Stroke Flashcards
(21 cards)
How classify stroke?
Oxford classification system
TACS - total anterior
PACS - partial
POCS - posterior
LACS - lacunar
What is more clinically relevant? - i.e. how differentiate artery affected
MCA
ACA
Posterior cerebral artery
What does PCA stand for?
MCA - face and arms more than legs, hemiparesis
ACA - legs > face, arms
PostCA - isolated homonymous hemianopia
Posterior communicating artery
Define stroke
Sudden neurological event of vascular origin, that does not include subarachnoid haemorrhage.
Deficit lasts >24h…
What proportion are haemorrhages?
How rule this out with imaging?
When is imaging essential?
1 in 6
CT head
Before thrombolytic or anticoagulant therapy
First step in management?
Wht Ix?
Look at hand out from study group!!!
ABCDE
Investigations -
B - urine dip (? glucose, infx), BM, ECG
B - CRP (vasc), FBC (hyperviscosity/plt), U+E, LFT, CSc (esp if on warfarin), Glucose, Lipids,
I - CT-head is key, + carotid doppler, echo,
O - EEG if epilepsy suspected
How do you manage stroke acutely?
Look at hand out from study group!!!
ABCDE
Investigations -
CT head to rule out haemorrhage (infarct only visible at 24h)
Stabilise glucose, don’t reduce BP
NBM until swallow assessed
Keep hydrated ? catheter
explain fully what has happened
Refer to Neuro Reg
What is the overall risk within a year of:
Recurrent stroke
Death
Dependency
Independent living
1 in 6
1 in 4
2 in 4
1 in 4
What are features of TACI?
At one year Mortality?
Chance of good recovery to indp living?
- Hemiparesis - contralateral, severe
- Homonymous hemianopia
- Higher cortical function defect e.g. Dysphasia, inattention, dyspraxia
60% mortality and 5% independent recovery
Features of PACI?
What is the significant risk?
2 out of 3 TACI
Usually: Higher cortical dysfunction + contralateral weakness or sensory loss
Incomplete deficit and risk of recurrence
3 main possibilities that would suggest POCI?
Risk of late recurrence?
What cranial nerve and weakness sign might be seen?
- Contralateral homonymous hemianopia OR
- Cerebellar signs OR
- Brainstem signs - Horner’s, conjugate gaze palsy, ipsilateral cranial nerve lesion with contralateral hemiparesis
What features are absent in a LACI?
- No higher cortical dysfunction
- No homonymous hemianopia
- No drowsiness
- No brainstorm signs
What lacunar syndromes are there? 4
- Pure motor (posterior limb internal capsule)
- Pure sensory (posterior thalamus)
- Sensorimotor (internal capsule)
- Dysarthria-clumsy hand
What are some medical complications of a stroke?
Pressure sores
Amongst others…
Aspiration pneumonia
VTE
recurrent ischaemic stroke
When assessing patient disability, what elements form part of the screen? (Think about stroke caused deficits)
- GCS
- swallow
- Speech and language
- Visual fields
- Gait
Post acute management? (4)
Reduce risk factors - e.g.
- Carotid artery disease >> stent or endarterectomy
- Drug prophylaxis - daily anti platelets e.g clopidogrel, aspirin, statin and ACEI +- thiazides (aim <130/80)
- If in AF – warfarin to INR 2-3, depending on chads score…
DC with community care - intermediate care team
GP follow-up
What are the indications for thrombolysis?
Acute ischaemic stroke. Benefit if given within 4.5 h (?3)
Main risk is haemorrhage
What are the major contraindications to thrombolysis ?
Haemorrhagic diathesis
Overt bleeding or haemorrhage on CT
Neoplasm with increased bleeding risk
Pregnancy
Oral anticoagulation (INR > 1.4)
Seizure at stroke onset
Systolic BP > 185 or Diastolic > 110 pre-treatment
how manage if present beyond 4.5 hours?
What else to manage?
Aspirin 300mg for 2 weeks, then clopidogrel 75mg thereafter
Hyperglycaemia - insulin may be required
Don’t manage BP unless symptomatic
Treat raised temp with paracetamol
Risk factors for stroke?
Non-modifiable - male, age, FH
CVD risk factor s- BP, Cholesterol, DM, previous MI
Embolus risk - AF, Valvular heart disease, Carotid stenosis
Clot risk - HRT, OCP
What scoring system used to assess risk of stroke following TIA?
ABCD2 - high risk if >6, ≥5 seen in TIA clinic; >1 episode in last week needs admission
- Age >60
- BP > 140/90
- Clinical features - 2 points for unilateral weakness, 1 point if just speech, 0 if other
- Duration >60 min is 2, 10-60 is 1
- Diabetes
What factors increase the risk of stroke in AF? (scoring system)
CHADS2 VASC
- > 2 needs oral anticoagulant*
- > 1 aspirin or oral anticoagulant*
Congestive heart failure
Hypertension
Age > 75 (2 points)
Diabetes
Stroke - Previous Stroke (2 points)
Vascular disease
Age 65-74
Sex (female)