Stroke - ischaemic 2

Question 1

Why does the secondary treatment of stroke differ between cardioembolic and atheroembolic strokes ?

Answer 1

• As cardioembolic is caused by Fibrin dependent “red thrombus”
• And atheroembolic is caused by Platelet dependent “white thrombus”

Question 2

What are the risks/causes for developing cardioembolic strokes ?

Answer 2

• Having AF
• External cardioversion carries a risk of emboli
• Prosthetic valves carry a risk of emboli
• Having a MI recently
• Heart defects e.g. patent foramen ovalae, ASD, VSD
• Having had cardiac surgery e.g. bypass graft
• Valve vegetations due to infection e.g. infective endocarditis carry risk of emboli

These can all cause emboli which travel up to the brain and cause an infarction ==> cardioembolic stroke

Question 3

What is the most common of the 2 main types of ischaemic strokes ?

Answer 3

Atheroembolic

Question 4

What initial assessment tool should be used in A&E to assist with more rapid diagnosis of stroke ?

Answer 4

• ROSIER scale
• If score >0 then likely to have had/having a stroke
• Score ranges from -2 to 5
• https://dundeemedstudentnotes.files.wordpress.com/2012/03/rosier.pdf

Question 5

What is the initial first investigation done to diagnosis and differentiate between ischaemic and haemorrhagic strokes ?

Answer 5

1. CT
2. If they present after 1 week then do an MRI as CT is no longer any good

Question 6

What are the risk factors for people developing atheroembolic strokes ?

Answer 6

• High cholestrol and BP
• Smoking
• Diabetes and obesity
• Physcial inactivity

Question 7

What are the other initial investigations done for someone with a stroke ?

Answer 7

• ABC - protect the airway and prevent aspiration
• Do pulse, BP and 24hr ECG - purpose of ECG is to look for AF
• Blood glucose - to rule out hypoglycaemia
• Cardiac enzymes
• Electolytes, FBC, serum urea and creatinine
• Check PT and PTT times to rule out a bleeding disorder (coagulopathy) If patient has no history of anticoagulant use, or of coagulopathy or a condition that may lead to it, then thrombolysis does not need to be delayed until the test results are available

Question 8

What are the other investigations done for someone with a stroke ?

Answer 8

1. CXR - may show enlarged L atrium
2. Echocardiogram - may show mural thrombosis seen in AF ,or show signs they’ve had an MI or may show valvular lesions in infection endocarditis or rhematic heart disease
3. Carotid artery doppler ultrasound +/- CT/MRI angiography
4. Check for conditions which might cause clots e.g. vasculitis, thrombophilia, antiphospholipid syndrome (only if suggested)

Question 9

What is the investigations done to differentiate between the cause of an ischaemic stroke being likely to be atheroembolic or cardioembolic ?

Answer 9

Assessing to see if cardioembolic likely:

• Echo - may show signs of post-MI, AF, infective endocarditis, rheumatic heart disease
• ECG 24hr - to look for AF
• CXR - enlarged atrium

Assessing to see if atheroembolic likely:

• Carotid doppler ultrasound - if stenosis > or equal to 70% then atheroembolic likely

Question 10

Describe small vessel disease

Answer 10

Its an umbrella term covering a variety of abnormalities realting to small blood vessels in the brain

Often seen lacunar infarcts (type of small stroke), white matter hyperdensities and cerebral microbleeds

Many problems have been associated with cerebral SVD including:

• congnitive impairment - When problems with thinking skills are associated with SVD, this can be called “vascular cognitive impairment.”
• Problems with walking and balance
• Strokes - white matter hyperintensities are associated with a more than two-fold increase in the risk of stroke.
• Depression
• Vascular dementia

Question 11

Causes of small vessel disease

Answer 11

• Arteriosclerosis
• Microatheroma of the ostium,
• Embolism (athero and cardioembolism)
• Changes in hemorrheology

Question 12

Where should stroke patients be admitted to in hospital ?

Answer 12

Stroke care unit

Question 13

What is the initial treatment of ischaemic stroke after using brain imaging to differentiate ischaemic from haemorrhagic stroke if they are seen within 4.5hrs of onset of symptoms?

Answer 13

1st = Thrombolyiss with aletepase (intravenous rt-PA)

Adjunct = aspirin given after 24hrs if recieved thromoblysis and continue for 2weeks following stroke

Adjunct = endovascular intervention (thrombectomy with stent retriever) in selected patients

Supportive care should be provided throughout treatment e.g. giving O2 or ventilation

Swallow assessment including nutrition and hydration assessment within 4hrs of presentation

VTE prophylaxis and early mobilisation

Question 14

What are the indications for use of thrombectomy ?

Answer 14

selected patients with acute ischaemic stroke who have confirmed large vessel occlusion:

have received intravenous r-tPA within 4.5 hours of onset;

have causative occlusion of the internal carotid artery or proximal middle cerebral artery - the main indication for its use is someone with a large proximal vessel occlusion of the anterior circulation (internal carotids and middle cerebral, think the anterior cerebral is a bit small or something)

aged ≥18 years;

can begin endovascular therapy within 6 hours of symptom onset. (think this means as long as it can be done within 6hrs)

Question 15

What is the initial management of ischaemic stroke when the patient is seen after 4.5hrs of symptom onset?

Answer 15

1st - aspirin continue for 2wks following stroke

• Supportive care
• Swallowing assessment including nutrition and hydration assessment within 4hrs of presentation

VTE prophylaxis + early mobilisation

Question 16

What is the recommended VTE management recommended in patients with stroke ?

Answer 16

Intermittent pneumatic compression + early mobilisation if possible reduces risk of DVT

Heparin not recommended

Question 17

Describe the mangement/screening for dysphagia in patients following stroke

Answer 17

1. Initial swallow screen
2. If abnormal ==> assessment by a speech and language therapist
3. May need NG tube placement or textured diet and thickened fluids depending on swallow

Question 18

How often should patients be screened for malnutrition following acute stroke ?

Answer 18

At least weekly

Question 19

Who should patients following acute stroke who are at risk of malnutrition or who require tube feeding or dietary modification be referred to ?

Answer 19

Dietician

Question 20

What is the inital management of patients with a cerebral venous sinus thrombosis ?

Answer 20

1st - anticoagulation initially with heparin then use warfarin

Supportive care

Swallowing assessment and DVT prohylaxis and early mobilisation

Question 21

For individuals aged up to 60 years who suffer an acute MCA territory ischaemic stroke complicated by massive cerebral oedema, what surgical procedure should be offered?

Answer 21

Surgical decompression by hemicraniectomy

Question 22

What is the secondary prevention treatment for atheroembolic strokes? (this is when its important to know if it was athero or cardioembolic)

Answer 22

1st line = clopidogrel

+ statin

+ anti-HTN treatment as per normal guidelines

2nd line = aspirin + dypridamole (this also applies to TIA just havent put it in that flashcard)

Question 23

What is the secondary prevention treatment for cardioembolic strokes?

Answer 23

1st line = warfarin

+ statin

+ anti-HTN treatment as per normal guidelines

Question 24

Along side medications what should you always provide for the secondary prevention of strokes ?

Answer 24

Lifestyle modification advice - i.e. smoking, diet, alcohol, exercise etc