Stroke

Stroke is also referred to as cerebrovascular accident (CVA).

Cerebrovascular accidents are either:

  • Ischaemia or infarction of brain tissue secondary to inadequate blood supply
  • Intracranial haemorrhage

 

Disruption of blood supply can be caused by:

  • Thrombus formation or embolus, for example in patients with atrial fibrillation
  • Atherosclerosis
  • Shock
  • Vasculitis

 

Transient ischaemic attack (TIA) was originally defined as symptoms of a stroke that resolve within 24 hours. It has been updated based on advanced imaging to now be defined as transient neurological dysfunction secondary to ischaemia without infarction.

Transient ischaemic attacks often precede a full stroke. A crescendo TIA is where there are two or more TIAs within a week. This carries a high risk of developing in to a stroke.

 

Presentation

In neurology, suspect a vascular cause where there is a sudden onset of neurological symptoms.

Stoke symptoms are typically asymmetrical:

  • Sudden weakness of limbs
  • Sudden facial weakness
  • Sudden onset dysphasia (speech disturbance)
  • Sudden onset visual or sensory loss

 

Risk Factors

  • Cardiovascular disease such as angina, myocardial infarction and peripheral vascular disease
  • Previous stroke or TIA
  • Atrial fibrillation
  • Carotid artery disease
  • Hypertension
  • Diabetes
  • Smoking
  • Vasculitis
  • Thrombophilia
  • Combined contraceptive pill

 

FAST Tool for Identifying a Stroke in the Community

  • FFace
  • AArm
  • SSpeech
  • TTime (act fast and call 999)

 

ROSIER Tool for Recognition Of Stroke In Emergency Room

ROSIER is a clinical scoring tool based on clinical features and duration. Stroke is likely if the patient scores anything above 0.

 

Management of Stroke

This is adapted from the NICE guidelines updated in 2017 to help your learning. See the full guidelines before treating patients.

  • Admit patients to a specialist stroke centre
  • Exclude hypoglycaemia
  • Immediate CT brain to exclude primary intracerebral haemorrhage
  • Aspirin 300mg stat (after the CT) and continued for 2 weeks

 

Thrombolysis with alteplase can be used after the CT brain scan has excluded an intracranial haemorrhage. Alteplase is a tissue plasminogen activator that rapidly breaks down clots and can reverse the effects of a stroke if given in time. It is given based on local protocols by an experienced physician. It needs to be given within a defined window of opportunity, for example 4.5 hours. Patients need monitoring for post thrombolysis complications such as intracranial or systemic haemorrhage. This includes using repeated CT scans of the brain.

 

Thrombectomy (mechanical removal of the clot) may be offered if an occlusion is confirmed on imaging, depending on the location and the time since the symptoms started. It is not used after 24 hours since the onset of symptoms.

 

Generally, blood pressure should not be lowered during a stroke because this risks reducing the perfusion to the brain.

 

Management of TIA

Start aspirin 300mg daily. Start secondary prevention measures for cardiovascular disease. They should be referred and seen within 24 hours by a stroke specialist.

 

Specialist Imaging

The aim of imaging is to establish the vascular territory that is affected. It is guided by specialist assessment.

Diffusion-weighted MRI is the gold standard imaging technique. CT is an alternative.

Carotid ultrasound can be used to assess for carotid stenosis. Endarterectomy to remove plaques or carotid stenting to widen the lumen should be considered if there is carotid stenosis.

 

Secondary Prevention of Stroke

  • Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily)
  • Atorvastatin 80mg should be started but not immediately
  • Carotid endarterectomy or stenting in patients with carotid artery disease
  • Treat modifiable risk factors such as hypertension and diabetes

 

Stroke Rehabilitation

Once patients have had a stroke they require a period of adjustment and rehabilitation. This is essential and central to stroke care. It involves a multidisciplinary team including:

  • Nurses
  • Speech and language (SALT)
  • Dieticians
  • Physiotherapy
  • Occupational therapy
  • Social services
  • Optometry and ophthalmology
  • Psychology
  • Orthotics

 

Last updated April 2019
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