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Stroke

From Mediwikis

This focal neurological deficit can be caused by either infarction or haemorrhage, the former being more common, accounting for 85% of cases. Risk factors include smoking, alcoholism, high blood pressure, Diabetes, or previous stroke/TIA.

Symptoms

Are diverse depending on the area affected, but are acute onset of:

  • Unilateral facial drooping, limb weakness, loss of sensation, Speech Problems, visual field changes, disturbances to memory and other higher brain function eg movement planning, personality.

Signs that can be elicited by the bedside:

  • Abnormal reflexes(reduced, increased, or odd, e.g. upcurling plantars), reduced sensation in specific areas, reduced power in limb(s), nystagmus, altered gait.

Try and identify the location of the stroke using your knowledge of functional anatomy- remember that the ACA supplies the top "mohawk" section of the brain, the MCA supplies the sides, and PCA supplies the posterior end.

Total Anterior Circulation Syndrome

Higher dysfunction, homonymous hemianopia, motor/sensory dysfunction to 2 of legs, arms, face.

Partial Anterior Circulation Syndrome

2 of the above 3 criteria, OR higher dysfunction alone, OR partial motor/sensory deficit.

Posterior Circulation Syndrome

Any of Cranial Nerve palsy, Bilateral motor/sensory deficit, Cerebellar dysfunction, Homonymous Hemianopia(alone).

Lacunar Circulation Syndrome

Any of Purely motor deficit, Purely sensory deficit, Ataxia, Dyspraxia

Investigations

CT to identify infarct vs haemorrhage. Carotid Doppler to find Carotid plaques.

Management

The longer a stroke is left untreated, the more nerve cells die, increasing the risk of brain damage. Therefore Time=Brain.

Acute Management

Further Management

ABCs, then for infarct, typically thrombolysed with Alteplase, then give Aspirin, and statins. Haemorrhagic strokes may require more finesse via neurosurgery, or at least anticoagulants and antithrombotics.

Secondary Prevention

Fibrates may be beneficial in preventing further CVA[1]

Impact

Physical

  • Immobility
  • Incontinence
  • Visual Impairment
  • Dysphagia
  • Dysphasia

Psychological

  • Mood changes
  • Cognitive impairment

Social

  • Driving
  • Jobs
  • Dependence on carers eg relatives
  • Relationships (both getting into one, and maintaining one)

Scoring Systems

FAST

  • Face
  • Arms
  • Speech
  • Time to go to hospital

Rosier [2]

Example Yes No
Has there been loss of consciousness or syncope? -1 0
Has there been seizure activity? -1 0
Is there a NEW ACUTE onset:
Asymmetric facial weakness 1 0
Asymmetric arm weakness 1 0
Asymmetric leg weakness 1 0
Speech disturbance 1 0
Visual field defect 1 0

Score > 0 means high probability of stroke.

ABCD2 TIA tool[3]

Age>60 +1
Blood pressure >140/90mmHg +1
Clinical Features:
Unilateral Weakness +2
Speech Disturbance without weakness +1
Other 0
Duration:
>60 minutes +2
10-60 minutes +1
<10 minutes 0
Diabetes +1

If score > 5, treat urgently:

ABCD2 Score Risk of Stroke at 2 days
0-3 1%
4-5 4%
6-7 8%

References

  1. Wang D, Liu B, Tao W, Hao Z, Liu M. Fibrates for secondary prevention of cardiovascular disease and stroke. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD009580. DOI: 10.1002/14651858.CD009580.pub2
  2. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. The Lancet Neurology, Volume 4, Issue 11, Pages 727 - 734, November 2005
  3. Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S. (2007) Lancet, 369, 283-292.