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Stroke (Risk factors (Age*, HTN*, Smoking, DM, IHD, AF, Prev TIA),…
Stroke
Risk factors
Age*
HTN*
Smoking
DM
IHD
AF
Prev TIA
Clinical presentation
Anterior/
carotid
territory
Amaurosis fugax/
retinal infarct
Hemiparesis
Hemisensory loss
Hemianopia
Dysphasia
Sensory/visual
innatention
Posterior/
vertebrobasilar
territory
Ataxia
CN palsy
CN III, IV, VI: diplopia
CN V: facial sensory loss
CN VII: LMN facial palsy
CN VIII: vertigo
CN IX/X: dysphagia, dysarthria
Hemiparesis
(may be bilateral)
Hemisensory loss
(may be bilateral)
Hemianopia
Cortical blindness
Lacunar stroke
Pure motor
(internal capsule)
Pure sensory
(thalamus)
Ataxic hemiparesis
(pontine)
Clumsy hand/dysarthria
(pons, internal capsule)
Management
Conservative
Admit to
stroke unit
NBM until SALT
(may need NG/PEG)
Physio, OT
Psych assessment
Medical
General
Supplemental O2
(if sats low)
Manage blood glucose
(hyperglycaemia)
DVT prevention
(if high risk)
Manage BP
Cerebral autoreg can be disturbed
Optimal management unclear
Often don't treat in acute stage
(can cause infarct)
Stop anticoagulation/antiplatelets
(if haemorrhagic stroke)
Correct coagulation deficits
(haemorrhagic stroke)
Specific
(ischemic stroke)
Thrombolysis
TPA best <90m, use <4.5h
Give TPA, Delay aspirin until 24h post-thrombolysis
scan has excluded haemorrhage
Antiplatelets
Aspirin <48h (300mg STAT, 75mg OD)
Clopidogrel if aspirin intolerant
Anticoagulants
If AF/other cardioembolic cause,
start anticoagulation after 2wk
(or immediately if TIA and MRI clear)
Surgical
Decompressive surgery
Infarcts: large cerebellar, malignant
middle cerebral territory synd
Haemorrhage causing hydrocephalus
Shunting
Haemorrgages causing hydrocephalus
Diagnosis
History
Examination
Investigations
Bloods
General:
FBC, ESR/CRP, U+E, Cr, LFT, TFT,
glucose, lipids, clotting, Ca
Specifics:
thrombophilia screen, genetic screens
(coag disorders), autoimmune screen
Troponins
Blood cultures
Imaging
ECHO
CT head <24h*
Carotid USS
MRA/CTA
Bedside
Urine
Dipstick
(glucose, blood)
Toxicology screen
ECG
Definition
Stroke: "rapid onset of focal neurological deficit
due to infarct or hemorrhage, lasting >24h"
TIA: "symptoms and signs of stroke resolve <24h"
Aetiology
Ischemic
stroke (80%)
Vascular
Cardioembolism
Atherothromboembolism
Small vessel disease
(lacunar)
Autoimmune
GCA
SLE, vasculitis
Angitis
Anti-phospholipid syndrome
Infection
HIV
Meningitis
Congenital/
genetic
CADASIL
Mt disorders
Drugs
COC
Haematological
Sickle cell
Thrombophilia
Hemorrhage (15%)
ICH
Vascular
HTN
AVM
Cerebral venous
thrombosis
Haematological
Coagulation
disorders
Neoplastic
Drugs
Antiplatelets
Anticoagulants
Anti-thrombolytic
therapy
Cocaine
SAH
Vascular
Aneurysm
Dural AV fistula
AVM
Trauma
Epidemiology
3rd most common
cause of death
Most common cause
of neuro disability
Prevention
Primary
Ischemic
stroke
Treat HTN
Treat DM
Stop smoking etc.
Treat lipids
Treat AF
Warfarin if >65y, DM, HTN
Aspirin if <65y and no other factors
Haemorrhagic
stroke
Treat HTN
Secondary
Medical
anti-HTN
ACE-i or CCB
Anti-lipids
Statin
Antiplatelet
Aspirin or clopidogrel
(both 75mg OD)
Anticoagulant
(if AF)
NOAC (rivaroxiban, apixiban, dabigatran)
Warfarin
Surgical
Carotid endarctectomy
Beneficial if >70% stenosis, mod if 50-69%
Carotid stent
Similar outcomes to endarctectomy if <70y,
use if endartectomy is not suitable
Conservative
Stop smoking
Lose weight
Increase physical activity
Reduce alcohol
Prognosis
High risk of stroke/MI
after TIA (particularly <14d)