Professional Documents
Culture Documents
• Risk factors.
○ Hypertension
○ Smoking
○ Diabetes
○ Heart disease.
IHD
Valvular disease
AF
○ Peripheral vascular disease
○ Previous TIA
○ Raised packed cell volume
○ Caroid bruit
○ COCP
○ Raised lipids
○ Alcoholism
○ Increased clotting
Raised plasma fibrinogen
Lowered antithrombin III levels.
• Signs.
○ Sudden onset, or stepwise progression over days.
Rarely can progress over days.
○ In theory, focal signs relate to distribution of affected artery.
Can be complicated by collateral supply .
• Arterial territories.
• Carotid artery.
○ Internal carotid occlusion can cause total and fatal infarction of anterior two – thirds of:
Ipsilateral hemisphere.
Basal ganglia
○ Most commonly, picture is similar to that of middle cerebral infarction.
• Cerebral artery anatomy.
○ 3 pairs of arteries leave the circle of Willis.
○ Anterior and Middle cerebral arteries are branches of the carotid arteries.
○ Basilar artery splits to form the two posterior cerebral arteries.
○ Ischemia due to occlusion of arteries may be prevented or reduced by retrograde supply by
meningeal arteries.
• Anterior cerebral artery.
○ Supplies forntal and medial parts of cerebrum.
○ Occlusion may cause.
Weak, numb contralateral leg
Milder weak, numb contralateral arm.
Facial sparing
Bilateral infarction can cause a kinetic mutism.
• Due to damage to cingulated gyri
• Can also, rarely, cause paraplegia.
• Middle cerebral artery.
○ Supplies lateral (external) parts of the cerebral hemisphere
○ Occlusion may cause.
Contralateral hemiplegia.
Hemisensory loss.
• Mainly face and arm.
Contralateral homonymos hemianopia
• Due to involvement of optic radiation.
Cognitive change.
• Dysphagia if dominant hemisphere affected.
• Visuo – spatial disturbances if non – dominant hemisphere affected.
○ Inability to dress
○ Getting lost.
• Posterior cerebral artery.
○ Supplies occipital lobe.
○ Occlusion causes contralateral homonymous hemianopia.
Often with macula sparing.
• Vertebrobasilar circulation.
○ Supplies.
Cerebellum
Brainstem
Occipital lobes
○ Occlusion causes.
Hemianopia
Cortical blindness
Diplopia
Vertigo
Nystagmus
Hemi – or quadriplegia
Unilateral or bilateral sensory symptoms.
Hiccups
Dysarthria
Dysphagia
Coma
○ Infarctions of the brainstem can produce various syndromes.
Eg. Lateral medullary syndrome
• Occlusion of one vertebral artery or the posterior inferior cerebral artery.
• Due to infarction of lateral medulla and inferior cerebellar surface.
• Results in.
○ Vertigo with vomiting
○ Dysphagia
○ Nystagmus
○ Ipsilateral ataxia
○ Soft palate paralysis
○ Ipsilateral Horner’s syndrome
○ Crossed – pattern sensory loss.
Analgesia to pin prick on ipsilateral face and contralateral
trunk and limbs.
• Subclavian steal.
○ If there is subclavian stenosis proximal to origin of vertebral artery, use of the arm may lead to
retrograde flow away from the brain into the arm, causing brainstem ischemia.
○ Suspect if BP in arms differs by > 20 mmHg.
• Arterial dissection
○ Disection of carotid or vertebral artery causes an acute ischemic stroke.
○ Usually occurs in younger patients.
○ May have preceding neck trauma
○ Need MRI or MR angiography.
○ Treat with antiplatelets and anticoagulants
○ Most patients will be part of a RCT.
• Cerebral Venous Thrombosis
○ Rare
○ More common in.
Pregnancy.
Local infection
Dehydration
Widespread malignancy.
○ Headaches and seizures are common.
○ Require
MRI
CT
MR venography.
○ Management.
Anticoagulation
• Heparin
• Warfarin.
Investigations
• Should be done promptly to confirm diagnosis and avoid further strokes.
• Consider whether investigations will actually change management.
• Bloods
○ Glucose
○ Clotting
• CT scan.
○ Immediately if.
Thrombolysis being considered
Patient already anticoagulated
Patient has known bleeding tendency
GCS < 13
Unexplained progressive/ fluctuating symptoms
Papilloedema/ Neck stiffnes/ Fever
Severe headache at onset of stroke symptoms.
○ Otherwise get one within 24 hours.
Thrombolysis
• Normally with Alteplase
• Has to be given within 3 – 4 hours of onset of symptoms.
• Only to be given by somebody experienced in thrombolysis in an appropriate stroke unit.
○ Telemetry
○ Stroke nurses
○ 24 hour access to CT & MRI
• Must exclude haemorrhagic stroke on CT before thrombolysis is given.
• Other contraindications.
○ Age < 18
○ Age >80
○ Convulsions accompanying stroke
○ Previous stroke within 3 months
○ Severe stroke
○ Recent haemorrhage, trauma or surgery.
• Intercranial bleeds are the most significant side effects.
• Dose calculated based on patient’s weight.
○ IV boluse followed by infusion over 1 hour.
○ Costs £480 for a dose for a 75 kg person.
Other management.
• High flow oxygen if Sats < 95%
• Maintain blood glucose between 4 – 11 mmol/L
○ Use glucose and insulin protocols for stroke if diabetic.
• Ensure good hydration.
• Aspirin
○ 300 mg within 24 hours
○ If history of dyspepsia, give PPI protection but still give aspirin.
○ If aspirin allergic give clopidogrel.
○ Continue for 2 weeks, then change to definitive anti – thrombotic therapy.
• Multidisciplinary management
○ Nursing.
Monitoring bladder and bowels
Monitor for pressure sores
Co – ordinating social issues.
○ SALT & Dieticians.
Swallow assessment on admission
Nutritional assessment
Modified diet
○ Physio/ occupational therapy.
Early mobilisation & positioning
Assessment of activities of daily living with Barthel Index.
Provide.
• Mobility aids
• Exercises
• Passive stretching to prevent spasticity
• Strength training
• Task specific training.
Follow up.
• After initial management, investigate for modifiable risk factors for future stroke.
• CXR
○ Big heart suggests hypertension
○ Dilated left atrium can suggest AF.
• Echocardiogram
○ Dilated left atrium can suggest AF
○ Mural thrombus suggests previous MI
○ Endocarditis
• Carrotid artery Doppler.
○ Surgery for stenosis > 70% or rapidly progressing.
• ESR
○ Giant cell arteritis
• Syphilis screen
• FBC
○ Polycythemia.
• Clotting screen
• Sickling screen.
Complications.
• Spasticity.
○ Botox
○ Baclofen
○ Gabapentine
○ Tizanidine
• Pain.
○ Neuropathic.
Antidepressants
Anticonvulsants
○ Muskuloskeletal.
Exercise
Paracetamol
NSAIDs
Codeine.
• Depression/ Emotionaluism.
○ Increase social interaction
○ Exercise
○ Set goals.
○ Antidepressants
• Anxiety.
○ Provide information and support.
○ Desensitise
○ CBT
• Malignant Middle Cerebral Artery infarction.
○ Rare
○ Life threatening
○ Space occupying brain oedema.
Affects younger patients more often due to lack of brain atrophy meaning less space
to expand.
○ Presents within 2 – 5 days of stroke.
○ Treatment with Decompressive Hemicraniectomy if:
Age > 60 years
NIHSS score of > 15
Decreased level of consciousness
CT signs of infarct in > 50% of middle cerebral artery territory.
Management of Haemorrhagic stroke.
• Reverse any anticoagulation.
○ Prothrombin complex concentrate
○ IV Vitamin K
• Surgery if hydrocephalus develops
○ Carotid endarterectomy.
If origin of carotid has > 70% stenosis, and risk of stroke greater than that of surgery.
• Surgery risk increased by:
○ Female
○ Age > 75
○ High SBP
○ Contralateral carotid occlusion
○ Stenosis of ipsilateral carotid siphon/ external carotid.
○ Wide territory TIA vs. Amaurosis fugax
For benefit to outweight stroke risk, death rate from surgery must be < 3%
Intra – operative Doppler can monitor middle cerebral artery flow.
Using patches may reduce chances of restenosis.
Don’t stop aspirin until after surgery.
Do surgery within 2 weeks of TIA.
○ Avoid driving for at least 1 month.
○ MRI/CT if.
Unclear which territory has been affected.
Patient is on anticoagulant and a bleed is possible.
If other diagnoses are suspected.
• Migraine
• Epilepsy
• Tumour.
• Prognosis.
○ Combination risk of stroke and MI is 9% per year.
○ Risk of stroke is 12% in first year after TIA
○ Risk is > 10% in subsequent years if carotid stenosis is > 70%
○ Mortality is 3 times that of the TIA – free population.
○ In one study, 60% of patients are dead within 10 years of a TIA.