What is the definition of stroke?
- Sudden onset, focal neurological deficit
- Lasting >24 hours
What is the definition of TIA?
What is a crescendo TIA?
Transient neurological dysfunction secondary to ischaemia, without infarction
A crescendo TIA is where there are two or more TIAs within a week
How would you assess the risk of stroke in a patient who has had a TIA?
ABCD2 score
What are the components of the ABCD2 score?
A - age > 60 years (1 point)
B - BP > 140/90 mmHg (1 point)
C - clinical features:
unilateral weakness (2 points)
speech disturbance only (1 point)
D - duration:
> 60 mins (2 points)
10-59 mins (1 point)
< 10 mins (0 points)
D - diabetes (1 point)Which is more common: ischaemic stroke or haemorrhagic stroke?
Ischaemic (85%)
What are the different types of intracranial bleed?
Types of intracranial bleed:
- Intracerebral haemorrhage (intraventricular or intraparenchymal)
- Subarachnoid haemorrhage
- Subdural haemorrhage
- Extradural haemorrhage
Describe the pathophysiology of intracerebral haemorrhage
Rupture of Charcot-Bouchard aneurysm (aneurysms of the perforating arteries)
Describe the pathophysiology of subarachnoid haemorrhage
Rupture of saccular (berry) aneurysm within the Circle of Willis
What is the main risk factor for haemorrhagic stroke?
Chronic hypertension
Give a major risk factor for ischaemic stroke
Atrial fibrillation (AF)
Which scoring tool is used to assess the risk of stroke in a patient with AF? Describe the components of this scoring tool
How is the score interpreted?
CHAADS2-VaSC score:
- Congestive heart failure (1 point)
- Hypertension (1 point)
- Age >75 (2 points)
- Age 65-74 (1 point)
- Diabetes mellitus (1 point)
- Stroke/TIA/VTE in past (2 points)
- Vascular disease (1 point)
- Sexual Characteristics: female (1 point)
Scores:
- A score of 1 warrants consideration for anticoagulant therapy (unless the patient has scored 1 for gender alone, i.e. female with no other risk factors)
What characteristics on ECG suggest AF?
- Irregularly irregular rhythm
- No distinct P waves
Describe the management of a patient who has had a…
a) TIA within the last week
b) TIA more than a week ago
c) Crescendo TIA
What should you advise about driving?
NICE guidelines:
a) Give aspirin 300mg immediately and arrange urgent assessment by a specialist stroke physician within 24 hours
b) Refer for assessment by specialist stroke physician ASAP (within 7 days)
c) Same as (a)
In all above cases, advise patient not to drive until they have been seen by a specialist
In an anterior circulation stroke, which arteries may be affected?
- Anterior cerebral arteries
- Middle cerebral arteries (most common)
In a posterior circulation stroke, which arteries may be affected?
- Posterior cerebral arteries
- Basilar artery
- Vertebral arteries
- Superior cerebellar arteries
- Anterior inferior cerebellar arteries (AICA)
- Posterior inferior cerebellar arteries (PICA)
Which structures are supplied by the posterior circulation?
- Occipital lobe (+ some of the temporal lobe)
- Thalamus
- Brainstem (midbrain, pons, medulla)
- Cerebellum
Describe the features of Anterior Circulation Stroke using the Bamford classification
Classified as either TOTAL or PARTIAL Anterior Circulation Stroke
Total anterior circulation stroke - all THREE of the following:
1) Unilateral motor and/or sensory deficit of the face, arm and leg
2) Homonymous hemianopia
3) Evidence of higher cerebral dysfunction, e.g. dysphasia
Partial anterior circulation stroke - TWO of the following:
1) Unilateral motor and/or sensory deficit of the face, arm and leg
2) Homonymous hemianopia
3) Evidence of higher cerebral dysfunction, e.g. dysphasia
Describe the features of Posterior Circulation Stroke using the Bamford classification
ONE of the following:
1) Cranial nerve palsy and a contralateral motor/sensory deficit
2) Bilateral motor/sensory deficit
3) Conjugate eye movement disorder, e.g. gaze palsy
4) Isolated homonymous hemianopia
5) Cerebellar dysfunction (think - DANISH)
Describe the features of Lacunar Stroke using the Bamford classification
ONE of the following:
- Pure sensory stroke
- Pure motor stroke
- Ataxic hemiparesis
Describe the investigation of a patient who has had a suspected stroke - why is this done?
Urgent CT head (to rule out haemorrhagic stroke)
Describe the management of a patient who has had an acute ischaemic stroke, confirmed by CT (immediate management and secondary prevention)
Immediate management:
- Aspirin 300 mg
- Thrombolysis, e.g. IV alteplase (if patient presents within 4.5 hours and there are no contraindications)
- Thrombectomy (if patient presents within 6 hours)
Secondary prevention:
- Continue aspirin 300mg for 2 weeks, then replace with clopidogrel to be continued lifelong
- Manage risk factors (e.g. anticoagulation if in AF)
- Carotid endarterectomy if carotid stenosis >70 %
Give some examples of contraindications for thrombolysis?
Factors that predispose to bleeding:
- Recent haemorrhage
- Recent trauma or surgery
- Bleeding disorders (e.g. thrombocytopenia)
- Anticoagulated
- Severe hypertension (>180 systolic, >110 diastolic)
Describe the management of a patient who has had an acute haemorrhagic stroke
- Stop anticoagulants (reverse if necessary) and antiplatelets
- Control hypertension
- Neurosurgical referral may be necessary
The (…?) index is a scale that measures disability or dependence in activities of daily living in stroke patients
Barthel
