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?
- Has there been seizure activity?
- Is there a NEW ACUTE onset (or on awakening from sleep) of:
- Asymmetric facial weakness
- Asymmetric arm weakness
- Asymmetric leg weakness
- Speech disturbance
- Visual field defect
- 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
- Blood pressure
- 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
- >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
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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