Stroke: signs, causes, risk factors and investigations

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Stroke

Stroke -vascular insult to the brain causing a focal neurological deficit. This occurs due to ischaemic infarct or haemorrhage, which disrupts the blood supply to brain.

Signs and symptoms:

these vary depending on the circulation affected by the infarct or haemorrhage

FAST:

Face - unilateral drooping

Arms - may feel weak and numb. patient may not be able to lift them

Speech - slurred speech

time - time for emergency medical attention, call 999

stroke may also be associated with transient ischaemic attack TIA. this is a focal neurological deficit where symptoms last <24h due to temporary occlusion of the cerebral circulation. patients may describe amaurosis fugax- loss of sight as curatins desendings. phenoman lasts <24 h and usually followed by stroke within 9- days

risk factors:

hypertension

atrial fibrillation

diabetes melitus

smoking

alcohol

previous stroke

oral contraceptive pill

disorder that increases clotting

cocaine use

high cholestrol

investigations

blood: fbc, u&e, lft, ptt, gliucose, cholestrole levels

ecg for af and echo for structral abnormlaities

glascow coma scale to ssesss level of conciousness

radiology: ct head and diffusion weighted mri immediately if any indication of a storke.

complications

hydrocephalus

increased risk of deep vein thrombosis

aphasia

dysphagia

decreased muscle movement

amnesia

depression

causes:

haemorrhagic stroke: central nervous system bleeds from trauma

ruptured anueysym

ischaemic causes small vessel occlusion

atherothromembolism

cardiac emboli

emboli secondary to AF

treatment:

conservative - patient and family education, initiate early mobilisation, commerce stroke rehabilitation, assess speech and swallowing. assess impact of activities of daily living using barthel index.

TIA patients - assess risk of subsequent stroke using ABCD2 - high risk is a score >6

low risk if a score less than 4

age over 60

blood pressure

unikateral weakness

isolated speech disturbance

duration of ssymptoms

diabetes

start aspirin 300 mg

ischaemic stroke patients without haemorrhage:

thrombolysis with alteplase within 3 hours - patients more than 80 years and within 4.5 h - patients under 80

start aspirin - 300mg (unless contraindication)

haemorrhagic stroke patient-

prothrombin complex concentrate

intravenous vitamin K

surgical - referral for acute intracereberal haemorrhage

referral for decompressive haemicarniaectomy

alzheimer's disease- unknown cause. down syndrome due to APP gene loud

familial gene association- amyloid precursor protein - APP- chromosome 21

presenilin-1: chromosome 14

presenlin-2: chromosome 1

apolipoprotein E4 (ApoE4) alleles: chromosome 19

hypothyroidism

previous head trauma

family history of alziehmers disease

signs and symptoms: amnesia, disorientation, changes in personality, decreasing self care, apraxia, agnosia, aphasia, lexical anomia, paranoid delusions, depression, wandering, aggression, sexual disinhibition

investigations: mental state examination, addenbrooke's cognitive examination ACE-111

blood: FBC, U&E, LFT, TFT, CRP,ESR, GLUCOSE, CALCIUM, MAGENSSIUM, PHOSPHATE, VDRL, HIV, SEROLOGY, VITAMIN B12, FOLATE LEVELS, BLOOD CULTURE, ECG, LUMBAR PUNCTURE, CXR, CT, MRI, SPECT

histology: beta amyloid plaques, decreased acetylcholine, neurofibrilarly tangles

memantine: inhibits glutamate by blocking n-methyl-d-asprate receptors

donepezil: acetylcholinestreaste ingibitor

rivastigimine: acetylcholinestrase inhibitor

amenias, incease risk of infeciton, dysphagia, urinary incontinence, increased risk of falls

vascular dementation- second most common cause of dementia - caused by infarcts of small and medium sized vessels in the brain

genetic association with cerebral autosomal dominant arteriopathy with subcortical infarcts and leuoencephalopathy on chromosome 19

signs and symptoms: follows a deteriorating stepwise progression- vascular dementia following stroke, multi infarct dementia following multiple strokes. binswanger disease following microvascular infarcts.

amnesia

disorientation

change in personality

decreasing self care

depression

signs of upper motor neuron lesions

brisk reflexes, seizures

mental state examination= ACE-III

bloods: fbc, u&e, lft, tft, crp, esr, glucose, calcium, magnesisum, phispahe, vdlr, hiv, serology, vitamin b12, folate levels, cholestorl levels, vasculitis screen, syphilis serology, ecg, lumbar puncture, cxr, ct, mri, spect

dietary advice

smoking cessation

treat diabetes melitis

hypertesion

aspirin

signfiicant co-moribididty

e,g, cardiivascular disease and renal disease