STROKE REVIEW

Dr Lindsay Erwin

RAH Paisley

Definition

Sudden onset of focal or global

loss of cerebral function

TRANSIENT

MONOCULAR

BLINDNESS

OR

CORTEX ANATOMY

CORTEX MAP

Stroke mimics

Seizure

Mass lesion

Migraine

Hypoglycemia

Systemic infection

Toxic-metabolic encephalopathy

Multiple sclerosis

Intracranial (sub / epidural) hematoma

Taci – Total Anterior Circulation

Paci – Partial Anterior Circulation

Laci - Lacunar

Poci – Posterior Circulation

Different Mechanisms / Aetiology

+ Outcome

CLASSIFICATION

1 unilateral weakness (and / or sensory deficit) affecting face.

2 unilateral weakness (and / or sensory deficit) affecting arm

3 unilateral weakness (and / or sensory deficit) affecting hand

4 unilateral weakness (and / or sensory deficit) affecting leg

5 unilateral weakness (and / or sensory deficit) affecting foot

6 Dysphasia, dyslexia, dysgraphia, (i.e. dominant hemisphere cortical)

7 Visuospatial disorder / inattention / neglect (i.e. non – dominant hemisphere)

8 Homonomous hemianopias/ or quadrantopia

9 Brainstem / cerebellar signs other than ataxic hemiparesis

10 Other deficit

TACS 1+2+3+4+5+6+7

LACS 1+2+3+4+5 OR 1+2+3 OR 2+3+4+5

POCS 8 OR 9 OR 8 +9

PACS Other combinations excluding 9 and 10

CLASSIFICATION

Small vessel block

Big vessel block – good collateral

Big vessel block – no collateral

Stroke Types

• Bleeds - 20%- subdural- subarachnoid- intracerebral

• Infarcts - 80%- atheroembolic- borderzone- vasculitis

Stroke Types - subdural

Trauma usual cause

Stroke Types - subarachnoid

Aneurysm rupture common cause.

“Worst headache”

Stroke Types - intracerebral bleed

OFTEN HAVE HEADACHE, DROWSINESS, HBP AT ONSET

Atheroembolic; source anywhere from heart to intracranial vessels

Stroke Types - Infarct sources

Stroke Types - borderzone

Low flow - usually hypotension; blood loss / cardiac arrest

Stroke Types - vasculitis

Primary vasculitis:

Giant cell

Takayasu’s

Polyarteritis nodosa

Churg Strauss

Wegener’s

Secondary vasculitis

LupusRheumatoidSjogren’sDrug induced immune

Risk factors / etiologyHBP

Hypotension

Lipids

AF

Endocarditis

Smoking / alcohol

Diabetes

Drugs

Trauma

Genetics

HBP

Risk factors / etiologyLipids

Atheroma

Risk factors - Lipids Primary prevention

QuickTime™ and a decompressor

are needed to see this picture.

Risk factors - Lipids Stroke prevention -SPARCL

Risk factors / etiology AF

AF affects 5% of people > 65

Atrial Fibrillation

• Aspirin minimally effective

- 22% risk reduction

• Warfarin best protection

- 62% risk reduction

• Need tight INR control -- INR 2 - 3.

• How to make it safe??

AF - CHADS2

• C ONGESTIVE FAILURE 1

• H YPERTENSION 1

• A GE > 75 1

• D IABETES 1

• S TROKE OR TIA 2

AF – CHADS risk score

Risk factors / etiology

Hypotension

Smoking / alcohol

Diabetes

Drugs

Trauma

Genetics

Cardioembolism

PFO

May allow paradoxical embolism.

Risk higher if PFO and atrial septal aneurysm.

Getting the blood to flow!

Thomas, S. H. et al. N Engl J Med 2006;354:2263-2271

Representation of Penumbra in Acute Stroke.

ACUTE CARE

Time of onset.

Any fluctuation in symptoms?

Previous stroke, TIA, recent head injury or fall? Witness report if anyone available.

Confirm current drugs, especially antiplatelet agents and anticoagulants.

Check Baseline Bloods U/E, FBC and GLUCOSE.

Immediate CT if any possibility of thrombolysis, fluctuating GCS, pyrexia, patient on warfarin.

ECG & Chest X-ray

Next StepsHypoxic patients (saturation <95%) should have Oxygen

Start I.V. saline as necessary. Avoid dextrose on day 1.

Swallow assessment ASAP. NBM till then.

If no bleed, start aspirin. If on aspirin, stop

on admission, and resume if no bleed.

Rectal aspirin if unable to swallow.

Blood Pressure should not be lowered unless encephalopathy or aortic dissection or BP VERY high

Next Steps 2

Hyperglycaemia – treat if diabetic. Avoid hypo;

DVT prophylaxis – If leg paralysis, heparin is not indicated unless there is co-existing DVT or PE.

Pyrexia over 37 C must be treated at once by oral or rectal paracetamol.

Nursing Assessments – pressure area risks, fluid balance, weight. Avoid catheter unless critical for measuring output or to relieve retention.

Continuing Management

Refer to Stroke Team within 24 hours of admission

Transfer to Stroke Unit / Stroke \Team Care same day if possible

Why?

Continuing Management – Stroke Unit

Meta-analysis by the Stroke Unit Trialist's collaboration

18% + reduction in death or dependencedeath or need of institutional care.

Absolute changes were a 3% reduction in all cause mortality (NNT 33), a 3% reduction in the need for nursing home care, and a 6% increase in the number of independent survivors (NNT 16).

Also 14 days less hospital stay

Acute Treatment

• Easy – early aspirin for almost all.

• 10 in 1000 extra will walk out

• Harder – thrombolysis for a few.

• 1 in 10 extra will walk out

Per 1000 treated

• Intracranial bleed NNH 22

• Death NNT 236

• Death / Dependent NNT 10

• 1 or more point >mRS NNT 3

Will it work?

•THE EARLIER THE BETTER

Reverse coagulopathy

Refer neurosurgery for cerebellar bleeds

Less evidence for other sites

? > 30ml near the surface.

Bleeds

Is it a TIA?

Sudden onset of focal or global

loss of cerebral function

TRANSIENT

MONOCULAR

BLINDNESS

OR

Is it a stroke /TIA?

POSITIVE FEATURES - TIA LESS LIKELY

TINGLING rather than numbness

Flashing lights rather than loss of vision

Jerking rather than paralysis

Depends on a good history / witness statement

Is it a stroke / TIA?

23% of strokes preceded by TIA

stroke risk after TIA: 2 days - 3.1%

7 days - 5.2%

90 days - 10.5%

ABCD2 Score

A) Age 60 or older = 1

B) Raised BP – systolic > 140 / diastolic > 90 = 1

C) Unilateral weakness = 2 Speech disturbance without weakness = 1 other = 0

D) Duration > 60 min = 2 10 - 59 min = 1 < 10 min = 0D) Diabetes = 1

3 or over is significant6/7 may need admitted.

ABCD 2 SCORE - risk prediction

Is the ABCD Score Useful…… TRIAGE of TIA with MRI

MRI DWI +ve scans thought to be extra useful

STROKE RATE after TIAEXPRESS study

Risk of recurrent stroke after first seeking medical attention in patients with TIA

ROTHWELL, The Lancet 2007;370:1432-144

Before

After

INITIAL MANAGEMENT OF TIA

Establish diagnosis / Check risk factors:

Aspirin Cholesterol Blood Pressure AF

Diabetes Ischaemic Heart Disease PVD

Carotid disease Cardioembolic source

If “classic” TIA < 20 min, may give aspirin till seen at OPC.

Risk factor reduction

Blood pressure to target ~ 130 / 80

Cholesterol to target ~ <4.0 mmol/l

Antiplatelet drugs:

Anticoagulation for AF

Lifestyle advice

Drug treatment

Blood pressure: diuretic / ACE combination

Cholesterol - simvaststatin / atorvastatin

Antiplatelet: aspirin 300 mg for 2 weeks, then 75mg; clopidogrel 75 mg or aspirin + dipyridamole retard

Anticoagulation for AF - INR 2 - 3

Recurrence

1 month 1yr 2 yrs 3yr11.4 17.1 20.7 26.7

BLEEDS: 20 - 42 % DEATH RATE AT 1 MONTH

(worst in men >75)

REINFARCTS: 12 % FIRST YR 4-5% / YR AFTER

VASCULAR DEATH %

Road to Recovery -

Sitting balance first, standing unsupported, walking, then independence

Why did it get worse?

• Stroke in progression

• Vessel re-embolises / dissects

• Bleed into infarcted area

• Seizure

• Hypoxia

• Underperfusion

If only I had / hadn’t………

• Usually not true - inevitable.

• The usual ONLYwarning is a TIA.

• Long term primary prevention best

• ….even then

• Could prevent only half of all stroke.

Is that his last slide??

Dr Lindsay Erwin

RAH Paisley

Lindsay.erwin at rah scot nhs uk