What is an ischaemic stroke
A clot blocks blood flow to an area of the brain
Ischaemia is reversible, infarction is not
What are the stages of infarction in stroke
Hyperacute (0 - 6 hours)
Acute (up to 7 days)
Subacute (up to 4 months)
Chronic (beyond 4 months)
How are hyperacute infarctions managed
IV thrombolysis (alteplase)
Do not give thrombolysis until haemorrhagic stroke has been excluded
Why is it important to get an uninhanced CT for suspected strokes
Highly sensitive for haemorrhage
See signs of stroke mimics
What are the early signs of infarction in CT
Hypoattenuation
Sulcal effacement
Obscuration and loss of grey matter
What is meant by potentially salvageable brain
Infract core area minus ischaemic penumbra
Thrombolysis only benefits ischaemic penumbra (no penumbra = no benefit)
Thrombolysis in large cores increases risk of secondary haemorrhage
What is catheter-guided intervention in strokes
Used to physically remove clots
What is haemorrhagic stroke
Bleeding inside or around brain tissue
What are the primary causes of haemorrhagic stroke
Hypertension
Cerebral amyloid angiopathy
What are the secondary causes of haemorrhagic stroke
Haemorrhagic transformation infarct
Tumours
Aneurysms
Vasculitis
Coagulopathies
Warfarin, aspirin
Cocaine, alcohol
What causes neurological deficits up to 72 hours after a haemorrhagic stroke
Continued bleeding
Oedema, brain swelling, mass effect
Raised intracranial pressure
What are the predictors of poor outcome for haemorrhagic stroke
Radiological signs (> 30 mls, intraventricular component, deep location, brainstem)
Clinical factors (>80, GCS < 9)
What is the management for haemorrhagic stroke
Neurosurgery
Clot reduction, decompression craniotomy
Intraventricular shunting for hydrocephalus
What are the causes of anticoagulant haemorrhagic strokes
Heparin
Warfarin
Thrombolysis
Antiplatelets
Alcohol abuse
Chemotherapy
Coagulopathies
Give an overview of extradural haemorrhages
Young men
Acute presentation
90% have skull fracture
Biconcave, hyperdense
Limited by sutures
Blood between bone and meningeal dura
Bleeding from meningeal vessels or dural sinus
Give an overview of subarachnoid haemorrhages
Bleeding into subdural space
Bloods spreads around brain
Convex
Bleeding from torn bridging veins or lacerations
At extremes of age (elderly have atrophy, children have interhemispheric fissure)
Crescent shape
Not hyper-dense
What are the elements of post-stroke secondary prevention
Lifestyle modification (smoking cessation, healthy weight, decrease alcohol, aerobic exercise)
Antithrombotic therapy (clopidogrel, aspirin, anticoagulate AF (warfarin, DOACs))
Risk factor modification
Address specific causes
What are the 5 Rs of rehabilitation
Realisation of potential
Reablement
Resettlement
Role fulfilment
Readjustment
What is early supported discharge
Hospital level of therapy at home
Reduces average stay by 8 days
What is the rehab transfer criteria
Medically stable
Need no more than 24% oxygen
NG established with no risk of refeeding
Consultant review twice per week
What are the positive prognostic factors in stroke rehabilitation
Absence of coma
Early motor recovery
Continence
What are the poor prognostic factors in stroke rehabilitation
Severe communication deficit
Old age
Incontinence
Neglect
No leg movements at 2 weeks
Severe upper limb weakness at 4 weeks
What are the main problems during rehab
Aphasia and dysarthria
Impaired swallowing
Malnutrition
Impaired balance and walking
Fatigue
Incontinence
Spasticity and contractures
Altered sensation
Mouth care
Cognitive impairment
Anxiety and depression
Neuropathic pain
What are the non-pharmacological management strategies for incontinence
Timed toileting
Review caffeine intake
Medications review
Bladder retraining
Pelvic floor exercises
Minimise constipating drugs
Oral laxatives
