1. Priyanca Patel and Fil Sianos
STROKE
Priyanca Patel and Fil Sianos

2. What is a stroke? What are the 2 main types of 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

3. Stroke risk factors Hypertension Hypotension Hypercholesterolemia
Obesity
Atrial fibrillation
Due to clot formation from erratic flow and pooling of blood in the atria

4. How can we recognise a stroke?
Face weakness
Arm weakness
Speech problems
Time to call 999

6. Oxford stroke classification
Total Anterior Cerebral Infarct (TACI)
Partial Anterior Cerebral Infarct (PACI)
Lacunar Infarct (LACI)
Posterior Cerebral Infarct (POCI)

7. TACI (aka. TACS) DEATH: common
Higher dysfunctions (cognitive, emotional and issues with defecation and micturition)
Dysphagias
Visuo-spatial problems
Homonymous hemianopia
Motor/ sensory deficits

8. PACI (aka. PACS) LACI (aka. LOCS) POCI (aka. POCS)
- 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
Motor
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
Dysdiodochokinesia
Dysmetria
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
Sensory

9. Watershed infarcts Due 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

10. 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

11. 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

12. ABCD2 A: Age (> or = 60yrs: 1 point)
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)

13. CHADS2 and CHA2DS2-VASc C: Congestive heart failure (1 point)
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)

14. Stroke Management
KEY: Rapid identification and treatment to reduce damage and disability
Determine whether the stroke is ISCHAEMIC or HAEMORRHAGIC:
Urgent scan- CT and sometimes DWI (secondary for ischaemic stroke but takes longer- tells you how far the ischaemia has gone)
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)
DWI- Diffusion Weighted Imaging

15. CT imaging/ MRI CT – fast, easy to spot haemorrhage
DWI – best for ischaemic damage

16. 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
PSP- due to occlusion to the thalamo-geniculate arteries
Gabapentin can also be used to treat post-stroke pain

17. Thank You!
Any Questions?