1. Dr Lindsay Erwin RAH Paisley
STROKE REVIEW
Dr Lindsay Erwin
RAH Paisley

2. Definition

3. TRANSIENT MONOCULAR BLINDNESS
Sudden
onset of focal or global
loss
of cerebral function OR
TRANSIENT
MONOCULAR
BLINDNESS

4. CORTEX ANATOMY

5. CORTEX MAP

6. Stroke mimics Seizure Mass lesion Migraine Hypoglycemia
Systemic infection
Toxic-metabolic encephalopathy
Multiple sclerosis
Intracranial (sub / epidural) hematoma

7. CLASSIFICATION Different Mechanisms / Aetiology + Outcome
Taci – Total Anterior Circulation
Paci – Partial Anterior Circulation
Laci - Lacunar
Poci – Posterior Circulation
Different Mechanisms / Aetiology
+ Outcome

8. CLASSIFICATION
1 unilateral weakness (and / or sensory deficit) affecting face.
2 unilateral weakness (and / or sensory deficit) affecting arm
3 unilateral weakness (and / or sensory deficit) affecting hand
4 unilateral weakness (and / or sensory deficit) affecting leg
5 unilateral weakness (and / or sensory deficit) affecting foot
6 Dysphasia, dyslexia, dysgraphia, (i.e. dominant hemisphere cortical)
7 Visuospatial disorder / inattention / neglect (i.e. non – dominant hemisphere)
8 Homonomous hemianopias/ or quadrantopia
9 Brainstem / cerebellar signs other than ataxic hemiparesis
10 Other deficit
TACS
LACS OR OR
POCS 8 OR 9 OR 8 +9
PACS Other combinations excluding 9 and 10

9. Small vessel block

10. Big vessel block – good collateral

11. Big vessel block – no collateral

12. Stroke Types Bleeds - 20% - subdural - subarachnoid - intracerebral
Infarcts - 80% - atheroembolic - borderzone - vasculitis

13. Stroke Types - subdural
Trauma usual cause

14. Stroke Types - subarachnoid
Aneurysm rupture common cause.
“Worst headache”

15. Stroke Types - intracerebral bleed
OFTEN HAVE HEADACHE, DROWSINESS, HBP AT ONSET

16. Stroke Types - Infarct sources
Atheroembolic; source anywhere from heart to intracranial vessels

17. Stroke Types - borderzone
Low flow - usually hypotension; blood loss / cardiac arrest

18. Stroke Types - vasculitis
Primary vasculitis:
Giant cell
Takayasu’s
Polyarteritis nodosa
Churg Strauss
Wegener’s
Secondary vasculitis
Lupus
Rheumatoid
Sjogren’s
Drug induced immune

19. Risk factors / etiology
HBP
Hypotension
Lipids AF
Endocarditis
Smoking / alcohol
Diabetes
Drugs
Trauma
Genetics

20. HBP

21. Risk factors / etiology
Lipids

22. Atheroma

23. Risk factors - Lipids
Primary prevention

24. Risk factors - Lipids
Stroke prevention -SPARCL

25. Risk factors / etiologyAF
AF affects 5% of people > 65

26. Atrial Fibrillation Aspirin minimally effective - 22% risk reduction
Warfarin best protection % risk reduction
Need tight INR control -- INR
How to make it safe??

27. C ONGESTIVE FAILURE 1 AF - CHADS2 H YPERTENSION 1 A GE > 75 1
D IABETES 1
S TROKE OR TIA 2

28. AF – CHADS risk score

29. Risk factors / etiology
Hypotension
Smoking / alcohol
Diabetes
Drugs
Trauma
Genetics
Cardioembolism

30. PFO May allow paradoxical embolism.
Risk higher if PFO and atrial septal aneurysm.

31. Getting the blood to flow!

32. Representation of Penumbra in Acute Stroke.
Thomas, S. H. et al. N Engl J Med 2006;354:

33. ACUTE CARE
Time of onset.
Any fluctuation in symptoms?
Previous stroke, TIA, recent head injury or fall? Witness report if anyone available.
Confirm current drugs, especially antiplatelet agents and anticoagulants.
Check Baseline Bloods U/E, FBC and GLUCOSE.
Immediate CT if any possibility of thrombolysis, fluctuating GCS, pyrexia, patient on warfarin.
ECG & Chest X-ray

34. Next Steps If no bleed, start aspirin. If on aspirin, stop
Hypoxic patients (saturation <95%) should have Oxygen
Start I.V. saline as necessary. Avoid dextrose on day 1.
Swallow assessment ASAP. NBM till then.
If no bleed, start aspirin. If on aspirin, stop
on admission, and resume if no bleed.
Rectal aspirin if unable to swallow.
Blood Pressure should not be lowered unless
encephalopathy or aortic dissection or BP VERY high

35. Next Steps 2 Hyperglycaemia – treat if diabetic. Avoid hypo;
DVT prophylaxis – If leg paralysis, heparin is not indicated unless there is co-existing DVT or PE.
Pyrexia over 37 C must be treated at once by oral or rectal paracetamol.
Nursing Assessments – pressure area risks, fluid balance, weight. Avoid catheter unless critical for measuring output or to relieve retention.

36. Continuing Management
Refer to Stroke Team within 24 hours of admission
Transfer to Stroke Unit / Stroke \Team Care same day if possible
Why?

37. Continuing Management – Stroke Unit
Meta-analysis by the Stroke Unit Trialist's collaboration
18% + reduction in death or dependence
death or need of institutional care.
Absolute changes were a 3% reduction in all cause mortality (NNT 33), a 3% reduction in the need for nursing home care, and a 6% increase in the number of independent survivors (NNT 16).
Also 14 days less hospital stay

38. Acute Treatment Easy – early aspirin for almost all.
10 in 1000 extra will walk out
Harder – thrombolysis for a few.
1 in 10 extra will walk out

39. Will it work? Per 1000 treated Intracranial bleed NNH 22 Death NNT 236
Death / Dependent NNT 10
1 or more point >mRS NNT 3
THE EARLIER THE BETTER

40. Bleeds Reverse coagulopathy Refer neurosurgery for cerebellar bleeds
Less evidence for other sites
? > 30ml near the surface.

41. TRANSIENT MONOCULAR BLINDNESS
Is it a TIA?
Sudden
onset of focal or global
loss
of cerebral function OR
TRANSIENT
MONOCULAR
BLINDNESS

42. Is it a stroke /TIA? POSITIVE FEATURES - TIA LESS LIKELY
TINGLING rather than numbness
Flashing lights rather than loss of vision
Jerking rather than paralysis
Depends on a good history / witness statement

43. Is it a stroke / TIA? 23% of strokes preceded by TIA
stroke risk after TIA: 2 days %
7 days %
90 days %

44. ABCD2 Score A) Age 60 or older = 1
B) Raised BP – systolic > 140 / diastolic > 90 = 1
C) Unilateral weakness = Speech disturbance without weakness = other = 0
D) Duration > 60 min = min = < 10 min = 0
D) Diabetes = 1
3 or over is significant
6/7 may need admitted.

45. ABCD 2 SCORE - risk prediction

46. Is the ABCD Score Useful…… TRIAGE of TIA with MRI
MRI DWI +ve scans thought to be extra useful

47. STROKE RATE after TIA EXPRESS study
Before
After
Risk of recurrent stroke after first seeking medical attention in patients with TIA
ROTHWELL, The Lancet 2007;370:

48. INITIAL MANAGEMENT OF TIA
Establish diagnosis / Check risk factors:
Aspirin Cholesterol Blood Pressure AF
Diabetes Ischaemic Heart Disease PVD
Carotid disease Cardioembolic source
If “classic” TIA < 20 min, may give aspirin till seen at OPC.

49. Risk factor reduction Blood pressure to target ~ 130 / 80
Cholesterol to target ~ <4.0 mmol/l
Antiplatelet drugs:
Anticoagulation for AF
Lifestyle advice

50. Drug treatment Blood pressure: diuretic / ACE combination
Cholesterol - simvaststatin / atorvastatin
Antiplatelet: aspirin 300 mg for 2 weeks, then 75mg; clopidogrel 75 mg or aspirin + dipyridamole retard
Anticoagulation for AF - INR 2 - 3

51. BLEEDS: 20 - 42 % DEATH RATE AT 1 MONTH
Recurrence
VASCULAR DEATH %
1 month 1yr 2 yrs 3yr
REINFARCTS: 12 % FIRST YR 4-5% / YR AFTER
BLEEDS: % DEATH RATE AT 1 MONTH
(worst in men >75)

52. Road to Recovery -
Sitting balance first, standing unsupported, walking, then independence

53. Why did it get worse? Stroke in progression
Vessel re-embolises / dissects
Bleed into infarcted area
Seizure
Hypoxia
Underperfusion

54. If only I had / hadn’t………
Usually not true - inevitable.
The usual ONLYwarning is a TIA.
Long term primary prevention best
….even then
Could prevent only half of all stroke.

55. Is that his last slide??

56. Lindsay.erwin at rah scot nhs uk
Dr Lindsay Erwin
RAH Paisley
Lindsay.erwin at rah scot nhs uk