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Stroke (Ischaemic and Haemorrhagic) (Risk Factors (Increasing age, Heart…
Stroke (Ischaemic and Haemorrhagic)
Key Facts
Syndrome of RAPID onset of neurological deficit caused by focal, cerebral, spinal or retinal INFARCTION
Characterised by RAPIDLY DEVELOPING signs of focal or global disturbance of cerebral functions, lasting for MORE THAN 24hrs or leading to death
Epidemiology
Stroke rates are higher in Asian and black African populations
Uncommon in those under 40
Leading cause of adult disability worldwide
Incidence increases with age
3rd most common cause of death in high-income countries - 11% of all deaths in UK
More COMMON in MALES than females
Major neurological disease
Incidence is falling due to more vigorous approach to risk factors in primary care i.e. statin use & BP control
Aetiology
Other causes account for about 3%
Young people - vasculitis, thrombophilia, carotid artery dissection
Haemorrhagic account for 17% of strokes: CNS bleeds due to trauma, subarachnoid haemorrhage etc
Elderly - thrombosis in situ, heart emboli, CNS bleed, vasculitis
Ishcaemic/infarction account for 80% of all strokes: small vessel occlusion, cardiac emboli, hypoperfusion (watershed stroke)
Risk Factors
Increasing age
Heart disease (valvular, ischaemic)
Diabetes Mellitus
Alcohol
Smoking
Polycythaemia, thrombophilia
Past TIA
AF - stasis of blood in poorly contracting atria = thrombus formation
Hypertension
Hypercholesterolaemia
Black or Asian
Combined oral contraceptive pill
Male
Vasculitis
Infective endocarditis
Pathophyisology
Ischaemic
Thrombosis occurs at site of atheromatous plaque in carotid/vertebral/cerebral arteries
Large artery stenosis acts as an embolism source rather than occluding the vessel
Arterial disease and atherosclerosis is the main pathological process
Haemorrhagic
Cerebral amyloid antipathy - deposition of amyloid-B in the walls of the small and medium-sized arteries
Space occupying lesion e.g. tumour - rare
Hypertension resulting in microaneursym rupture
Clinical Presentation
Posterior cerebral artery (PCA) territory - visual issues
Prospagnosia - can't see faces
Colour naming and discriminate problems
Visual agnosia - can't interpret visual information, but can see
Cortical blindess (eye healthy, but brain issue causing blindness)
Unilateral headache - RARE in ischaemic stroke, so if you see headache then think PCA
CONTRALATERAL HOMONYMOUS HEMIANOPIA (loss of half the vision of the same side in both eyes
Posterior circulation territory - Vertebrobasilar artery
Motor deficits such as hemiparesis or tetraparesis and facial paralysis
Dysarthria (unclear speech articulation) & speech impairment
Likely to get 'locked in' in these strokes
Vertigo, nausea & vomiting
MORE CATASTROPHIC due to wide region supplied
Visual disturbance
Altered consciousness
Middle cerebral artery (MCA) territory
Hemianopia
Aphasia (inability to understand or produce speech)
CONTRALATERAL sensory loss
CONTRALATERAL ARM & LEG WEAKNESS
Dysphasia (deficiency in speech generation)
Facial droop
Anterior cerebral artery (ACA) territory
Truncal ataxia - patients can't sit or stand unsupported and tend to fall backwards
Incontinence
Gait apraxia (loss of ability to have normal function of the lower limbs such as walking)
Sensory disturbance in the legs
Drowsiness - since part of consciousness is in the frontal lobe (which the ACA supplies)
Leg weakness (more likely than arm weakness since more of leg in ACA)
Akinetic mutism
Decrease in spontaneous speech
Stuporous state
ANYTHING VASCULAR e.g. stroke is SUDDEN RAPID ONSET
Differential Diagnosis
Intracranial lesion - tumour or subdural haemotoma
Syncope due to arrhythmia
Hypoglycaemia, migraine aura, focal epilepsy
Always EXCLUDE hypoglycaemia as a cause of sudden onset neurological syndrome
Diagnosis
Pulse, BP & ECG
Look for AF
Be careful about treating high BP, since even a 20% fall may compromised cerebral perfusion
Bloods
FBC: look for thrombocytopenia & polycthaemia
Blood glucose - to rule out hypoglycaemia
Urgent CT head/MRI head BEFORE TREATMENT
To rule out haemorrhagic stroke before starting thrombolysis
Infarction is seen as a low density lesion, subtle changes evident within 3hrs
Urgent if suspected cerebellar stroke, unusual presentation, high risk of haemorrhage
In MRI appears hyper intense within hours of onset
Treatment
If the time of onset is unknown and thus thrombolysis is not suitable then give ASPIRIN DAILY for 2 weeks then lifelong CLOPIDOGREL
Risk management for stroke prevention
Platelet treatment (lifelong if already had stroke) e.g. ASPIRIN + DIPYRIDAMOLE or CLOPIDOGREL
Cholesterol treatment e.g. statins
Atrial fibrillation treatment e.g. warfarin or pixiban
Blood pressure treatment e.g. ACEi
Thrombolysis - can be given uptimes 4.5 hrs post onset of symptoms
Maximise reversible ischaemic tissue
Keep O2 sats > 95%
If ischaemic stroke confirmed by CT then proceed to thrombolysis
Ensure hydration