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Objectives
Define & differentiate stroke & TIA
Discuss management
Definition
Clinical diagnosis Stroke:
Stroke
The most common presentation is hemiplegia
85% caused by thromboembolic vascular occlusion Haemorrhagic strokes are often secondary to chronic
HTN (leading to rupture of microaneurysms)
TIA
Symptoms are usually of sudden onset, often
recurrent & repeat episodes are often stereotypical
Maximum deficit reached in <1m Due to focal hypoperfusion in the brain Up to 20% patients will have a subsequent stroke
within 90 days (half of these in first 2 days)
Epidemiology
Commonest cause of adult disability 12% all deaths 5% NHS budget Stroke incidence = 150-200 per 100,000/yr TIA incidence = 30 cases per 100,000/yr Incidence rates increase with advancing age
Prognosis of stroke
Worse prognosis:
Intracerebral haemorrhage has greater mortality but better functional recovery from acute, severe deficits
Common aetiologies
Atherosclerosis
Risk Factors
H - Hypertension: major RF for both ischaemic & haemorrhagic stroke A - cArdiac: Cardiac causes (AF, Arrhythmias, cardiomyopathy, valve disease etc linked to embolism) & coronary Artery disease is marker for atherosclerosis elsewhere L - hyperLipidaemia: less significant than in coronary artery disease
Oral contraceptive pill: may increase risk of thromboembolic stroke, central venous thrombosis & subarachnoid haemorrhage in the vulnerable
But, can occur in any part of the cortex, pons or cerebellum Clinical signs vary by location but often associated with mass
effect with reduced consciousness
Localisation
Arterial supply
Posterior communicating artery Posterior cerebral artery Basilar artery Junction of vertebral arteries
Circle of Willis
www.meducation.net/encyclopedia/27006
Vascular territories
http://missinglink.ucsf.edu
MCA is the artery most commonly involved in stroke Largest branch of the internal carotid & supplies the largest area of cerebral cortex Wernicke's & Broca's are found in the dominant hemisphere, therefore in most individuals speech will only be affected by a left MCA occlusion Non-dominant lesions cause visuospatial problems eg inattention Initially limbs are flaccid & areflexic; then reflexes recover & exaggerate; plantar responses become extensor and spastic limb tone develops There is variable weakness over days, weeks or months
Motor cortex
Visuospatial
Sensory cortex
Hemianopia
http://medical-dictionary.thefreedictionary.com/homonymous+hemianopia
Lacunar stroke
25% ischaemic strokes
Hemisensory loss
Ataxic hemiparesis
Opthalmic artery
Amourosis fugax
Complete visual loss with reduced/no insight Ipsilateral third nerve palsy with contralateral
hemiplegia
'Locked-in' syndrome
Specific brainstem syndromes
Patient is conscious
History
Onset - spread of symptoms; warning TIA? Focal symptoms - language/motor/sensory/visual
Examination
CVS:
embolus (pulse for AF, bruits esp carotid, valve lesion, signs of endocarditis) hypertension (BP, lying & standing) stenosis (asymmetric brachial BPs, pulse delay)
Chest:
Neuro:
Stroke
Seizure Systemic infection Brain tumour Toxic-metabolic
Most likely
Least likely
Basic Investigations
FBC: polycythaemia, infection
ESR & CRP: inflammatory disease Urinalysis & blood sugar: diabetes mellitus Cholesterol Blood culture: if suspect endocarditis or superadded infection Autoantibodies & coagulation studies: in young patients connective tissue disorder or prothrombotic disorder ECG/echo: arrhythmia; myocardial infection/ischaemia
Neuroimaging
All stroke patients should have a CT scan <24h to
differentiate ischaemia & haemorrhage
Vascular imaging
Carotid doppler: Effective, non-invasive demonstration of internal carotid artery stenosis when carotid bruit heard or carotid thromboembolism suspected
CTA & MRA CT & MR angiography (CTA & MRA) can help visualise carotids & posterior circulation for atheromatous disease, dissections & aneurysms
Angiography: Used to locate intracerebral aneurysms and diagnose cerebral vasculitides which are poorly detected on MRA Do not consider in first 2 weeks after acute stroke
Management
Neurological:
Non-neurological:
Cerebral oedema
Completion of stroke Early recurrence Haemorrhagic transformation Obstructive hydrocephalus Seizures Incorrect diagnosis
Large 'malignant' MCA territory infarcts are the commonest cause of death in the first week (peaks at 24h & 4-5 days) Severe hemispheric stroke syndrome; hemiplegia; forced eye & head deviation; progressive deterioration within 1st 2 days CT signs of infarct within 12 hours 80% mortality
Steroids have no effect on outcome Mannitol has no effect on outcome but may stabilise rapidly deteriorating patient Early hemicraniectomy improves survival & functional outcome almost threefold (NNT=2)
Rehabilitation
Control hypertension if >220/120 Give aspirin (300mg)/dipyridamole or clopidogrel
Control cholesterol
Smoking cessation advice Good glycaemic control Remove/treat embolic source (nb no anticoagulation in 1st 7 days even if indicated for cardiac embolus) Treat inflammatory or connective tissue disorders
Carotid endarterectomy
Disadvantages of a procedure: Significant risk of inducing stroke Risk of CN palsy or cardiac event Neck incision/haematoma
Criteria for intervention: 70% or more stenosis of internal carotid artery ipsilateral to affected cortex (contralateral to symptoms) 50-69% stenosis considered <50% stenosis not suitable for surgery
Management of TIA
Confirm diagnosis (history & examination) Refer immediately to A&E for any 1 of the following: Symptoms present at time of assessment ABCD2 score 4 or more & within 7 days of symptoms
Patient in AF
Patient with recurrent TIAs
ABCD2 Score
Criteria Age Qualifier 60 yrs + Points 1
Under 60
BP Over 140 Under 90 Clinical features Unilat weakness Speech disturbance only
0
1 0 2 1
Other
Duration of Sx Over 1 hour 10-59 mins Under 10 mins Diabetes
0
2 1 0 1
Management of TIA
Identify & treat risk factors
Aspirin/dipyridamole or clopidogrel Avoid anticoagulants (heparin/warfarin) in the short
term unless clear need eg AF
Driving
Patients with suspected TIA or stroke must not drive
for 1 month
Lifestyle interventions
Physical activity Weight reduction
Medical interventions
Aim for BP <130/80
Summary
Stroke is a clinical diagnosis and the commonest cause of adult disability in the UK
References
Oxford Handbook of Clinical Medicine
Pocket Essentials of Clinical Medicine 4th Ed, Ballinger & Patchett (Kumar & Clarke) SIGN: Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention (www.sign.ac.uk/guidelines/fulltext/108/index.html) NICE guidance CG68: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) July 2008 (www.nice.org.uk/CG68) LTHT TIA guidelines (LGI/SJUH intranet) GP notebook (www.gpnotebook.co.uk DVLA (www.dvla.gov.uk) About.com (http://stroke.about.com) The Neurosurgeons Handbook, Samandouras
Questions?