Stroke

Question 1

what are the main mechanisms through which an ischemic storke occurs?

Answer 1

venous and atrio embolism

Question 2

what is lost after stroke

Answer 2

sensory/motor function

Question 3

what are stroke subtypes?

Answer 3

ischaemic stroke
haemorragic stroke
subarachnoid haemorrhage
vonous sinus thrombosis

Question 4

what causes a haemorragic stroke?

Answer 4

• blood vessels rupture due to arterial disease
• bleed into enclosed space and builds up pressure in the skulls compressing the cells causing damage
• usually small capillaries
• most ocmmon cause is malignant hypertension

Question 5

what are intracerebral haemorrage secondary mechanisms

Answer 5

intial blood vessles rupture and furhter haematoma expasion causing re-bleeding, intracranial pressure evelation and oedema
generates systemic inflammatory response

Question 6

what is the stroke incidence?

Answer 6

87% ishcemic
10% intracranial haemorrhage
3% subarachnoid

Question 7

what is penumbra

Answer 7

the zone of damage

Question 8

what does alteplase do?

Answer 8

breaks down clots

Question 9

wat is the patiogenesis of large artery artherosceloris and ischemia

Answer 9

• endothelial injury
• migration of macrophages into site of injury
• formation of fatty streaks
• deposition of foam cells
• continued infalmmation
• continued seposition of foam cells
• stenosis and/or occlusion
• ulceration of plaque and emboli formation

Question 10

how does intraplaque haemorrage occur and how can this lead to stroke?

Answer 10

rupture of plque in carotid artery could break off and lodge deeper downstream (clot fomation = emboli)

Question 11

What is gloobal ischemia?

Answer 11

occurs over a large area

Question 12

what is the ischemic penumbra?

Answer 12

• focal point occlusion
• downstream spread of ischemic blood flow
• acute hypoxia/anoxia
• inflammation
• necrosis

Question 13

what is surgical/medical interventions of stroke?

Answer 13

• medical managment - thrombolysis
• surgical thrombectomy
• CT scan/ MRI to ensure no bleeding

Question 14

what is the mechnaism of action of alteplase?

Answer 14

recombinant tissue plasminogen activator used as a thrombolytic agent - natural clot busting

Question 15

what is a thrombectomy?

Answer 15

surgery to remove a blood clot from a blood vessel (thrombus)

Question 16

what is the aspirin dose for acute stroke?

Answer 16

aspirin daily 300mg until 2 weeks after onset of symptoms, then start definitive long term anti-platelet/anti-thrombotic treatment

Question 17

when are anti-coagulants used in stroke?

Answer 17

• not used in treatment of acute stroke
• used when there is longer term risk

Question 18

what scoring is used for bleeds?

Answer 18

HASBLED or orbit score

Question 19

what interventions need to be done in haemorragic stroke?

Answer 19

surgical

Question 20

what types of stroke are treated the same way?

Answer 20

embolic and thrombotic

Question 21

what is a thrombotic stoke?

Answer 21

blood clot blocks flow of blood in brain

Question 22

what is an embolic stroke?

Answer 22

fatty plaque or blood clot (embolism) breaks away and flows to the brain where it blocks an artery

Question 23

what is the difference between stroke and TIA?

Answer 23

stroke - sudden onset of rapidly developing focal or global neurological distrubance which lasts more than 24 hrs or leads to death

TIA - less than 24hrs - neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia

Question 24

what is a small vessel stroke?

Answer 24

lacunar - small vessels deep in the brian (doesnt need a big clot before blocked)

Question 25

what are pontial complications in stroke?

Answer 25

- haemorragic transformation of ischemic stroke - cerebral oedema - seizures - venous thromboembolism - cardiac complications - increased risk of infections

Question 26

what are mobility problems associated with stroke?

Answer 26

- hemiparesis or hemiplegia (weakness on one side of the body) - ataxia (lack of co-ordination in movement) - falls - spasticity

Question 27

what are sensory problems associated with stroke?

Answer 27

loss or alterationin sensations such as touch, temperature and pain

Question 28

what are other long term complications of stroke?

Answer 28

- continence issues - pain can be from neuronal damage or pre-existing conditons - dyphagia (associated with aspiration pneumonia, diability and death) - visual problems

Question 29

what can a CT scan determine in stroke?

Answer 29

whether haemorragic or clot

Question 30

what is the benefit of thrombosing a patient with a clot?

Answer 30

only within <4.5hrs to dissolve the clot as there is a higher risk of haemorragic stroke if left any longer

Question 31

what is TPA?

Answer 31

tissue plasminogen activator (eg. alteplase)

Question 32

what is the inclusion criteria for alteplase?

Answer 32

- dose 0.9mg/kg (max dose 90mg) - 10% of total as bolus over 2-3 mins (being aggressive to dissolve clot but not full amount because dont want pt to bleed) - 90% of total dose infuse over 60mins

Question 33

what are side effect of thrombolysis?

Answer 33

- intra-cerebral haemorrhage - angiodema - minor bleeding risk - anaphylaxis

Question 34

what can swallowing disorders lead to?

Answer 34

poor nutrition, pneumonia and increased diasbility

Question 35

what might you need to do if pt unable to swallow for 3-4 days?

Answer 35

nutrition via NG tube or TPN

Question 36

what medicaiton woyld you stop before CT scan?

Answer 36

anticoagulants, thrombolytics, antiplatelets and NSAIDS

Question 37

what medications will be witheld pending swallow assesment?

Answer 37

all medications - NIL by mouth

Question 38

what is the secondary prevention rule for stroke?

Answer 38

A - antiplatets/ anticoagulants B - blood pressure C - cholesterol D - diabetes E - exercise (lifestyle)

Question 39

when should aspirin be given after stroke?

Answer 39

day of admission or the following day with patients with haemorrhagic stroke or other complications

Question 40

what is the dose of aspirin initially as they arrive in to hospital with stroke?

Answer 40

300mg stat (orally or rectally)

Question 41

why should aspirin be aovided 24hrs post thrombolysis?

Answer 41

increased risk of bleeding

Question 42

what is the dose after stat dose of aspirin in stroke?

Answer 42

14 days 300mg asprin and then clopidegrel 75mg daily long term

Question 43

is clopidegrel licensed in TIAs?

Answer 43

no

Question 44

what is the dose of antiplatelets in patients with AF after stroke?

Answer 44

- 14 days aspirin 300mg depending on impact of stroke - anti-coagulation usually initiated after 10-14 days

Question 45

why do you not want to treat BP agressively in stroke?

Answer 45

dont want to lower it too much and reduce vital perfusion to organs

Question 46

what might they do in hospital after stroke to get blood to the head?

Answer 46

tilt the bed

Question 47

what dose of atorvastin is given after stroke?

Answer 47

40-80mg (most likely 80mg as need to be aggressive)

Question 48

when will statins not be used after stroke?

Answer 48

patients with haemorrhagic stroke unless risk of vascualr event outweighs the risk of haemorragic event

Question 49

what is sliding scale insulin?

Answer 49

IV short acting where you can adjust the dose every hour to be sure the blood glucose remains stable

Question 50

what is the effect of alcohol on stroke?

Answer 50

controversial but there is a protective effect in light/ moderate drinkers but elevated risk in heavy consumption

Question 51

what is the FAST acronym?

Answer 51

F - can they smile? does one side droop? A - can they lift both arms? is one weak? S - is there speech slurred or muddled? T - time to call 999