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Alasdair - Neurology > Stroke > Flashcards

Flashcards in Stroke Deck (20):
1

Definition of stroke

Rapid onset neurological deficit of vascular origin lasting >24h

2

Pathogenesis of stroke

80% ischaemic: atheroma or embolism (cardiac or atherothromboembolism)
20% hamorrhagic

3

Classification system for strokes

Bamford classification AKA Oxford Stroke classification:
TACS (total anterior circulation stroke) - carotid/MCA/ACA
PACS (partial anterior circulation stroke) - carotid/MCA/ACA
POCS (posterior circulation syndrome) - vertebrobasilar
LACS (lacunar syndrome) - infarct around basal ganglia/internal capsule/thalamus/pons

4

Features of TACS stroke

Carotid/MCA/ACA territory.
1. Hemiparesis and/or hemisensory deficit.
2. Homonymous hemianopia.
3. Higher cortical dysfunction: dominant side - aphasia, non-dominant - neglect, apraxia.

5

Features of PACS stroke

2 out of 3 of TACS features, usually: homonymous hemianopia + higher cortical dysfunction.

6

Features of POCS stroke

Vertebrobasilar territory.
Any of:
1. Cerebellar syndrome
2. Brainstem syndrome
3. Homonymous hemianopia.

7

Features of LACS stroke

Pure motor: posterior limb of internal capsule
Pure sensory: posterior thalamus (VPL)
Mixed sensorimotor: internal capsule
Dysarthria/clumsy hand
Ataxic hemiparesis: posterior limb of internal capsule

8

Differential for acute stroke

Head injury
High or low glucose
SOL
Infection
Drugs e.g. opiate OD

9

Acute management of stroke

1. Resuscitate:
Airway - consider NGT. NBM until assessed by SALT. Don't over hydrate - risk of cerebral oedema. BM to exclude hypoglycaemia.
2. Monitor: glucose 4-11mM (sliding scale if DM). BP: Rx of HTN can decrease cerebral perfusion. Neuro obs.
3. Bloods
4. Imaging
5. Medical:
Aspirin 300mg PO/PR once haemorrhage stroke excluded by CT, then continue 75mg OD indefinitely, + clopidogrel 75mg OD, ± PPI.
Thrombolysis with alteplase if within 4.5h and haemorrhage excluded. Pause antiplatelets. Re-image 24h afterwards to check for haemorrhage.

10

Blood tests in acute stroke

FBC: infection. sepsis may cause stroke.
U+E: electrolyte disturbance may mimic stroke.
Glucose: exclude hypoglycaemia.
Clotting: high or low INR may indicate cause.

11

Imaging in acute stroke

Urgent CT/MRI
Diffusion-weighted MRI is most sensitive for acute infarct
CT will exclude primary haemorrhage

12

Surgical tx in acute stroke

Neurosurgical opinion if intracranial haemorrhage
May coil bleeding aneurysms
Decompressive hemicraniotomy for some forms of MCA infarction

13

Main functions of a stroke unit

Specialist nursing and physiology
Early mobilisation
DVT prophylaxis

14

Post-acute management of stroke

Secondary prevention
Rehabilitation

15

Non-acute stroke work-up investigations

ECG ± 24h tape: arrhythmia, old ischaemia.
Bloods: FBC (high or low Hb), U+E (association with renovascular disease), glucose (exclude DM), lipids (CV risk), clotting and thrombophilia screen, vasculitis (ESR, ANA),
Imaging: CXR (cardiomegaly, aspiration), carotid doppler, echo (mural thrombus, RWMA, ASD/VSD (paradoxical emboli)).

16

Components of a thrombophilia screen

FBC, clotting, fibrinogen concentration.
APC resistance AKA factor V Leiden.
Lupus anticoagulant.
Anti-cardiolipin antibodies.
Assays for protein C and S and AT3 activity.
PCR for prothrombin gene mutation.

17

Secondary prevention of stroke

AABCDEE
Antiaggregants and anticoagulants.
Blood pressure drugs.
Cigarette smoking cessation.
Diet
Exercise
Endarterectomy of carotids if stable and stenosis >50%.

18

Rehabilitation after stroke

MENDS
MDT
Eating: screen swallowing and screen malnutrition (MUST tool). NG/PEG and nutritional supplements as needed.
Neurorehab: physiology and speech therapy. Botulinum for spasticity.
DVT prophylaxis.
Sores must be avoided.

19

Tool for assessing malnutrition

MUST tool (malnutrition universal screening tool)

20

Prognosis for stroke @ 1 year

10% recurrence
PACS: 20% mortality, 1/3 survivors independent.
TACS much worse: 60% mortality, 5% independent.