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!