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12.11.02 Stroke teaching

Stroke definition
  • Sudden onset
  • Focal neurological deficit
  • Vascular cause
  • Lasting >24 hrs
    • But note most TIAs are <15 mins
    • So if it's >15 mins, can presume it's a stroke


Screening tools

  • FAST for stroke
    • But only 80% of strokes are FAST +ve
  • ROSIER for stroke
  • ABCD2 for patients with suspected TIA


ROSIER

  • Questions:
    • Has there been loss of consciousness or syncope?
      • Yes -1
    • Has there been seizure activity?
      • Yes -1
    • Is there a NEW ACUTE onset (or on awakening from sleep) of:
      • Asymmetric facial weakness
        • Yes +1
      • Asymmetric arm weakness
        • Yes +1
      • Asymmetric leg weakness
        • Yes +1
      • Speech disturbance
        • Yes +1
      • Visual field defect
        • Yes +1
  • Stroke is likely if total scores are > 0
  • Scores of </= 0 have a low possibility of stroke but not completely excluded


Swallow screen

  • Give teaspoon of water to drink
  • Listen to voice to check for aspiration
  • Repeat x3


ABCD2

  • Age
    • >60 => 1 point
  • Blood pressure
    •  >140/90mmHg => 1 point
  • Clinical features (max. score 2 points)
    • Unilateral weakness => 2 points
    • Speech disturbance without weakness => 1 point
  • Duration
    • > 60 mins => 2 points
    • 10 – 60 mins => 1 point
    • < 10 mins => 0 points
  • Diabetes
    • 1 point
  • >4 => Likely TIA
  • High risk patients (six to seven points) have an 8.1% two-day recurrent stroke risk
  • Any patient with more than one episode in the last week is at a greater than 30% risk of stroke within a week

Thrombolysis
  • Time cutoff now 4.5 hrs
  • Done in 10% of ischaemic strokes
  • Outcomes:
    • 1/8 are cured
    • 1/3 are improved
    • 1/18 get worse
      • Haemorrhagic transformation

Surgery
  • NO role in haemorrhagic stroke
  • 2 (rare) indications:
    • Malignant MCA syndrome
      • => Decompression (craniectomy)
      • If age <60, early (<48hrs), no significant comorbidities
    • Large cerebellar infarct

Intracerebral haemorrhage

  • BAD
    • 40% 1 year mortality
    • High risk of early progression
  • Reverse anticoagulation
    • Vit K
    • FFP

Notes

  • Cortical features indicated large rather than small artery
  • Treat fever aggressively
    • Reduces cerebral O2 demand
  • DVT prophylaxis
    • TED stockings don't work
    • LMW heparin might work
    • HYDRATION and MOBILISATION definitely work
  • Lose 2E6 brain cells per minute
  • Stroke 1 month mortality:
    • 25% in 2000
    • 8% now at SGH
    • 6% now in Germany
  • Treat SBP >200 mm Hg
    • Use IV LABETALOL
      • Mixed alpha/beta adrenergic antagonist
      • Fast onset (10-15 mins)
  • BP target post-stroke: <130/80
  • Avoid statins after haemorrhagic stroke unless strongly indicated
    • Particularly if they have inadequately controlled hypertension
    • Small increased risk of further haemorrhagic stroke
      • May be offset by benefit (ischaemic stroke/CHD)
      • But seek advice!

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