Week 9 - Stroke

Question 1

What are the risk factors for stroke

Answer 1

Non-Modifiable:
- Age
- risk doubles every year after 55
- Gender
- men = at higher risk
- female = more likely to die from stroke
- Family history
- Afro-caribbean

Modifiable:
- Smoking
- Hypertension
- Hyperlipidemia
- Diabetes
- Atrial fibrilation

Question 2

What are the symtpoms of a stoke

Answer 2

• droopy face
• loosing power on one side

Question 3

What are the 2 main types of stroke

NOTE: both are treated DIFFERENTLY

Answer 3

1. Ischaemic
   - blood supply is disrupted due clot or plaque
   - MOST common
2. Haemorrhagic
   • bleeding in the brain

Transiet Ischaemic Attack (TIA) - symptoms of stroke that resolve within 24hrs
- lasts 5-10 minutes

In stroke symptoms last 24hrs if not resolved immediately

Question 4

What are the 2 causes of Ischaemic stroke

Answer 4

1. Cerebal Thrombosis
   
   • have fatty depsoits in vessel = clump together = athersclerosis plaque / clot
   • clot blocks brain vessel
2. Distal Embolism
   
   • a clot somewhere else in body that travels to brain + lodges in vessel

Question 5

What are the 2 causes of Haemorrhagic stroke

Answer 5

1. Intracerebal
   
   • rupture of small vessel in brain
2. Subarachnoid
   
   • rupture of intracranial aneurism in subarachnoid space (lining of brain)

Question 6

How is the type of stroke diagnosed

Answer 6

1. Rule out other possible causes
   
   • e.g. seizeures, drug toxicity, brain tumour, migraine (with aura)
2. CT Scan
   
   • is quick procedure compared to MRI
   • Ischaemic - diff. to spot, clinican has to use clinical knowledge
   • Haemorrhagic - easier to spot / very visible (areas will appear very bright on scan)
3. MRI Scan
   - time-consuming
4. BP (cardiac events)
5. ECG (clotting, renal)
6. FBC and U&Es
7. Blood glucose (undiagnosed diabetes)
8. Inflammatory markers (infection, cancer)

Question 7

What happens after diagnosis

Answer 7

1. Patient transferred to hyper-acute stroke unit
   - only stay here whilst medically unstable
2. Once stable patient moved to stroke rehab unit or general medical ward

NOTE: NO treatment is admintsered until CT scan back to confirm diagnosis

Question 8

List the drugs used ACUTELY in IMMEDIATE ISCHAEMIC stroke treatment

Acute = done immediately after stroke diagnosis

Answer 8

1. Thrombolysis
   
   • DRUG USED: Altepase
     Works best when:
   • given within 3hrs of symptom onset (can be given up to 4.5hrs)
   • 2x as effective if given within 1.5hrs
   • CAUTION: risk of bleeding
   • CAUTION: >80 (complication of stroke ~ haemorrhagic transformation = bleeding)
   • CONTRAINDICATION: atrial fibrilation
2. Thrombectomy
   
   • surgery to remove clot
   • NOT receieved by all patients
3. Aspirin 300mg (anti-platelet)
   
   • for 14 days
   • given to ALL ischaemic patients
     - IF patient THROMBOLYSED = wait 24hrs + another CT scan (no bleed) before initiating aspirin

Question 9

List the drugs used ACUTELY in IMMEDIATE HAEMORRHAGIC stroke treatment

Acute = done immediately after stroke diagnosis

Answer 9

1. Anticoagulants are STOPPED and REVERSED
   
   • drugs stopped include: warfarin, aspirin, NSAIDS
   • if on warfarin GIVEN Vitamin K (reverse)
2. Analgesia for headache
   
   • inc. paracetamol OR codeine
3. Neurosurgical Intervention
   
   • clipping or coiling ruptured aneurysm

NOTE for subarachnoid haemorrhage
- Give Nimodipine
- 60mg 6 x daily for 21 days
- MUST be strated within 4 days
- To minimise secondary cerebral ischaemia

Question 10

How and when do we control BP for both types of strokes: Acute treatment

BP = blood pressure

Answer 10

Fluctuating (high) BP is common after acute stroke
- will resolve itself
- if need to control use IV routes (short-acting = can be removed from body quick)

Ischaemic:
- ONLY manage high BP if patient is eleigble for thrombolysis or hypertensive emergency
- BP for thrombolysis < 185/110 mmHg
- High BP CAUSE: brain detects lack of O2 = body sends more blood to brain

Haemorrhagic:
- AIM: 130-140 systolic for 7 days
- TREAT if:
- within 6hrs of symptoms >150mmHg systolic
- after 6hrs of >220mmHg

Question 11

What other factors need to be monitored / assesed: Acute Treatment

Answer 11

1. Ability to swallow (seen by SALT)
   - may have to change formulations / route of administartion
2. FLuid balance is montored + fluids replaced if needed
   - prevent dehydration / fluid overload
3. Monitor temp.
   - can be high after stroke
   - use paracetamol to reduce
4. Control blood glucose
   - using IV insulin
5. DVT prophylaxis
   - use intermittent pneumatic compression (a machine the expands + collapses around their leg)

Question 12

How do we prevent further strokes: Long-term Management

4 things

Answer 12

For BOTH Ischaemic and Haemorrahgic:
1. Control hypertension
2. Control blood glucose

For Ischaemic:
1. Use antiplatelet (or anticoagualnt)
2. Control cholesterol

Question 13

Why do we control hypertension: Long-term Management

BOTH Ischaemic and Haemorrahgic

Answer 13

↓ risk of further strokes in hypertensive AND non-hypertensive patients
START after 2 weeks (stroke occured)

• USE: Antihypertensives
  
  • if >55 OR Afro-Caribbean = USE CCB or thiazide-diuretic
  • if young patient = USE ACE inhibitor
• AIM: <130mmHg systolic

Question 14

Why do we control blood glucose: Long-term Management

BOTH Ischaemic and Haemorrahgic

Answer 14

Controlled in both diabetic and non-diabetic pateints

Question 15

Why is a long-term antiplatelet (or anticoagulant used)

Ischaemic ONLY

Answer 15

Started after finishing 2 weeks of 300mg Aspirin

• USE: Clopidogrel 75mg OR Aspirin 75mg
• Anticoagulant: Warafrin OR DOAC
  - DOAC = apixaban, rivoroxaban (5mg BD)
  - DOAC: monitor renal function, bleeding risk, adherance

Question 16

Why do we lower cholesterol: Long-term Management

Ischaemic ONLY (unless haemorrhagic patient has CV risk)

Answer 16

Many strokes are caused by arthersclerosis (fatty plaques in vessels)

• USE: Statins (e.g. atorvastatin 20-80mg)
  - higher dose used if patien has CV risk factors
• AIM: to lower lcholesterol / lipid levels

Question 17

What are the 5 complications of stroke

Answer 17

1. Swallowing difficulties
2. ↑ risk of depression
3. Dry mouth OR Drooling
4. Seizures
5. Muscle spasticity

Question 18

How do we pharmacologically manage stroke complications

Answer 18

1. Swallowing difficulties
   - change formulations to liquids
   - LOOK under suggestions / reccomendations heading
   - if have limited swallowing can add meds. to thickened liquid
   - may need temp. NG tube
   - OR may need perm. PEG tube (surgical procedure, tube inserted rhtough skin into GI tract)
   - with tubes: dilute meds with water, admisnter then flush tube out with 50ml of water
2. ↑ risk of depression
   - depression screening annually
   - anti-depressants (NICE Guidelines)
3. Dry mouth OR Drooling
   - use artifical saliva
   - hysocine patch
4. Seizures
   - if diagnosed as epileptic given antiepileptic drug
5. Muscle spasticity
   - use muscle relaxants e.g. balcofen
   - inject muscle spasms with botox