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Lect 13: Stroke (Stroke means to patient (2) Psychological effects …
Lect 13: Stroke
Stroke means to patient
2) Psychological effects
depression
anger & fear of further stroke
3) Social effects
Driving (if x recovered must inform DVLA)
Employment
Relationships (carers/family/friends)
1) Physical effects
immobility
dep on others for personal care
visual impairment (reading, watching TV)
Specific treatment of ischaemic stroke
Thrombolysis
Drugs that break down blood clot & therefore restore blood flow
With a drug known as TPA -> dissolve clot
Given under right circumstances -> within 4.5 hours immediately after stroke -> the sooner the better; within 1st hour -> sig better benefits
10% patients -> sig better
5% patients -> some improvement but still disabled
85% -> x benefit
10% intracranial haemorrhage
Since trying to dissolve clot -> side effect -> bleeding
Thrombectomy
7 RCTs published since Dec14 with imaging confirmed then modern device thrombectomy
24% absolute difference
St.Georges doing it
Aspirin
Antiplatelet effect
Decreases mortality
Decrease further stroke risk
4th most common of death in UK
Defn: Sudden onset of a focal/global neurological impairment which lasts for greater that 24 hours/leads to death of presumed vascular origin
Sudden damage to part of the brain due to a problem with blood supply
Clinical effect dep on brain area damaged
Blood supply can be cut off (leading to infarction) or a vessel can bleed into the brain (haemorrhage)
80% due to infarction & 20% due to haemorrhage
Tests -> to tell bet blockage & haemorrhage
Haemorrhage -> white on CT; infract -> black on CT
Common clinical features of stroke
Face/arm/leg weakness
Face/arm/leg sensory loss
Speech disturbance (dysarthria- slurred speech or dysphasia- unable to get words out/saying strange words)
Visual disturbance (homonymous hemianopia-x able to see to one side)
Loss of co-ordination (ataxia) -> affects cerebellum
Treatment
Is it a stroke?
Type of stroke
Specific treatment for stroke
General medical care for patient
How to prevent another stroke?
Rehab treatment needed?
Causes of Infarction 80%
Atherosclerosis & Thrombosis
Narrowing of blood vessels followed by final occlusion by clot
In thrombotic stroke, a thrombus (blood clot) forms around atherosclerotic plaques
Since arterial blockage gradual -> onset of thrombotic strokes slower than hemorrhagic stroke.
A thrombus itself can lead to embolic stroke -> if the thrombus breaks off & travels in the bloodstream -> embolus
Sickle-cell anemia -> cause RBCs to clump & block blood vessels -> stroke.
Stroke is the second leading cause of death in people under 20 with sickle-cell anemia (NIH,1999)
Embolism
Clot from heart/large blood vessel cuts loose & gets stuck in smaller artery downstream causing blockage
Embolic stroke -> arterial embolism (arterial blockage) by an embolus (traveling particle/ debris in arterial bloodstream originating from elsewhere)
Frequently a thrombus but it can be other substancess including fat (e.g., from bone marrow in a broken bone)
Since arise from elsewhere -> local therapy -> temporary solution -> embolus must be identified
Since embolic blockage sudden in onset -> symptoms maximal at start.
Others (rarer)
Dissection
Inflammation
Hyperviscosity
Clinical classification of stroke based on area of brain damaged & cerebral circulation
Affecting front of brain -> Anterior circulation stroke (carotid arteries affected)
Posterior circulation stroke/verterbrobasilar stroke -> (back of brain -> pons,medulla & cerebellum affected)
Clinical classification
1) unilateral weakness (and/or sensory deficit) of FACE
2) unilateral weakness (and/or sensory deficit) of ARM/HAND
3) unilateral weakness (and/or sensory deficit) of FOOT
4) Dysphasia
5) Homonymous hemianopia
6) Visuospatial disorder
7) Brainstem/cerebellar signs
8) Other deficits
1-8 allow -> clinical classification of stroke -> 4 types
1)
Total anterior circulation stroke (TACS)
Main artery to one hemisphere
Full house: 1-3, hemianopia & higher cortical deficit
Massive stroke
Infarct
Full house of effects
Complete hemiparesis/numbness
Loss of vision on one side
Loss of awareness on one side
Visuospatial disorder
Dysphasia if dominant side affected
2)
Partial anterior circulation stroke (PACS)
Branch of main artery
In between LACS & TACS
1/2/3 + higher cortical deficit
Face/arm or leg numb
1 higher deficit -> inattention/vision/dysphasia
3)
Lacunar stroke (LACS)
Too small to be seen on CT
Small artery
Mvmt & sensation pathways
1-3/1+2/2+3 & x higher cortical deficit
Pure motor/sensory issue
X problem with thinking/speech
4)
Posterior circulation stroke (POCS)
Brainstem/cerebellar
Any posterior artery
Causes combo:
Loss of balance
Vertigo
Double vision
Dysarthria
Visual loss
Recurrence rates in 1st year
LACI -> 9%
TACI -> 6%
PACI -> 17% -> embolic
POCI -> 20% -> embolic
Overall 14%
Risk factors for atherosclerosis
Smoking
Hypertension
Diabetes
Cholesterol
Physical inactivity
Poor diet
Risk factors linked with atherosclerosis/embolism
Age
Gender
Family history
Previous stroke
Heart disease
Causes of embolism
Blood clot in heart
Arterial fibrillation
Myocardial infarction
Ventricular aneurysm
Valve disease
Atherosclerosis in aorta
Atherosclerosis in blood vessels in neck
Hypercoagulability
Causes of Haemorrhage (20%)
Hypertension
Cerebral aneurysms
Arteriovenous malformations
Clotting disorder
Anticoagulants -> stop clots forming but leads to bleeding in brain
General medical care
Blood pressure
Oxygen
Swallowing -> food and drink goes wrong way -> cause pneumonia
Fluids & food
Temperature
Assistance with continence
Skin care
DVT Prophylaxis
deep vein thrombosis (DVT: blood clot devt within deep vein in the body usually leg) risk after stroke increased
Position/lifting
Treatment of other medical issues (diabetes)
Early detection & treatment of complications (UTI, chest infection)
Rehab & MDT
Treatment to prevent further stroke
Antiplatelet e.g. clopidogrel
Better drug -> clopi dog
Essentially treating risk factors
Hypertension
Hypercholesterolaemia (statins)
Stop smoking
Optimise diabetic treatment
Improve diet & lifestyle
A cardiac source of emboli -> req other specific treatment
E.g. arterial fibrillation treated with warfarin or new anticoagulant
Patients whom need blood to be thinned are thinned to prevent cardiac stroke
Carotid stenosis (blockage) -> do carotid endarterectomy
Plaque in carotid -> causing narrowing -> operation to unblock narrowing
Stoke rehab
Minimising stroke impact & helping ppl to live with its consequences
Physiotherapy + Occupational therapy
Mobility interventions
Mobility scooter
Robotics/Virtual reality
Practising activities
Video games + remote therapist for the future