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Stroke
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- 1WHO definition of a strokeA clinical syndrome, of presumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral functions lasting more than 24 hours or leading to death
- 2Prevalence of different stroke typesCerebral infarction accounts for about 70% of strokes.
Posterior circulation stroke accounts for 20-25% of ischaemic strokes
Primary haemorrhage accounts for about 15%.
Subarachnoid haemorrhage accounts for approximately 5% - 3Aetiology of stroke in an older patientThrombosis in situ.
Athero-thromboembolism - eg, from carotid arteries.
Heart emboli (particularly associated with AF, infective endocarditis or MI)
CNS bleed (associated with hypertension, head injury, aneurysm rupture)
Sudden blood pressure drop by more than 40 mm Hg.
Vasculitis - eg, giant cell arteritis.
Venous sinus thrombosis - 4Epidemiology of strokeStroke is the third most common cause of death in the UK.
In England, about 110,000 people have a first or recurrent stroke each year.
A further 20,000 people have a TIA
More than 900,000 people in England are living with the effects of stroke and about half of these people are dependent on other people for help with everyday activities - 5Risk Factors for strokeHypertension.
Smoking.
Diabetes mellitus.
Heart disease (valvular, ischaemic, atrial fibrillation).
Peripheral arterial disease.
Post-TIA
Polycythaemia vera.
Carotid artery occlusion; carotid bruit
Combined oral contraceptive pill
Hyperlipidaemia
Excess alcohol
Clotting disorders - 6Common presentation of cerebral hemisphere infarctContralateral hemiplegia which is initially flaccid (floppy limb, falls like a dead weight when lifted) and then becomes spastic.
Contralateral sensory loss.
Homonymous hemianopia.
Dysphasia - 7How might posterior circulation ischaemia present?Motor deficits (weakness, clumsiness, or paralysis of any combination of limbs)
'Crossed' syndromes: ipsilateral cranial nerve dysfunction and contralateral long motor or sensory tract dysfunction.
Sensory deficits: numbness, including loss of sensation or paraesthesia in any combination of extremities
Homonymous hemianopia.
Ataxia, imbalance, unsteadiness, or disequilibrium.
Vertigo, with or without nausea and vomiting.
Diplopia (ophthalmoplegia).
Dysphagia or dysarthria.
Isolated reduced level of consciousness can result from bilateral thalamic or brain stem ischaemia.
Complete infarction affecting the pons causes 'locked-in syndrome' with quadriparesis, loss of speech, but preserved awareness and cognition, and sometimes preserved eye movements. - 8Lacunar infarctsSmall infarcts around the basal ganglia, internal capsule, thalamus and pons.
May cause pure motor, pure sensory, or mixed motor and sensory signs, or ataxia.
Intact cognition/consciousness - 9Differential diagnoses for strokeHypoglycaemia
TIA in the first 24 hours of the stroke
Epilepsy
CNS tumour
Subdural bleed
Todd's palsy
Migraine
Consider a drug overdose if the patient is comatose - 10Immediate management of stroke: examinations and investigations• Check BP, pulse (no need to reduce BP unless > 200 systolic or >110 diadtolic or patient is for thrombolysis)
BM, O2 sats, Temperature
Investigations: FBC, INR, U&Es, LFTs, Ca2+, Glucose, TFT/TSH, Cholesterol and lipids
- Coagulation
ESR ?AF ?MI
ECG
CXR
CT scan: RCP guidelines state all strokes to be scanned within 24 hrs. Urgent scanning is required when: ?thrombolysis, on anticoagulation, bleeding tendancy, unexplained progressive/fluctuating symptoms, depressed conscious level, suspicion of SAH
*Exclude a bleed*
Urine dip/MSU - 11Management of infarction: indications for thrombolysisUp to 4.5 hours
Clear time of onset
Clinical symptoms and signs of a stroke
Haemorrhage excluded
No upper age limit
Use alteplase 0.9mk/kg - 12Management of infarction: contraindications for thrombolysisRapidly improving or minor stroke symptoms
Stroke or serious head injury 3 months
Major surgey, obstetric delivery, external heart massage 14 days
Seizure at onset of stroke
Bleeding tendancy - 13General management for cerebral infarctAspirin 300mgs for 2 weeks then 75mgs PO/PR (ischaemic infarct/pt is not for Thrombolysis)
Paracetamol iv prn
Metoclopromide iv prn
IV fluids
O2 Inhalation
No urinary catheters please
Swallowing assessment
Dietician
Sit out
NG tube - 14Expressive dysphagiaDue to a lesion in Broca's area of the brain.
Understanding is preserved and the patient tries to convey meaningful responses to the questions asked.
Response is non-fluent, patient recognises that their speech is incorrect
Reading and writing may be impaired, but understanding is intact - 15Receptive dysphagiaDue to a lesion in Wernicke's area of the brain
Inability to understand language correctly - 16What is dysarthria?Motor disturbance of speech
Individuals know what they want to say, but cannot get the words out correctly, because of weakness to the tongue or facial muscles - 17DysphagiaAbnormality of swallow
Common in stroke (30-50% initially)
Can result in aspiration pneumonia - 18Signs of dysphagiaUsually there are obvious signs of aspiration such as coughing, choking and becoming short of breath. However some can aspirate silently and this has to be detected with fibreoptic endoscopic examination of the swallow (FESS), which involves a nasal endoscope during swallowing to assess airway protection. The long term signs of aspiration are: loss of weight, respiratory infections, refusal to eat etc
- 19Management of dysphagiaPatients may need to alter diet to reduce risk of aspiration e.g. thickened fluids
May need NG tube or PEG
Speech and Language Therapist (SALT) assesses the patient further to check the risks for oral intake
Input from physio, OT, dietician etc - 20Parietal lobe signsSensory neglect - patient has intact sensation when tested unilaterally but when confronted by bilateral stimuli, ignores the affected side
Agnosia - inability to familiar recognise objects
Astereognosis - inability to recognise numbers drawn on the hand.
Dyspraxia - inability to perform tasks, despite having the necessary strength and sensation, problem with processing information - 21Hemiparesis, hemiplegia and hemisensory lossHemiparesis -weakness down one side of the body of an upper motor neurone nature
Hemiplegia - complete paresis (MRC grade 0 power)
Hemisensory loss - loss of light touch sensation down one side - 22Emotional changes following strokeFeelings of shock, denial, anger, grief and guilt are normal
Depression and anxiety are very common after stroke
Many people have problems controlling their mood and emotions. This is known as emotionalism (or emotional lability). It can mean they cry or laugh more, sometimes for no reason. Some people start to swear when they didn’t before
Frustration - can build up and make people irritable. Can also lead to aggressive behaviour
Talking therapy can help, as well as antidepressants
These feelings are usually easier to live with over time - 23Cerebellar signs of strokeDysarthria, nystagmus, intention tremor, past pointing and a broad based staggering gait
'Drunken sailor' - 24Bamford classification of strokeLacunar - Motor or sensory deficit only
Partial anterior circulation - 2 of following: motor or sensory deficit; higher cortical dysfunction; hemianopia
Total anterior circulation - All of: motor or sensory; cortical; hemianopia
Posterior circulation - isolated hemianopia; brain stem signs; cerebellar ataxia - 25Central post-stroke painSpontaneous pain and painful overreaction to objective stimulation
8% of stroke patients
Most <2 months, but up to 6 years post ictus
Variety of sensory disturbances: reduced pain/temp sensation, poor pain localisation on affected side - 26Treatment of central post-stroke painStart low and go slow (up to 6 weeks)
Opiates: morphine, tramadol PLUS:
Antidepressants: amitriptyline 10-25mg and titrate to 50mg
Anticonvulsants: gabapentin 300-600mg TDS (sedation), pregabalin (75mg OD, BD), lamotrigine, carbamazepine
Deep brain stimulation (deep nuclei) - 27Prognosis: dead, dependent, independent and 1 year recurrence
Información
- Descripción
- Health Care of the Elderly Fichas sobre Stroke, creado por Liam Musselbrook el 20/03/2017.
- Creado por
- Liam Musselbrook
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