What is a stroke?A neurovascular deficit of cerebrovascular
cause that persists beyond 24hrs or is interrupted by death within 24hrs
What are the 2 main types of stroke?• Ischemic
• Something is reducing the blood flow eg. Thrombi, emboli
• Hemorrhagic• Rupture of a vessel eg. Aneurysm
Stroke risk factors
• Hypertension • Hypotension• Hypercholesterolemia• Obesity• Atrial fibrillation• Due to clot formation from erratic flow
and pooling of blood in the atria
Oxford stroke classification
• Total Anterior Cerebral Infarct (TACI)
• Partial Anterior Cerebral Infarct (PACI)
• Lacunar Infarct (LACI)
• Posterior Cerebral Infarct (POCI)
TACI (aka. TACS)
• DEATH: common• Higher dysfunctions (cognitive, emotional and
issues with defecation and micturition)• Dysphagias• Visuo-spatial problems• Homonymous hemianopia• Motor/ sensory deficits
PACI (aka. PACS)- 2/3 similar to TACI- Partial motor/ sensory deficits- Higher dysfunction alone
LACI (aka. LOCS)- Pure motor or sensory or sensorimotor loss- focal- Common in brainstem regions and deep cerebral white
matter
POCI (aka. POCS)
- Cranial nerve palsy and contralateral motor/sensory deficit
- Bilateral motor or sensory deficit- Cerebellar signs - DANISH- Eye movement deficits/ isolated homonymous hemianopia
Motor
Sensory
Watershed infarctsDue to a rapid drop in cerebral perfusion caused by a systemic drop in blood pressure • Occurs in boundaries of the arterial supplies• These areas are supplied by a fine network of vessels
Eg. Carotid artery occlusion ACA-MCA- Loss of motor function
(sometime identical sensory loss) in:- TRUNK- PROXIMAL UPPER LIMBS
MCA-PCA- Problems with visual processing Man in a barrel
syndrome
Transient Ischaemic Attacks (TIA’s)Transient loss of perfusion to an area with full recovery within 24hrs- Often results in lacunar infarcts - A key warning sign, if lest untreated 10% of cases will progress
into a full stroke within 1yr- Often causes of TIA are
- Carotid insufficiency- Vertebrobasilar insufficiency
Amourosis fugax: a transient loss of vision (usually in one eye). This is a characteristic type of TIA caused by loss of perfusion in the retinal or ophthalmic arteries
How can we assess the risk of an individual having a stroke?
There are a number of scaling systems that can be used to assess the risk of an individual having a stroke:
• ABCD2
• CHADS2
• CHA2DS2-VASc
ABCD2
• Does the patient require urgent specialist stroke assessment- ie. After having a TIA?
• Score between 0 and 7• Score > or = 4 are at a HIGH risk of stroke and need immediate
assessment • <4 should be given 300mg of aspirin/day, risk reduction discussed
and referred to a TIA clinic within a week
A: Age (> or = 60yrs: 1 point)
B: Blood pressure at presentation (> or = 140/90mmHg: 1 point)
C: Clinical features (unilateral weakness = 2 points, speech disturbance without weakness: 1 point)
D: Duration of symptoms (> or = 60mins: 2 points, 10-59mins: 1 point)
D: Diabetes (1 point)
CHADS2 and CHA2DS2-VASc• Risk of stroke in patients with atrial fibrillation• Used to determine whether treatment with anticoagulant or
antiplatelet therapy is required• Clinically has been superseded by the CHA2DS2-VASc:
C: Congestive heart failure (1 point)
H: Hypertension (1 point)
A2: Age >75yrs (2 points)
D: Diabetes mellitus (1 point)
S2: Prior stroke or TIA or thromboembolism (2 points)
V: Vascular disease (eg. peripheral artery disease, MI, aortic plaque)
A: Age 65-74yrs (1 point)
Sc: Sex category (ie. Female- 1 point)
Stroke ManagementKEY: Rapid identification and treatment to reduce damage and disability
Determine whether the stroke is ISCHAEMIC or HAEMORRHAGIC:1. Urgent scan- CT and sometimes DWI (secondary for ischaemic
stroke but takes longer- tells you how far the ischaemia has gone)2. Signs of blood? YES: Haemorrhagic (get neurosurgery in as they may need to stop the bleed/ evacuate)NO: Ischaemic need to get blood flow back so proceed with thrombolysis
NB: Current recommendation is 4.5hrs for thrombolysis (ALTEPLASE)
Long Term Management of stroke• Blood thinners eg. aspirin or clopidogrel • Lifestyle changes
Long-term COMPLICATIONS of STROKE:• Post-stroke pain • Burning pain with sharp components • Hyperalgesia• Allodynia• Treat as neuropathic pain eg. AMITRIPTYLINE
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