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Stroke review for undergraduate medical education

Stroke review for undergraduate medical education

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  • In the uK someone has a stroke every 5 minutes. 1/3 recover, 1/3 have disability, 1/3 die. 3 rd biggest uk killer.
  • Alteplase Hemicraniectomy: if referred within 24 hours of onset of symptoms and treated within a maximum of 48 hours. If aged 60 years or under. Clinical deficits suggestive of infarction in the territory of the middle cerebral artery, with a score on the National Institutes of Health Stroke Scale (NIHSS) of above 15. Decrease in the level of consciousness to give a score of 1 or more on item 1a of the NIHSS. Signs on CT of an infarct of at least 50% of the middle cerebral artery territory, with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume greater than 145 cm3 as shown on diffusion-weighted MRI.
  • Clotting reversal: prothrombin complex concentrate and intravenous vitamin K.

Stroke Stroke Presentation Transcript

  • Stroke Mark HallClinical Teaching Fellow pathways for clinical learning
  • Objectives• Revise definitions of stroke and TIA• Discuss how a patient with a stroke presents and stroke mimics• Elicit a relevant history from a patient with suspected stroke• Examine a patient with suspected stroke• Revise initial investigation and treatment of a patient with suspected stroke pathways for clinical learning
  • What is a stroke?“…a clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin.” Hatano S. Experience from a multicentre stroke register: a preliminary report. Bulletin of the World Health Organisation 1976;54(5):541–553. pathways for clinical learning
  • What is a TIA?“A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours.”Hatano S. Experience from a multicentre stroke register: a preliminary report.Bulletin of the World Health Organisation 1976;54(5):541–553.The National Collaborating Centre for Chronic Conditions National clinicalguideline for diagnosis and initial management of acute stroke andtransient ischaemic attack (TIA). Royal College of Physicians London 2008 pathways for clinical learning
  • Stroke• Stroke is the third commonest cause of death and the most frequent cause of severe adult disability in Scotland• High mortality (10 - 20% at 30 days)• 50% of survivors are dependent• 10% will have a recurrence within 1 year pathways for clinical learning
  • Stroke - Causes• Causes of stroke – Ischaemic (80 %) • Embolic (AF, embolus from metallic valve, carotid artery plaque) • Atherosclerotic • Prothrombotic state – Haemorrhagic (10-20 %) • Hypertension • Cerebral artery aneurysm • Over-anticoagulation • Bleeding diathesis pathways for clinical learning
  • Stroke – Risk Factors• Risk factors – Age – Smoking – Family history – Hypertension – Diabetes – Hyperlipidaemia – AF, prothrombotic state pathways for clinical learning
  • The Brainpathways for clinical learning
  • How might a person with a stroke present? pathways for clinical learning
  • How might a person with a stroke present?• Arm weakness• Leg weakness• Facial Droop• Slurred speech• Unable to get the right words out• Uncomprehending• Falls• Fractures pathways for clinical learning
  • History(who gives the history?)• Onset• Symptoms• Time course• Risk factors• Past Medical History• Medications pathways for clinical learning
  • Examination• Pronator drift •Cranial Nerves• Tone •Gait• Power •Visual Fields• Reflexes •Speech• Coordination •Comprehension •Swallow pathways for clinical learning
  • Which Pattern?Upper Motor Neuron Lower Motor Neuron• Muscle weakness • Muscle weakness• Increased Tone • Fasciculations• Increased Reflexes • Decreased tone• Up going plantar - • Decreased reflexes Babinski • Absent Babinski pathways for clinical learning
  • pathways for clinical learning
  • Clinical assessment• Hemianopias pathways for clinical learning
  • • Expressive dysphasia – ‘telegraphic speech’• Receptive dysphasia – Fluent meaningless speech – Neologisms pathways for clinical learning
  • pathways for clinical learning
  • pathways for clinical learning
  • pathways for clinical learning
  • pathways for clinical learning
  • pathways for clinical learning
  • Classification of Stroke• TACS (Total anterior circulation stroke) – A combination of: • New higher cerebral dysfunction (eg: dysphasia) • Homonymous visual field defect • Motor and / or sensory deficit of (at least 2 of) face / arm / leg• PACS (partial anterior circulation stroke) – 2 or 3 of TACS – OR New higher cerebral dysfunction alone (eg: dysphasia) – OR motor or sensory deficit more restricted than for LACS• LACS (Lacunar anterior circulation stroke) – Pure motor • Unilateral weakness (2 or 3 of face / arm / leg) – Pure sensory • Unilateral sensory disturbance (2 or 3 of face / arm / leg) – Sensory motor (combination of above) – Ataxic hemiparesis • Hemiparesis with ipselateral cerebellar ataxia• POCS (posterior circulation stroke) – Cerebellar dysfunction – Brainstem signs – Occipital lobe dysfunction – Bilateral weakness / sensory dysfunction – Ipselateral CN palsy with contralateral weakness (crossed signs) pathways for clinical learning
  • Investigations pathways for clinical learning
  • Investigations• Bloods• ECG• CXR• CT Brain• (echocardiogram)• (carotid doppler) pathways for clinical learning
  • pathways for clinical learning
  • Current guidance - evaluation• NIHSS (National Institute of Health Stroke Scale) – To evaluate neurological status / predict severity of Stroke – Complete hemiparesis with dysphasia, dysarthria, hemianopia and sensory loss scores 25+ (often cut off point for thrombolysis) pathways for clinical learning
  • Current guidance – Acute Stroke Care• NICE pathway - Acute stroke• SIGN guidance 108• Perform brain imaging (CT scan) immediately if: – Indications for thrombolysis – Possible haemorrhage / RICP • On anticoagulant treatment • Known bleeding tendency • Reduced consciousness (GCS <13) • Unexplained progressive or fluctuating symptoms • Papilloedema, neck stiffness or fever • Severe headache at onset of stroke symptoms • Brainstem or cerebellar stroke• Otherwise imaging ASAP (within 24 hours) pathways for clinical learning
  • Current guidance – Acute Stroke Care• Criteria for thrombolysis – No sign of haemorrhage on immediate brain imaging – Definite onset within 4.5 hours – No contraindications • These may be relative depending on clinical picture – discuss with stroke team on call• Acute stroke unit admission pathways for clinical learning
  • Contraindications to thrombolysis• Bleeding – Known history of or suspected intracranial haemorrhage – Anticoagulants (except warfarin if INR<1.4) – Treated with LMW Heparin within last 48 hours & APTT is still raised – Platelet count of below 100,000/mm3 – Known haemorrhagic diathesis – Severe liver disease – GI / Menstrual / urinary bleeding during the last 21 days – Major surgery or significant trauma in last 14 day• Physical status – Seizure at onset of stroke – BP > 185 mmHg systolic (or diastolic > 110 mmHg) – BM < 2.8 or > 22 mmol/l – Bacterial Endocarditis / Pericarditis – Symptoms rapidly improving before thrombolysis – NIH Stroke Scale <5 (very minor neurological deficit) or > 25 (very severe)• Other – Head injury within the last 3/12 – Other stroke within last 3/12 – History of stroke PLUS diabetes pathways for clinical learning
  • Stroke mimics• Seizure• Hypoglycaemia• Electrolyte disturbance (Na+, Ca++)• Subdural haematoma• Brain tumour• Lower Motor Neurone Lesion pathways for clinical learning
  • Treatment-ischaemic/embolic• Consider thrombolysis• Aspirin 300mg od for 2 weeks then clopidogrel 75mg od• Statin• Surgery? pathways for clinical learning
  • Treatment-haemorrhagic• Reverse anticoagulation• Surgery is rarely needed• Usually for hydrocephalus• Monitor for neurological deterioration• Re-image pathways for clinical learning
  • Complications of stroke• Pressure sores• Pneumonia (including aspiration)• DVT / PE• UTI• Incontinence• Depression• Seizures• Fatigue• Spasticity / contractures• Shoulder pain• Impact on relationships / driving / work / independence pathways for clinical learning
  • Transient Ischaemic Attack• TIA – Sudden onset neurological dysfunction lasting < 24 hours – Often lasts for minutes – No lasting structural neurological damage – Aetiology as for stroke – May predict future stroke • Scoring scales for likelihood • Secondary prevention pathways for clinical learning
  • • TIA – risk stratification a TIA ABCD2 algorithm predicts very early risk of stroke following – A – Age • >60 =1 – B – Blood pressure • >140/90 mmHg = 1 – C – Clinical features of the TIA • Unilateral weakness = 2 • Speech disturbance without weakness = 1 – D1 – Duration of symptoms • > 60 min = 2 • 10-59 min = 1 • <10 min = 0 – D2 – Diabetes • Diagnosed with diabetes = 1• The corresponding 2 day risks for a subsequent stroke are – ABCD2 scores • 0-3 = 1% (low risk, Start Aspirin 300mg OD and refer to TIA clinic) • 4-5 = 4% (High risk, consider admission. Aspirin 300mg OD, urgent TIA clinic) • 6-7 = 8% (As above) pathways forSC et al (2007)learning283-292 Johnston clinical Lancet, 369,
  • TIA - management• Start Aspirin 300mg OD• Depending on ABCD2 – Admit to hospital – Refer to TIA clinic (within 24 hours or 1 week)• Secondary prevention as per stroke• Consider Anticoagulation if in AF – Based on CHADS2VASC score • Calculates stroke risk for patients with AF pathways for clinical learning
  • AF – risk stratification• CHADS2 VASc Score – Congestive Cardiac Failure = 1 – Hypertension = 1 – Age 65-74 years = 1 – Age > 75 years = 2 – Diabetes = 1 – Stroke / TIA history = 2 – Vascular Disease (PVD or IHD) = 1 – Sex (Female) = 1 – Maximum Score 9 points • 0 = Low risk, no need to anticoagulant • 1 = Low – Moderate risk, consider oral anticoagulation or Aspirin • 2 = High risk, consider oral anticoagulation pathways for clinical learning
  • Summary• Act FAST• Think of thrombolysis early• Focus on onset (sudden/stuttering)• Ask about progress• Ask yourself – Have they had a stroke? – If they have had a stroke, why?• Examine carefully – look for patterns pathways for clinical learning
  • Summary• Remember to assess swallow and act accordingly• Communication is vital – take time to do it well• Haemorrhage – reverse anticoagulation – think about hydrocephalus• Infarct – Aspirin 300mg od for 2 weeks then clopidogrel 75mg od pathways for clinical learning
  • Further Reading• Hacke, W., Kaste, M., Bluhmki, E., Brozman, M., Dávalos, A., Guidetti, D., Larrue, V., Lees, K., Medeghri, Z., Machnig, T., Schneider, D., von Kummer, R., Wahlgren, N., Toni, D. and the ECASS Investigators (2008) Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. The New England Journal of Medicine,359(13), 1317-1329.• SIGN guideline 118 http://www.sign.ac.uk/pdf/sign118.pdf• SIGN guideline 108 http://www.sign.ac.uk/pdf/sign108.pdf pathways for clinical learning