Stroke

Question 1

what is a stroke?

Answer 1

rapidly developing clinical symptoms and/or signs of focal and at times global loss of brain function with symptoms lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin

Question 2

key features?

Answer 2

rapid (few mins-hours)
focal (can identify lesion in part of brain causing symptoms)
loss of brain function (visual, speech, movement issues, not pain)
vascular

Question 3

how common are stroke mimics?

Answer 3

1/3 of all stroke presentations

Question 4

what can mimic stroke?

Answer 4

seizures
sepsis
toxic/metabolic (glucose etc)
SOL (space occupying lesions)
syncope/pre-syncope
acute confusion/delirium
vestibular dysfunction
functional (neurological with no real pathological cause)
dementia

Question 5

what is the rosier score?

Answer 5

recognition of stroke in the emergency room
-1 point each for 
- loss of consciousness or syncope
- seizure activity
\+1 point each for
- asymmetrical facial weakness
- asymmetrical arm weakness
- asymmetrical leg weakness
- speech disturbance
- visual field defect
score >0 = likely stroke

Question 6

what is the FAST score?

Answer 6

aimed at public
Face
Arms
Speech
Time

Question 7

Is stroke a diagnosis?

Answer 7

no

experience of persisting neurological complications of cardio disease

Question 8

what are the 3 types of stroke?

Answer 8

haemorrhagic
subarachnoid haemorrhage
infarct

Question 9

types of haemorrhagic stroke?

Answer 9

structural abnormality (poor quality vessels)
hypertensive
amyloid angiopathy

Question 10

types of infarct stroke?

Answer 10

artheroembolic (same process as MI - plaque disease)
small vessels (damage to small vessels over time - hypertension, diabetes etc - cause clots to form and small vessels occlude easily)
cardioembolic (AF causing clots)

Question 11

how can you tell between infarct and haemorrhage stroke clinically?

Answer 11

no real way until imaging

Question 12

stroke imaging?

Answer 12

CT (quicker and sensitive to picking up blood)

Question 13

how does haemorrhage appear in the brain on imaging?

Answer 13

white areas of blood

iron in blood absorbs X rays

Question 14

how does an infarct stroke show on CT?

Answer 14

mushy, blurry, darker shadowy area of the brain
(increase in oedema and fluid caused by the inflammatory response to the necrosis of tissue after infarct appears darker)

Question 15

infarct stroke may be missed initially on CT, why is this?

Answer 15

takes time for oedema etc to develop so CT can be clear if done very quickly

Question 16

what is used if CT is clear but infarct stroke still suspected?

Answer 16

MRI
shows diffusion weighted abnormality (abnormalities of fluid and ion flow)
infarct shows as a white area or black area depending on type of MRI

Question 17

how may a haemorrhagic stroke appear on CT after 2-3 weeks?

Answer 17

darker, almost like an infarct as blood has disappeared but damage is seen

Question 18

what is done if imaging is performed weeks after symptoms?

Answer 18

MRI instead of CT

Question 19

acute management of stroke?

Answer 19

thrombolysis/thrombectomy
imaging
swallow assessment (risk of aspiration pneumonia after stroke)
nutrition and hydration
antiplatelets
stroke unit care
DVT prevention

Question 20

how quickly is brain damaged in stroke?

Answer 20

230 million synapses lost per second

14 billion per min

Question 21

how can stroke damage differ in people?

Answer 21

some people have more of a collateral blood supply to the brain so can cope better and for longer with an occlusion

Question 22

what is used in thrombolysis?

Answer 22

inject artificial TPA which breaks down clots

Question 23

what is taken into account when deciding whether to thrombolyse?

Answer 23

age
time since onset (quicker = better benefit)
previous intracerebral haemorrhage or infarct (more risk of bleed)
atrophic changes (bleeding risk)
BP (bleeding risk, >185 = contraindication)
diabetes
potential benefit (possible QoL after)

Question 24

at what time after symptoms onset does thrombolysis stop being beneficial?

Answer 24

around 5 hours

don’t really thrombolyse after 4.5 hours

Question 25

why is imaging always performed before thrombolysis?

Answer 25

incase its haemorrhagic | establishes diagnosis

Question 26

what else might indicate infarct on CT?

Answer 26

hyperdense middle cerebral artery sign | single, asymmetrical which spot/blood vessels showing the clot

Question 27

what types of clots are less likely to benefit from iv tPA? what is done in this case?

Answer 27

large and proximal clots endovascular therapy, interventional radiology - put wire in through the vessel and through to other side of clot, open stent and then pull the clot out

Question 28

which is more successful, thrombolysis or endovascular therapy?

Answer 28

``` endovascular therapy (thrombectomy) not currently available in Scotland yet ```

Question 29

how effective is the stroke unit care?

Answer 29

1 extra survivor for every 33 people in the unit | 1 person sent home for every 20

Question 30

important immediate therapy for infarct?

Answer 30

300mg aspirin ASAP to reduce risk of further infarct (don't give for 24 hours after thrombolysis) CT first to exclude bleed 300mg aspirin for 2 weeks after

Question 31

how is DVT prophylaxis delivered after stroke?

Answer 31

heparin (including LMWH) causes a bleeding risk TED stockings don't make a difference best = intermittent pneumatic compression (stockings with pumps)

Question 32

how is dysphagia managed?

Answer 32

initial swallow screen assess by speech and language therapist if abnormal may need NG tube or textured diet and thickened fluids depending on swallow

Question 33

what is a TIA?

Answer 33

transient ischaemia attack same process as stroke but shorter symptoms technically should be under 24 hours

Question 34

is TIA safe?

Answer 34

no | still causes brain damage and risk of further stroke (almost the same risk as a minor stroke)

Question 35

what is involved in the rapid access neurovascular TIA clinic?

Answer 35

``` rapid assessment - history - carotid imaging - ECG - blood tests diagnosis - immediate therapy - medication, carotid endarterectomy hugely decreases risk of further stroke after TIA ```

Question 36

how can further stroke be prevented after TIA?

Answer 36

rapid access clinic any statin any antiplatelet (or dual antiplatelet - aspirin + clopidogrel)

Question 37

ABCD2?

Answer 37

risk assessment for recurrent TIA

Question 38

how is haemorrhagic stroke managed?

Answer 38

aggressive BP control (IV treatment if seen <6 hours) stop any anticoagulant or reverse anticoagulation - can give vit K if on warfarin