stroke review dr lindsay erwin rah paisley. definition
TRANSCRIPT
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