What is the difference between an ischemic and hemorrhagic stroke?
Ischemic: A clock blocks the blood flow to an area of the brain
Hemorrhagic: Bleeding occurs inside or around the brain tissue
What is the difference between ichaemia and infarction?
Ischaemia is a condition in which there is insufficient blood flow to the brain to meet metabolic demand. This leads to poor oxygen supply or cerebral hypoxia, and may in turn lead to the death of brain tissue or cerebral infarction.
Ischaemia may be reversible whereas infarction is irreversible.
What is TIA?
A brief episode of neurological dysfunction caused by focal brain and/or retinal ischaemia, with clinical symptoms typically lasting < 1 hour, and without evidence of acute infarction.
Describe the 4 ages of an infract.
- Hyperacute (1st 6 hours)
- Acute (up to 7 days)
- Subacute (up to 4 months)
- Chronic (after 4 months)
How do you treat a hyper acute infarct?
Intravenous thrombolysis with Alteplase
Why do we CT patients with suspected stroke?
- Available 24/7
- Fast
- Not limited by contraindications, intolerances and the need for life support/monitoring equipment
How can intracranial haemorrhages be classified?
- Primary (small vessel) haemorrhage
- Secondary haemorrhage
Give some causative examples of primary haemorrhages.
- Hypertension
- §Cerebral amyloid angiopathy (CAA)
Give some causative examples of secondary haemorrhages.
- Tumour
- Vascular
- Coagulopathy, warfarin, aspirin
- Cocaine, alcohol
Describe the neurosurgery management of an intracranial haemorrhage.
- Clot reduction
- Decompression craniotomy
- Intraventricular shunting
Describe the medical management of an intracranial haemorrhage.
Supportive Blood pressure Mass effect Seizures Secondary prevention
Where is a typical hypertensive bleed located?
Basal ganglia
2/3rds Putamen 1/4 Thalamus
Name the location of a Cerebral Amyloid Angiopathy (CAA) intracranial haemorrhage.
Corticomedullary junction
What features in the clinical history would mean you suspect a patient is suffering from a Intratumoral Haemorrhage?
- Stuttering onset
- Oedema
- Irregular nature of clot
Name some complications of intracranial haemorrhage.
- Effacement of the ventricles
- Displacement of the ventricles
- Midline shift
- Twisted ventricle
- Hydrocephalus
- Cerebral herniation
(Subfalcine, uncal, tenting, coning) - Raised intracranial pressure
How do you calculate Cerebral Perfusion Pressure (CPP).
CPP= Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)
What is the source of the bleed in an extradural haematoma?
Meningeal vessels
What is the source of the bleed in a subdural haematoma?
Bridging veins
Describe some lifestyle modifications that patients can make to reduce their risk of a stroke.
- Smoking cessation
- Weight management
- Alcohol avoid heavy intake
- Dietary modifications: Low fat, low salt, low sugar, high fibre
- Aerobic exercise
Describe the stroke rehab criteria.
- Medically stable
- Needing no more than 24% oxygen
- NG feeding established with no risk of refeeding
- Stroke consultant review twice a week
- Do not need to await echo etc before transfer unless urgent.
- Transfer around day 7 (flexible)
Describe some good prognostic factors following a stroke.
- Absence of coma
- Early motor recovery
- Continence
Describe some poor prognostic factors following a stroke.
- Severe communication deficit
- Old age
- Incontinence
- Neglect
- No leg movement at 2 weeks
- Severe upper limb weakness at 4 weeks
Name some problems patients experience during stroke rehab.
- Aphasia
- Dysarthria
- Impaired swallowing
- Hydration and malnutrition
- Balance and walking
- Fatigue
- Continence
- Spasticity and contractures
- Sensation
- Mouth care
- Anxiety and depression
- Neuropathic pain
Name some stroke secondary prevention techniques.
- Antithrombotic therapy (antiplatelet versus anticoagulation)
- BP control(average BP<130/80)
- Lipid control (t. chol<4, LDL chol<2)
Glycaemic control (HbA1c <7) - Carotid endarterectomy (symptomatic ICA >50% lumen reduction NASCET)
- Lifestyle changes (smoking cessation, weight loss, optimisation of sleep, exercise)
