Stroke

Question 1

what is the WHO defintion of a stroke?

Answer 1

rapidly developing clinical signs of disturbance of cerebral function lasting for more than 24 hours (or leading to death) with no apparent cause other than that of vascular origin

Question 2

what are the 2 types of stroke?

Answer 2

• Ischaemic stroke

* Haemorrhagic stroke

Question 3

what is an ischaemic stroke?

Answer 3

– 70% strokes
– Cerebral thrombosis from atherosclerotic disease
– Distal embolism from cardioembolic disease

Question 4

what is a haemorrhagic stroke/

Answer 4

– Intracerebral haemorrhage (rupture of small vessel in brain)
– Subarachnoid haemorrhage (rupture of intracranial aneurism in the subarachnoid space)

Question 5

what are the symptoms of a stroke?

Answer 5

F acial weakness: can the person smile? Has their mouth or eye drooped?
A rm (or leg) weakness: Can the person raise both arms (or legs)?
S peech: Can the person speak clearly and can you understand what they say?
T ime: to call 999
• A stroke is suspected if ANY of these symptoms are displayed
• Also ROSIER (recognition of stroke in emergency room) scale used

Question 6

what are the non-modifable risk factors of a stroke?

Answer 6

age - risk doubles every decade over 55
gender - men are at higher risk but more women die
- family history
- afro-caribbean

Question 7

what are the modifable risk factors of a stroke?

Answer 7

• hyper tension
• atrial fib
• diabetes
• hyperlipidaemia
• smoking

Question 8

what investigations need to be carried out?

Answer 8

• CT quickly
• MR scan
• BP
• ECG
• FBC
• Blood Glucose
• inflammatory markers

Question 9

what would you see in a CT scan of a ischaemic stroke?

Answer 9

demarcated hypodense zone (although often difficult to spot)

Question 10

what would you see in a CT scan of a haemorrhagic stroke?

Answer 10

haemorrhage clearly visible – areas of high attenuation (appear bright)

Question 11

what are the acute treatments of a stroke?

Answer 11

• Patients should be transferred to a hyper-acute stroke unit as soon as possible
• Investigations performed to confirm diagnosis

Question 12

why do you need to know what type of stroke it is?

Answer 12

– One is a blockage  give anticoagulants

– One is a bleed  this would kill them if you gave anticoagulants

Question 13

what is thrombus management?

Answer 13

the window for treating a stork if smaller, the longer you wait the less likely it is to be effective.
if you wait TOO long you are likely to have another bleed on top of it

Question 14

what is thrombolysis?

Answer 14

clot busting drug to try and break the clot and allow oxygen to get round to parts of the brain which will have been damaged
- ALTEPLASE

Question 15

when is Alteplase needed to be given?

Answer 15

• Give within 3 hours of symptom onset – very first time tingling/speech issues you have 3 hours to get to hospital and get a CT scan.
– (licensed up to 4.5 hours, but efficacy drops off massively during this; much safer the more under 80s safer, as over this the risk of bleeding is much higher and need to check that this is still eligible)
– But twice as effective if given before 1.5 hours

it is the gold standard if given within the correct time scale

Question 16

what is thrombectomy?

Answer 16

procedure to remove the clot with or without thrombolysis

- but needs to be done fairly quickly

Question 17

what antiplatement should you give to an ischaemic stroke?

Answer 17

Aspirin 300mg
• Give as soon as possible (once bleed ruled out), even without a Rx as soon as the risk of bleeding has gone
• Give PR or via NG tube if necessary – dispersible aspirin can be given or given rectually
• Continue for (up to) 14 days not just a stat dose
– This depends on if they are ready to go home, we may change there treatments for long term secondary prevention, also AF needs a different set up

Question 18

what happens if a patient has been thrombolysed?

Answer 18

NEED TO WAIT 24 HOURS BEFORE GIVING AN ANTIPLATELET

- this increases risk of bleeding if you give them together

Question 19

what is acute treatment of a haemorrhagic stroke?

Answer 19

• Stop anything that will be making the bleed worse
– Anticoagulants – reverse them. So if they are on warfarin give them Vitamin K or transfusion of a prothrombin complex
• Neurosurgical intervention sometimes necessary
– Operate and stent that part of the brain and stop the bleed
• Anticoagulants stopped plus reversed if INR >1.4
– Vitamin K
• Prothrombin complex concentrate

Question 20

how do you control blood pressure?

Answer 20

• Fluctuating BP (esp high BP) common after acute stroke

* When you have a stroke the body increases blood pressure to try and increase oxygen to the brain. NORMAL response

Question 21

what is the treatment of Blood pressure for an ischaemic stroke?

Answer 21

• Only manage high BP if hypertensive emergency with complications of hypertension (e.g. MI) or if patient is eligible for thrombolysis
• Less than 185/110 mmHg required for thrombolysis if you are within the 3 hour window and this is the only reason you would treat the high blood pressure
• If hypertensive emergency  heart attack you would reduce blood pressure as you don’t want any further complications

Question 22

what is the treatment of high blood pressure for a haemorrhagic stroke?

Answer 22

• Treat if greater than 150mmHg systolic (up to 6 hours after symptom onset) or if greater than 220mmHg systolic beyond 6 hours. Aim for 130 - 140mmHg systolic for at least 7 days. This would increase risk of bleed becoming uncontrolled if you did not treat.

Question 23

what are general measure you need to bare in mind post stroke?

Answer 23

• ability to swallow
• ensure fluid balance
• monitor temp
• control blood glucose
• DVT prophylaxis

Question 24

why do you need to monitor blood glucose levels?

Answer 24

– If it falls within the diabetic range then you need to treat this – finger prick test every few hours
– Patients with metformin chances are it will be stopped and just keep the glucose levels very steady by giving iv insulin

Question 25

how do do DVT prophylaxis?

Answer 25

– LMWH NOT routinely used (risk of bleed)
– Anti-embolism stockings NOT used
– Intermittent pneumatic compression should be used if patient is immobile – ballons around calves that inflate and deflate

Question 26

what is secondary prevention for a stroke?

Answer 26

– Antiplatelet (or anticoagulant in embolic stroke) –clopidogrel 1st line
– If patient has had an ishaemic stroke but also has AF, then the AF puts them at higher risk so we would give them an anticoagulant INSTEAD of an antiplatelet
• NOT in haemorrhagic stroke
– Lower cholesterol (ischaemic) slow the disease process down, doesn’t matter what there cholesterol was
– Control hypertension
– Control blood glucose

Question 27

what would you give as long term antiplatelet?

Answer 27

– Clopidogrel, better then just low dose aspirin
– Aspirin plus MR dipyridamole if clopidogrel not tolerated
– MR dipyridamole if aspirin and clopidogrel not tolerated

Question 28

what would you give as an anticoagulant?

Answer 28

– in AF if CHA2DS2-VASC score of 2 or 1 if they are a man they need to be a anticoagulated
– Warfarin or DOAC (apixaban, rivaroxaban, dabigatran)
– Usually most patients DOAC the benefits outweigh the risks so you would use that first line but some patients warfarin may be the better choice (can be reversed with vitamin K, so this might be better for patients who are more at risk of bleeding)
– Need regular blood tests on warfarin – elderly usually prefer this

Question 29

what would you give as antihypertensive?

Answer 29

– Reduce risk of further ischaemic / haemorrhagic stroke in both hypertensive and previously normotensive patients
– Start after 2 weeks or sooner if discharged from hospital
– Follow NICE guidance for hypertension
• Aim for BP less than 130mmHg systolic

Question 30

what would you give as a statin?

Answer 30

atorvastatin
– Lipid lowering reduces risk of ischaemic stroke
• High intensity statin e.g. atorvastatin 20 – 80mg
– Avoid in haemorrhagic stroke unless patient has CV risk requiring treatment

Question 31

what would you do for swallowing difficulties?

Answer 31

– NG / PEG feeding may be needed
– Thickened fluids and / or puree diet (SALT)
– Review all medication
– Necessary medication in appropriate formulation

Question 32

what would you give a patient for dry mouth?

Answer 32

– Artificial saliva and good oral hygiene / mouthcare

Question 33

what would you give for sialorrhoea?

Answer 33

this is excessive salvia production

– Oral glycopyrronium / atropine eye drops (in mouth) / hyoscine patch – these are for excessive salvia production

Question 34

what do you do for patients if they have depression?

Answer 34

– Screen all patients for depression (30% experience)

– Treat as per NICE (i.e. SSRI first line)

Question 35

what happens if a patient has seizures?

Answer 35

– Common problem (up to 67% late onset seizures post ischaemic stroke)
– Give prophylactic antiepileptic drugs if recurrent seizures diagnosed as epilepsy
– As per epliepsy lecture

Question 36

what do you give for a patient who is struggling with spasticity?

Answer 36

– Skeletal muscle relaxants – baclofen, tizanidine

– Botulinum toxin recommended by RCP stroke guidelines