Stroke & TIA Flashcards

Question

What are the symptoms of a brainstem infarct? Brainstem infarct is posterior circulation stroke.

Answer 1

Quadriplesia Disturbance of gaze & vision Locked in syndrome (aware but unable to respond) *symptoms depended on assoc. with cranial nuclei.

Answer 2

1. Rule out hypoglycaemia first (<3.3.mmol/L) - blood glucose 2. ECG to exclude arrhythmias 3. non-contrast CT head to exclude haemorrhage = FIRST LINE Diagnosis: ``` 1. FAST campaign used by the public F = face weakness A = arms weakness S = slurred speech T = time to call 999 ``` 2. ROSIER score used by medical professionals: * Exclude hypoglycaemia 1. Loss of consciousness / syncope => -1 point 2. Seizure activity => -1 point New, acute onset of: 1. Asymmetric facial weakness => +1 point 2. Asymmetric arm weakness => +1 point 3. Asymmetric leg weakness => +1 point 4. Speech disturbance => +1 point 5. Visual field defect => +1 point * STROKE is likely if >0

Answer 3

1. Immediate emergency admission to acute stroke facility 2. DO NOT start anti-coagulation or anti-platelet until haemorrhage is excluded 3. A-E exam until transferred to stroke unit => give supplemental O2 if sats <95% + no contraindication

Answer 4

1. Thrombolysis with alteplase => within 4.5h of onset of stroke symptoms => best result within first 90 mins => haemorrhage definitely excluded post CT head IV Alteplase 0.9mg/kg to a max of 90mg => agent of choice => 10% of total given as bolus and 90% given as an infusion => monitor v closely - as high risk of bleeding Always do CT/MRI 24h post-lysis to monitor for bleeds

Answer 5

``` 1. Absolute: => Previous intracranial haemorrhage => Seizure at onset of stroke => Intracranial neoplasm => Suspected subarachnoid haemorrhage => Stroke or traumatic brain injury in preceding 3 months => Lumbar puncture in preceding 7 days => Gastrointestinal haemorrhage in preceding 3 weeks => Active bleeding => Pregnancy => Oesophageal varices => Uncontrolled hypertension >200/120mmHg ``` Relative: => Concurrent anticoagulation (INR >1.7) => Haemorrhagic diathesis => Active diabetic haemorrhagic retinopathy => Suspected intracardiac thrombus => Major surgery / trauma in the preceding 2 week

Answer 6

NICE recommend a pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS) 1. Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have: => acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation shown in computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) 2. Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes): => confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and => if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume 3. Consider thrombectomy with intravenous thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes): => who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and => if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Answer 7

1. Clopidogrel is first line (NICE) in people who have had an ischaemic stroke 2. Aspirin + MR dipyridamole is now recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated 3. If the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation 4. Atrial fibrillation: anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days after the onset of an ischaemic stroke

Answer 8

1. Fluid management Regular assessment for fluid status must be undertaken to ensure patients remain normovolaemic The NICE guidelines recommend assessing the hydration of all patients with acute stroke on admission, with regular review during their stay Greater than 80% of patients who cannot swallow post stroke will recover within 2-4 weeks However, it is important to manage fluids in this immediate post-event period as hypovolaemia can worsen the ischaemic penumbra, as well as increase risk of other complications i.e. infection, DVT, constipation and delirium Conversely, over-hydration can also complicate matters by leading to cerebral oedema, cardiac failure and hyponatraemia, therefore it is important to regularly review fluid status in these patients Recommendations for management: => Oral hydration is preferable in all patients who are able to safely swallow => Intravenous hydration may be necessary otherwise - currently recommend isotonic saline without dextrose

Answer 9

2. Glycaemic control => Closely monitor and control blood sugar, particularly if they are nil by mouth due to concerns regarding swallowing safety post stroke, and/or in diabetics => Post stroke, patients with hyperglycaemia have increased mortality => NICE recommend maintaining a blood sugar level between 4 and 11 mmol/L in people with acute stroke => Hypoglycaemia also needs to be managed appropriately, as alone it can cause neuronal injury as well as mimic stroke-related neurological deficits

Answer 10

3. Feeding assessment and management: All patients presenting with acute stroke must be screened for safe swallowing function prior to further oral intake, as dysphagia is common after stroke This is to reduce the risk of aspiration and subsequent complications. Assessment should be prior to any oral intake of food, fluids, and/or medications If there are any concerns regarding swallowing, the NICE guidelines recommend specialist assessment of swallowing => within 24 hours of admission and not greater than 72 hours after Prior to assessment is undertaken, a patient should remain nil by mouth to prevent complications Recommendations for patients unsafe for oral intake: => Patients should receive nasogastric tube feeding, ideally within 24 hours of admission, unless they have had thrombolytic therapy => If nasogastric tube feeding is not tolerated, patients should be considered for a nasal bridle tube/gastrostomy instead => Medications need to be assessed to determine if formulations are available for nasogastric feeding, or if conversion to subcutaneous or intravenous forms are required => Nutritional support may be required for patients at risk of malnutrition post stroke, whether a result from dysphagia, poor oral health or reduced ability to self-feed due to weakness or paralysis

Answer 11

4. Disability scales: Stroke can result in a number of complications and subsequent disability, therefore disability scales are often used as a measure of functional decline post event and subsequent improvement after medical intervention Disability, often measured in terms of functional status (notably, basic activities of daily living), is often the leading cause of morbidity after stroke After a patient is medically stabilised after a stroke, they may require transfer to a rehabilitation team for ongoing treatment depending on their level of disability Disability is most commonly measured using the Barthel index (BI), an outcome measure for stroke Describes 10 tasks, and is scored according to amount of time or assistance required by the patient for each given task Tasks: feeding, moving from wheelchair to bed, personal toileting, getting on/off toilet, bathing, walking on level surface, ascending/descending stairs, dressing, controlling bowels and controlling bladder The total score is from 0 to 100, with 0 being completely dependent, and 100 being completely independent This index should be used to assess the functional status of a patient post stroke, and to monitor their improvement with ongoing rehabilitation to regain independence after the event

Answer 12

=> High dose Aspirin 300mg orally or rectally as soon as haemorrhage stroke rules out and thrombolysis contraindicated OR => On day 2 after a second CT scan post thrombolysis => Continue high dose aspirin 300mg for 2 weeks

Answer 13

1. Protect the airway => avoids hypoxia + aspiration 2. Maintain homeostasis => glucose between 4-11mmol/L 3. Screen swallow => till then nil by mouth but keep hydrated 4. CT/MRI within 1h => essential if thrombolysis considered or high risk of haemorrhage 5. Anti-platelet agents (aspirin 300mg) once haemorrhagic stroke ruled out 6. Thrombolysis or Thrombectomy 7. Admit to a high acute stroke unit (HASU) => improves outcomes + saves lives + reduces long-term disability 8. Rehabilitation => start early post stroke to maximise improvement and prevent complications 9. Nurse queries: *in acute initial stage = don't treat HTN because likely to make ischaemia worse if BP drops If massively elevated, consult senior advice (lobetalol?) => BP usually drops after alteplase - If BP still high a week or so post stroke then manage 10. Aspiration common post stroke - aspiration pneumonia => if pyrexial give paracetamol but first do a swallow assessment => check if can cough, lick lips, head control => then call SALT team

Answer 14

*Secondary preventative measures are initiated at diagnosis in secondary care. 1. Arrange follow up in primary care: => on discharge, => at 6 months, => at least annually afterwards to review health, social care needs (i.e. access to benefits, community participation, housing, and return to work), ongoing risk factors, and secondary prevention. Arrange review of carers of people with stroke at 6 months and then annually to assess their health and social care needs. 2. Offer information on stroke, TIA, and vascular risk factors to people with stroke or TIA and their family/carers: => Patient information is available from the Stroke Association. 3. Provide advice about driving if appropriate. 4. Provide advice about returning to work if appropriate. 5. Offer verbal and written information about medication for secondary prevention, including: => Reasons for medications. => How and when to take it. => Common adverse effects.

Answer 15

Encourage physical activity every day: => Individualized exercise programs (which may include muscle strengthening, balance, and coordination activities) for people with stroke should be prescribed, delivered, and monitored by the rehabilitation team. Advise smokers to stop smoking and non-smokers to avoid passive smoking: Options to help with smoking cessation include referral to an NHS Stop Smoking Service, drug treatment, and written patient information. Advise the person to eat a healthy balanced diet to help reduce cardiovascular disease (CVD) risk — they should aim to: => Eat at least five portions of fruit and vegetables (from a variety of sources) per day and two portions of oily fish per week. => Reduce intake of saturated fats. => Keep salt intake low — salt should not be added at the table, and processed foods should be kept to a minimum. => Advise people who drink alcohol to keep consumption within the recommended limits: Alcohol intake should be limited to 14 units a week, spread over at least 3 days. => Advise against routine dietary supplementation with: B vitamins or folate; vitamins A, C, or E; selenium; and calcium with or without vitamin D unless required for other medical conditions.

Answer 16

Antiplatelet therapy is initiated by secondary care on diagnosis of ischaemic stroke or TIA without paroxysmal or permanent atrial fibrillation for long-term vascular prevention: => The standard treatment is clopidogrel 75 mg daily. => Aspirin 75 mg daily with modified-release dipyridamole 200 mg twice daily may be used if clopidogrel cannot be tolerated. => Modified-release dipyridamole 200 mg twice daily may be used if both clopidogrel and aspirin are contraindicated or cannot be tolerated. => Aspirin 75 mg daily may be used if both clopidogrel and modified-release dipyridamole are contraindicated or cannot be tolerated. Unless contraindicated, treatment with statin (such as atorvastatin 20–80 mg daily) will be offered at diagnosis of ischaemic stroke or TIA by secondary care. If this reduction is not achieved within 3 months, consider adherence, diet, lifestyle, and increasing dose (if appropriate) — discuss with a stroke specialist if unsure. Statin treatment should be avoided in people with primary intracerebral haemorrhage unless advised for other indications. Anti-hypertensive drugs Treatment for hypertension following stroke or TIA should be initiated by secondary care following diagnosis Anticoagulant drugs will be initiated in secondary care for people with ischaemic stroke or TIA and paroxysmal, persistent, or permanent atrial fibrillation or atrial flutter once intracranial bleeding and other contraindications (such as uncontrolled hypertension) are excluded. Treatment in people with TIA will start immediately on diagnosis once imaging has excluded haemorrhage. Antithrombotic treatment in people with recurrent TIA or stroke should be the same as for those with a single event

Answer 17

Diabetes mellitus Hypertension Obstructive sleep apnoea People with stroke or TIA should be screened for obstructive sleep apnoea with a valid clinical screening tool. Refer anyone suspected of having sleep apnoea for a respiratory/sleep medicine assessment. Heart failure Obesity Refer people who are overweight or obese to a weight management service if appropriate. Manage other risk factors appropriately, such as: Contraception Do not offer pre-menopausal women with stroke or TIA the combined oral contraceptive pill. Consider progestogen-only and non-hormonal contraceptive methods instead. Hormone replacement therapy (HRT) Advise post-menopausal women with ischaemic stroke or TIA who wish to start or continue HRT on the risks and benefits of treatment. Influenza Arrange annual influenza immunizations.

Answer 18

Discuss the exclusion period and the person’s responsibility to notify the Driver and Vehicle Licencing Agency (DVLA) after stroke or TIA People who have had a stroke must not drive for 1 month but may not need to notify DVLA. Driving may resume after 1 month if there has been satisfactory clinical recovery. DVLA does not need to be notified unless there is residual neurological deficit 1 month after the episode and, in particular: visual field defects, cognitive defects, impaired limb function. Refer people with persisting cognitive, language, or motor disability after stroke who wish to return to driving for on-road screening and evaluation Inform people who wish to drive after stroke about eligibility for disabled concessions (for example the Blue Badge scheme) If the person wishes to return to work after stroke: Discuss the need for assessment for return to work with the rehabilitation team. The person can be referred through the job centre to a specialist in employment for people with disability or to the specialist vocational rehabilitation team if extra support or advice is needed.

Answer 19

1. Total anterior circulation infarct (TACI, 15%) => involves middle and anterior cerebral arteries => all 3 of the above criteria present 2. Partial anterior circulation infarcts (PACI, 25%) => involves smaller arteries of anterior circulation e.g. upper or lower division of MCA => 2 of above criteria present 3. Lacunar infarct (LACI, 25%) => involves perforation arteries around internal capsule, thalamus and basal ganglia => presents with 1 of the following: i) unilateral weakness/deficit of face and arm, arm and leg or all 3 ii) pure sensory stroke iii) ataxic hemiparesis ``` 4. Posterior circulation infarct (POCI, 25%) => involves vertebrobasilar arteries => presents with one of the following: i) cerebellar or brainstem symdromes ii) loss of consciousness iii) isolated homonymous hemianopia ```

Answer 20

4. Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain) => Ipsilateral CN III palsy Contralateral weakness of upper and lower extremity 5. Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome) => Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus 6. Anterior inferior cerebellar artery (lateral pontine syndrome) => Symptoms are similar to Wallenberg's (see above), but: Ipsilateral: facial paralysis and deafness 7. Retinal/ophthalmic artery => Amaurosis fugax 8. Basilar artery => 'Locked-in' syndrome

Stroke & TIA Flashcards

(44 cards)