stroke

Question 1

define stroke

Answer 1

clinical syndrome of presumed vascular origin characterised by rapidly developing signs of focal or global disturbance of cerebral functions which lasts longer than 24h or leads to death

Question 2

define TIA

Answer 2

transient (less than 24h) neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia, without evidence of acute infarction

Question 3

complications of stroke include

Answer 3

• neurological problems
• depression
• anxiety
• communication difficulties
• difficulties with activities of daily living

Question 4

once a person has had a stroke or TIA, they are at high risk of…

Answer 4

further vascular event(s)

Question 5

main differences between stroke and TIA

Answer 5

• TIA is caused by a temporary disruption in blood supply to the brain
• TIA does not last as long as a stroke, the effects last a few minutes to a few hours and fully resolve within 24h

Question 6

when to suspect TIA

Answer 6

• pt presents with sudden onset focal neurological deficit which has completely resolved within 24h onset
• most are thought to resolve within 1 hour, but can persist for up to 24h

Question 7

focal neurological deficits in TIA may include

Answer 7

• unilateral weakness or sensory loss
• dysphasia
• ataxia, vertigo, loss of balance
• syncope
• sudden transient loss of vision in one eye, diplopia (double vision), homonymous hemianopsia (loss of vision in the same halves of both eye)
• cranial nerve defects - pain, tingling, numbness, weakness, paralysis of face including eyes

Question 8

when to suspect stroke

Answer 8

• pt presents with sudden onset focal neurological deficits which are ongoing or have persisted for >24h and cannot be explained by other conditions e.g. hypoglycaemia

Question 9

clinical features of stroke vary depending on…

Answer 9

causative mechanism and area of brain affected

Question 10

list some clinical features of stroke

Answer 10

• confused, altered consciousness, coma
• unilateral weakness or paralysis in face, arm or leg
• sensory less - paraesthesia or numbness
• ataxia
• dysphasia
• visual disturbances
• gaze paresis, often hroiznonal and unidriectionla
• photophobia
• dizziness, vertiamo loss of balance
• specific cranial nerve deficits
• difficulty with fine motor coordination and gait
• neck or facial pain

Question 11

describe a headache in different types of stoke

Answer 11

• intracranial haemorrhage: usually insidious in onset and gradually increasing intensity
• subarachnoid haemorrhage: sudden severe headache which may be associated with neck stiffness
• sentinel headaches may occur in preceding weeks

Question 12

what is gaze paresis

Answer 12

inability to move both eyes together in a single horizontal (most common) or vertical direction

Question 13

what is diplopia

Answer 13

double vision

Question 14

isolated dizziness is usually a symptom of TIA - true or false

Answer 14

false

Question 15

state some specific cranial nerve deficits in stroke

Answer 15

• unilateral tongue weakness
• Horner’s syndrome e.g. miosis (small pupils), drooping eyelid, decreased sweating on affected side of face (anhidrosis)

Question 16

Posterior circulation stroke diagnosis

Answer 16

• can be difficult to diagnose
• suspect if pt presents with symptoms of acute vestibular syndrome (acute, persistent continuous vertigo or dizziness with nystagmus, n/v, head motion intolerance and new gait unsteadiness)

Question 17

Should you give an antiplatelet if suspected acute stroke or emergent TIA

Answer 17

NO! avoid until hemorrhagic stroke excluded

Question 18

After a stroke, follow up needs to be arranged on ….. (3)

Answer 18

on discharge, at 6 months, annually

Question 19

A follow up will consider of the following

Answer 19

• assess need for specialist review
• assess social and heart care needs of pt and family/carer
• optimise lifestyle measures and drug treatments for secondary prevention

Question 20

Management of suspected TIA

Answer 20

• aspirin 300mg OD ASAP until diagnosis established unless CI
• if CI or intolerant (even with +PPI), give suitable alt anti platelet
• pt presenting <24h of TIA who have low bleeding risk should be considered for DAT with C + A, following by C monotherapy
• alt: T + A, followed by either T or C monotherapy
• if not appropriate for DAT, give clopidogrel monotherapy
• consider PPI for pt with Hx dyspepsia associated with aspirin, or for concurrent use with DAT to reduce risk GI haemorrhage
• following confirmed diagnosis, give secondary prevention

Question 21

aspirin dose for suspected TIA

Answer 21

PO 300mg OD until diagnosis established

Question 22

aspirin dose for adult, disabling acute ischaemic stroke

Answer 22

• PO or rectal 300mg OD for 14 days to be started 24h after thrombolysis or ASAP within 24h of symptom onset in pt not receiving thrombolysis

Question 23

aspirin dose for TIA or minor stroke, in combination with clopidogrel in pt with a low risk of bleeding

Answer 23

300mg initially for one dose, to be started within 24h of onset of symptoms, then 75mg OD for 21 days

Question 24

management of ischaemic stroke - thrombolytics

Answer 24

• alteplase or tenecteplase (unlicensed use) recommended in treatment of acute ischaemic stroke if it can be administered within 4.5h of symptom onset and if intracranial haemorrhage excluded by appropriate imaging techniques
• needs to be given by experienced medical staff within a specialist stroke centre
• some pt: surgical management
• if intracranial haemorrhage excluded, pt who receive thrombolytics need to be started on anti platelet after 24h unless CI

Question 25

management of disabling acute ischaemic stroke (after thrombolysis has been given, or in pt who are not recieving thrombolysis)

Answer 25

- start aspirin unless CI, ASAP within 24h and continue for 2 weeks after stroke onset, when long term anti-thrombotic treatment should be started - if pt is being transferred to care at home before 2 weeks, ensure they are started on long term anti-thrombotic earlier

Question 26

when to consider giving PPI

Answer 26

- pt with Hx dyspepsia associated with aspirin or for concurrent use with DAT to reduce risk of GI haemorrhage

Question 27

ACs as an alternative to anti platelets?

Answer 27

not recommended in acute ischaemic stroke in pt who are in sinus rhythm

Question 28

pt with immobility after acute stroke

Answer 28

do not routinely give LMWH or graduated compression stockings for prevention of DVT

Question 29

use of warfarin in acute stage of ischaemic stroke

Answer 29

do not give!

Question 30

pt who receive AC for prosthetic heart valve who have a disabling ischaemic stroke

Answer 30

at significant risk of haemorrhagic transformation - stop AC treatment for 7 days and substitute with aspirin

Question 31

treatment of hypertension in acute phase of ischaemic stroke

Answer 31

can result in reduced cerebral perfusion so only give in the event of hypertensive emergency, or in pt considered for thrombolysis

Question 32

long term management following TIA or ischaemic stroke to reduce risk of further CV events - anti platelet

Answer 32

- long term clopidogrel monotherapy (unlicensed TIA) recommended in pt who present with either (not associated with AF) - if CI or not tolerated, give aspirin - also consider PPI need

Question 33

discuss AC use in long term prevention of recurrent stroke

Answer 33

- not routinely recommended, except when AF and other indications like cardiac source of embolism, cerebral venous thrombosis or arterial dissection present - if TIA/ischameic stroke associated with AF or atrial flutter, give long term AC treatment, timing depending on stroke severity and individual pt factors

Question 34

statin for long term prevention

Answer 34

- high intensity statin needs to be started in pt not already taking one as soon as they can swallow safely, irrespective of their serum-cholesterol conc

Question 35

define and name the high intensity statin

Answer 35

- high intensity = % reduction in LDL-C over 40 - atorv 20, 40, 80 - simv 80 - rosuv 10, 20, 40

Question 36

BB in management of hypertension following stroke

Answer 36

do not use unless indicated for a co-existing condition

Question 37

summarise the drugs that are given as long term prevention following a TIA or stroke

Answer 37

- high intensity statin to all pt irrespective of their serum cholesterol - clopidogrel monotherapy (aspirin if not appropriate) - Not ACs unless other indications are present

Question 38

initial management of intracerebral haemorrhage - surgery and BP

Answer 38

- surgical intervention may be needed to remove haematoma and relieve intracranial pressure - rapid BP lowering treatment to pt with underlying structural cause, Glasgow coma scale score <6, early neurosurgery to evacuate haematoma, very large haematoma with poor prognosis - consider rapid BP lowering in pt who present within 6h symptom onset and have systolic BP 150-220 and do not fit any exclusion criteria - aim for systolic BP target 130-139 within 1h and sustained for at least 7 days ensuring the magnitude drop doesn't exceed 60 within 1hr of starting treatment - also consider on case by case basis for pt who present >6h of symptom onset or who have systolic BP >220 and do not fit any exclusion criteria - specialist advice in considering BP lowering in 16-17yr olds who do not fit any exclusion criteria

Question 39

what is the Glasgow coma scale

Answer 39

- assesses pt level of consciousness - 1-15, lower scores = more impairment, coma etc

Question 40

initial management of intracerabral haemorrhage - AC

Answer 40

- pt taking ACs should have treatment stopped and reversed - however, AC therapy has been used in pt with intracerebral haemorrhage who are symptomatic of DVT or PE - in this situation, placement of a caval filter is an alternative

Question 41

pt with immobility after acute intracerebral haemorrhage

Answer 41

do not routinely give LMWH or graduated compression stockings for prevention of DVT

Question 42

long term management of pt after intracerebral haemorrhage

Answer 42

- specialist advice for pt with AF and pt at high risk of ischaemic stroke or cardiac ischaemic events - this is because aspirin and AC therapy not normally recommended after intracerebral haemorrhage - measure BP and initiate treatment were appropriate; take care to avoid hypo perfusion - avoid statins after intracerebral haemorrhage but can be used with caution when risk of vascular events outweighs risk of further haemorrhage - assess for lipid lowering therapy on basis of overall CV risk and underlying cause of haemorrhage