Stroke and TIA - Acute investigation and Management Flashcards
(38 cards)
If someone presented with clinical features suggestive of a stroke, what would you do?
- ABCDE
- History - Exact onset, changes/progression, Risk factors
- Examination - full neuro exam, systemic and risk fcator exam
- CT - within 1 hour presentation
When would you treat hypertension in someone presenting with a stroke?
- Hypertensive emergency (encephalopathy/aortic dissection)
- If thrombolysis is being considered
How long after presentation with symptos of a stroke should someone get a CT head?
Within 1 hour
When is CT/MRI within the first hour of presentation with stroke sypmtoms essential?
- If thrombolysis considered
- High risk of haemorrhage
- Unusual presentation - fluctuating consciousness
What is the most sensitive imaging modality for detecting acute infarction?
Diffusion-weighted MRI
What happens at a cellular level when cerebral infarction occurs?
Hypoxic damage:
-
Na+/K+ pump Fails -> Na+ accumulates in the cell -> osmotic shift into cell -> cellular swelling
- Cells in the immediate area around the infarct die very quickly, as they swell and burst. Cells in “penumbra” are relatively less oematous, and can be “saved”
-
Excitotoxicity - Damage as a result of prolonged depolarisation of cells in affected area
- Results in failure of AMPA and NMDA receptors - allows excessive calcium into the cell. This causes release of free radicals, production of cytokines, and direct apoptotic effects in the penumbra
What specific things might you look for on examination in someone presenting with features of a stroke?
- Thorough, full neruo exam - clinical diagnosis and lesion localisation
- Pulse (AF)
- Heart sounds (valve disorders)
- Carotid Bruit
- Signs of PVD
- Bruising/Bleeding
- Xanthalasma/Xanthoma/Corneal arcus
- Tar Staining
When would you consider thromblysis in someone presented with a stroke?
Once haemorrhage has been excluded as cause, and within 4.5 hour window of onset (benefits outweigh risks within this window)
Within what time frame are the best results achieved using thrombolysis?
Within 90 minutes of onset
What thrombolytic agent is most commonly used in stroke management?
Alteplase
What are contraindications to thrombolysis in a stroke?
Look them up - Impossible to remember all of them!!! - think of categories of contraindications
- Stroke related
- Neurological
- Bleeding tendency
- Trauma
- Medical problems
What are stroke related contraindications to thrombolysis
- Rapidy improving symptoms
- Ischaemia of >1/3 MCA territory
- Symptoms suggestive of SAH
- Seizure at start of stroke
What are neurological contraindications to thrombolysis?
History of intracrnal bleed, aneurysm or neoplasma
Spinal or cranial surgery/injury
What bleeding tendency risk factors are contraindicaitons to thrombolysis?
- Significant bleeding disorder
- Therapeutic anticoagulation - LMWH, DOACs, Warfarin
- Iron deficiency anaemia
- Thrombocytopenia
- Advanced liver disease
What are trauma related contraindications to thrombolysis in stroke?
- Significant head injury <3 months
- Major surgery/delivery/external heart massage <2 weeks
- Puncture of non-compressible blood vessel <2 weeks
What medical problems are contraindications for thrombolysis in stroke?
- SBP > 180/DBP >110
- Active internal bleeding
- Aortic aneurysm
- Bacterial endocarditis/pericarditis
- Acute pancreatitis
- Haemorrhagic retinopathy
- Oesophageal varices
- Ulceratie GI disease <3 months
- GI/GU haemorrhage < 3 weeks
If thrombolysis was contraindicated, what treatment would you start someone on for acute treatment of a stroke?
Aspirin PO/PR OD for 2 weeks
Why does diffusion weighted MRI detect early abnormalities seen in infarction better than normal MRI or CT?
This type of MRI exploits the fact that damaged cells fill with water – and thus contain more water than normal cells in the early stages of damage.
What intial investigations would you consider doing in someone presenting with a stroke?
- CT/MRI - within 1 hour
- MRI angiography
- ECG
- CXR
- Bloods - ESR, FBC, clotting screen, glucose, Lipids/cholesterol
Why might you do an ESR on someone presenting with features of a stroke?
If with headache and tender scalp - Giant cell arteritis
Why might you do FBC or clotting in someone presenting with a stroke?
Look for evidence of clotting/bleeding disorders - thrombocytopenia, polycythaemia
What would you want to prioritise in your ABCDE assessment in someone presenting with a stroke?
- Maintain airway
- Prevent hypoxia
- Hydrate
- Treat fever / source of fever – this can help to limit the extent of damage
- Treat hypo / hyperglycaemia
What dose of aspirin would you give someone if thrombolysis was contraindicated?
300 mg
How long would you put someone on aspirin treatment for following a stroke?
2 weeks
