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!