Stroke Week: Clinical Management

Question 1

What is meant by neuroplasicity?

Answer 1

Ability of brain to undergo biological changes; this could be small cellular changes or coritcal re-mapping. Neuoroplasticity allows us to:

• Learn a new skill
• Very important in recovery from stroke
• Changes resulting from socioeconomic condition
• Changes due to psychological stressors

etc….

Question 2

What is the commonest cause of long term disability?

Answer 2

Stroke

Question 3

Give an approximation of what % of strokes occur in under 65’s

Answer 3

• 25% occur in under 65’s
• 3% in under 40’s

*1 in 4 of us will have a stroke

Question 4

Complete the sentence:

Stroke is the ____ leading cause of death in the developed world

Answer 4

3rd

Question 5

What is the stroke pathway?

Answer 5

Document that details the core components of optimal service for someone who has suffered a stroke

Question 6

Sumarise the stroke pathway

Answer 6

• Pre-hospital
  
  • Hopefully patient will recognise signs of stroke (FAST) and ring 999
  • Priority 1 call for paramedics
  • Paramedics quickly assess patient
  • Paramedics use’ bat phone’ to alert hospital that they have a pt who may be having acute stroke
  • Stroke team is pre-alerted to be ready
• Acute response and treatment on HASU
  
  • Stroke team meet pt in A&E and do the following:
    
    • Brief focused history
    • IV acess to get bloods
    • ECG
    • Baseline observations
    • NOTE: some of this may happen on route to CT
  • CT scan is interpreted there and then
  • Determine immediate treatment (thrombolysis [start giving whilst in CT scanner], bp lowering, thrombolectomy)
  • Pt transferred onto stroke unit for up to 72 hours
• Life after HASU
  
  • Options: home, discharge at home with intensive therapy at home, rehabilitation, transfer to acute stroke ward

Question 7

State some questions you need to ask yourself during the initial assessment of a stroke patient

Answer 7

Question 8

What is the NIHSS?

Answer 8

National Institute of Health Stroke Scale: an assessment tool which gives a quantitative measure of stroke-related neurological deficit. It can be used as a measure of stroke severity.

It assess 11 key components:

• Level of consciousness & communication
• Eye movements
• Visual fields
• Facial palsy
• Upper limb motor
• Lower limb motor
• Limb ataxia
• Sensation
• Langauage/aphasia
• Dysarthria
• Extinction/inattention

Score ranges from 0 to 42

Question 9

Remind yourself of the Oxford clinical classification of strokes

Answer 9

Question 10

State the NIHSS scores for:

• No stroke
• Minor stroke
• Moderate stroke
• Moderate to severe stroke
• Severe stroke

Answer 10

• 0= no stroke symptoms
• 1-4= minor stroke
• 5-15= moderate stroke
• 16-20= moderate to severe stroke
• 21-42= severe stroke

Question 11

Is NIHSS a diagnostic tool?

Answer 11

NIHSS is NOT a diagnostic tool and it is NOT a substitution for a neuro exam

Question 12

What Oxford classification of strokes does NIHSS underestimate (in terms of severity)?

Answer 12

POCs

Question 13

How does fresh blood appear on CT scan?

Answer 13

FRESH blood on CT scan appears as bright white (high attenuation)

*If you did a CT scan 12 hours later, on a pt who had been given no treatment, there would be a dark area of infarcted brain (low attenuation)

Question 14

CT scans of patients suffering an ischaemic stroke are often normal in the acute phase following a stroke; true or false?

Answer 14

True

Question 15

Following immediate treatment of stroke, what happens on HASU

Answer 15

• Thrombolysis completed (if started in CT scanner)
• Observations every 15 mins
• Junior doctor completes thorough assessment, checks bloods and head scan report

In the next 24hr:

• Nurses complete nutrition & pressure area screening
• Consultant review
• Patient reviewed by physio, occupational therapy, speech & language therapy

Question 16

Image is a summary of stroke pathway

Answer 16

Question 17

What drug is commonly used for thrombolysis in strokes?

Answer 17

Alteplase

Question 18

Discuss the criteria which you must consider when considering whether to give intravenous thrombolysis for a stroke

Answer 18

• Clinical diagnosis of acute ISCHAEMIC stroke causing one or more of NIH score =/>4, binocular visual field deficit, swallowing deficit
• Imaging consistent with ischaemic stroke
• Symptom onset within 4.5 hours prior to initiation of thrombo

Question 19

What is the main complication of thrombolysis?

Answer 19

Bleeding (often in area where ischaemia occured)

Question 20

Only about 20% of patients are eligible for thrombolysis; state some other factors which make a bigger difference to the outcome for a patient

Answer 20

• Prompt admission to stroke unit
• Prompt secondary prevention
• Early MDT
• Maintaining homeostasis (hydration, nutrition, oxygenation, normoglycaemia)
• Preventing complications

Question 21

If a patient is not eligible for thrombolysis (as we know only about 20% are eligible) we can ofer them early secondary prevention; state some of these treatments

Answer 21

• Aspirin
• Statin
• Control bp (target <130/85)
• Anticoagulate if in atrial fibrillation (DOACs used as first line)
• Carotid surgery (e.g. carotid endarterectomy)

Question 22

State some ways in which we treat intracerebral haemorrhages

Answer 22

• Reversal of coagulopathy
• BP lowering if hypertensive
• Surgery only if:
  
  • Haemorrhage with hydrocephalus
  • Lobar haemorrhage with GCS between 9 and 12
  • Cerebellar haemorrhage

In terms of what doesn’t work for ICH:

• Surgery (most of the time)
• Steroids
• Platelets
• Aspirin
• VTE prophylaxis with compression stockings or LMWH

Question 23

State some potential complications following a stroke

Answer 23

• Pneumonia (Sit up? Safe swallow?)
• Seizures
• Pressure sores
• Dehydration/malnutrition
• Constipation
• Incontinece/retention
• Depression
• Spasticity
• Venous thromboembolism