ptx who’ve suffered haemorrhagic stroke are more likely to have vs ischemic?

Answer 5

1. decrease in the level of consciousness: seen in up to 50% of patients with a haemorrhagic stroke
2. headache is also much more common in haemorrhagic stroke
3. N & V is also common
4. seizures

Question 6

stroke mimics

Answer 6

BE HIM

Question 7

Oxford Stroke Classification

(also known as the Bamford Classification)

what 3 criteria should be assessed?

Answer 7

classifies strokes based on the initial symptoms

The following criteria should be assessed:

1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg (weakness)
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia

Question 8

Risk Factors

Answer 8

• Cardiovascular disease such as angina, myocardial infarction and peripheral vascular disease
• Previous stroke or TIA
• Atrial fibrillation
• Carotid artery disease
• Hypertension
• Diabetes
• Smoking
• Vasculitis
• Thrombophilia
• Combined contraceptive pill

Question 9

post-stroke complications:

Answer 9

PRISM R

1. Pain and fatigue Post-stroke
2. Recurrent stroke and extension of stroke
3. Infections > chest infection bc aspiration) UTI (bc incomplete bladder empty from constipation or bed bound
4. Spasticity, contractures & secondary epilepsy
5. Mood & cognitive dysfunction
6. Raised ICP

Question 10

What determines the recovery of the stroke?

Answer 10

due to loss of the ischaemic penumbra resulting from suboptimal physiology.

Question 11

Name 2 different types of tools used for stroke and what theyre used for?

Answer 11

FAST Tool for Identifying a Stroke in the Community

F – Face

A – Arm

S – Speech

T – Time (act fast and call 999)

ROSIER Tool for Recognition Of Stroke In Emergency Room

ROSIER is a clinical scoring tool based on clinical features and duration. Stroke is likely if the patient scores anything above 0.

Question 12

what is the ABCD₂ Score?

Answer 12

The ABCD2 score is used for assessing patients with a suspected TIA to estimate their risk of having a stoke.

The ABCD2 score is based on:

A – Age (> 60 = 1)

B – Blood pressure (> 140/90 = 1)

C – Clinical features (unilateral weakness = 2, dysphasia without weakness = 1)

D – Duration (> 60 = 2, 10 – 60 = 1, < 10 = 0)

D – Diabetes = 1

Question 13

what is the NIHSS

Answer 13

National Institutes of Health Stroke Scale

CALCULATES THE SEVERITY OF ISCHEMIC STROKE

It is a systematic neurological assessment for stroke which measures “neurological deficit”

• Score from 0 - 42

NICE: a score of more than 5 consider thrombectomy

Question 14

1st line investigation for stroke?

Answer 14

A non-contrast CT head scan–> exclude primary intracerebral haemorrhage

Question 15

Investigations of TIA

Answer 15

Carotid doppler uss

ECHO

CT OR MR ANGIOGRAPHY By specialist

Question 16

Management of TIA

Answer 16

• Start aspirin 300mg daily.
• Start 2ndry prevention measures for CVS disease.

If have crescendo TIAs –> should be seen w/in 24 hrs hours by a specialist.

• Perform an ABCD2 Score

≤ 3: specialist assessment within 1 week

> 3: specialist assessment within 24 hours

Question 17

Management of Stroke

Answer 17

1. Admit patients to a specialist stroke centre
2. Exclude hypoglycaemia and do ECG
3. Immediate Non-contrast CT brain to exclude primary intracerebral haemorrhage
4. Aspirin 300mg stat (after the CT) and continued for 2 weeks

Thrombolysis with alteplase w/in 4.5 hrs –> after CT scan has excluded an intracranial haemorrhage.

monitoring do repeat CT –> check post thrombolysis complications such as intracranial or systemic haemorrhage.

the ischemic Penumbra is targeted in thrombolysis

Question 18

Contraindications to thrombolysis

Answer 18

anticoagulation (INR >1.7)

Active bleeding (varices, ulcers)

Major surgery / trauma in the preceding 2 weeks

Uncontrolled hypertension >200/120mmHg

pregnancy

Question 19

Secondary Prevention of Stroke

when do u do endarterectomy?

Answer 19

SAC

anticoagulation is usualyy given cuz they have an AF

• after 2 weeks–> Clopidogrel 75mg once daily
• Atorvastatin 80mg should be started but not immediately
• Stenting or carotid endarterectomy in ptx w/ carotid artery disease

Treat modifiable risk factors such as hypertension and diabetes

⇒ if Stenosis is >70%

Question 20

what is the standard target time to offer thrombectomy

Answer 20

6 hrs!

ECEPTION CAN BE EXTENDED TO 6- 24hrs–> For PROXIMAL ANTERIOR CIRCULATION

if there is a potential to save brain tissue shown by CT perfusion or diffusion-weighted MRI showing not limited infarct core volume

(only “proximal” cuz its easier acces to put stent)

Question 21

if ptx cannot tolerate Clopidegrol or is allergic what do u give?

Answer 21

modified-release (MR) + aspirin

dipyridamole 200mg x2 daily

Question 22

who is involved in the Stroke Rehabilitation

Answer 22

MDT

• Nurses
• Speech and language (SALT)
• Nutrition and dietetics
• Physiotherapy
• Occupational therapy
• Social services
• Optometry and ophthalmology
• Psychology
• Orthotics

Question 23

Follow up post stroke/TIA?

Answer 23

1. Arrange follow up in primary care on discharge at 6 months
2. Then annually to review health & social care needs

Question 24

Name 6 non medical modification or advice you would give to somone who had a stroke?

Answer 24

1. Patient information is available from the Stroke Association.
2. Provide advice about driving if appropriate.
3. Provide advice about returning to work if appropriate.
4. Encourage physical activity every day
5. Stop smoking
6. Diet
7. Disability is most commonly measured using the Barthel index (BI), an outcome measure for stroke

Question 25

when to treat BP in acute ischemic stroke

Answer 25

* BP \> 185/110 or * hypertensive encepahlopathy, nephropathy, MI,AD * pre eclampsia/ eclampsia ## Footnote *because lowering blood pressure too much can potentially compromise collateral blood flow to the affected region, and possibly hasten the time to complete and irreversible tissue infarction*

Question 26

Malignant MCA

Answer 26

term used to describe **rapid neurological deterioration** due to the effects of SO cerebral oedema after a (MCA) territory stroke.

Question 27

Modified Rankin Scale & TOAST classification

Answer 27

RANKIN: measure of **global disability** used to assess baseline function and evaluate outcomes and Tx impact after interventions. TOAST: classification denotes **five subtypes of ischemic stroke** 1. large-artery atherosclerosis, 2. cardioembolism 3. small-vessel occlusion 4. stroke of other determined etiology 5. stroke of undetermined etiology.