Key facts:
Authors: Damian Mayo, Jonathan Birns, Kris Ghosh
Top Tip: A CT is required to distinguish between haemorrhage (white area) and ischaemia (can be normal initially) and other diagnoses
Key Differential Diagnoses
- SOL (incl SDH)
- Seizure
- Migraine
- Hypoglycaemia
Key Investigations
- FBC, U+E, Bone, LFTs, Coagulation, Glucose
- ECG, CXR
- CT head (urgently if suspected haemorrhage or suitability for thrombolysis)
Key Treatments
- Admit to Stroke Ward directly (via CT)
- If symptoms <4.5h, assess for suitability for thrombolysis with IV ALTEPLASE (rt-PA) (0.9 mg/kg (maximum 90 mg); 10% bolus over 1 to 2 min, then rest over 1 hour as infusion).
- Antithrombotic treatment for ischaemic stroke:
- PO ASPIRIN 300 mg od for 2 weeks, after CT head
- After 2 weeks, change Aspirin to 75 mg od + add PO DIPYRIDAMOLE MR 200 mg bd
OR
Replace aspirin with warfarin (if not contraindicated) if stroke is cardioembolic
- ROSIER (Recognition of Stroke in the Emergency Room) Scale
Key Management Decisions
- FAST (Face, Arm, Speech, Time) pathway (within 4.5 hours) Pathway
- ABCD2 Score for high risk TIAs (≥4, manage as stroke)
Background
Introduction
- Strokes are a heterogeneous group of disorders involving sudden, interruption of cerebral blood flow that causes focal neurologic deficit
- If you are going to do one thing for a person with a stroke (or high risk TIA), get them on to a Stroke Ward, immediately. This should be a dynamically run 'brain attack unit' (similar to CCU)
- NNT (mortality) for rapid transfer to Stroke Unit = 4
- If symptoms <4.5h, assess for suitability for thrombolysis
- NNT (morbidity) for thrombolysis is 11 <3h, 26 at 3-6h, and 100 at 4.5-6h. <5% pts with a stroke are suitable for thrombolysis
- Strokes can be ischaemic (85%) or haemorrhagic (15%). Read the NICE guidelines (2008)
- Headache, meningism and coma are pointers towards haemorrhage; carotid bruits, AF and previous TIA/Stroke point towards ischaemia. But, you need to get a CT to be certain. Not doing a CT ASAP in a patient with a ?stroke (or ?high risk TIA), is like not doing an ECG ASAP in someone with ischaemic-sounding chest pain
- If ischaemic, it is important to look for 'treatable causes' of stroke = AF and/or recent MI (with mural thrombus) (look at ECG), carotid artery disease and endocarditis
- Stroke symptoms lasting <24 hours (commonly <1 hour) are termed a transient ischaemic attack (TIA). Strokes damage brain tissue; TIAs often do not, and when damage occurs, it is less extensive than that due to strokes
- Patients who have suffered a TIA have an increased risk of stroke, with the risk being greatest early after the TIA
- TIAs should be risk stratified using the ABCD2 score with high-risk TIAs (ABCD2>4) being managed aggressively (admitted to Stroke Ward or assessed in a rapid access clinic, depending on local protocol)
- Watch out for aspiration pneumonia and seizures
- 'Time is brain': patients will lose 1.9 million neurones/minute when a stroke is untreated
WHO Definition
- Stroke is a clinical syndrome characterised by rapidly developing symptoms and/or signs of focal, and at times global (for patients in coma), loss of cerebral function, with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin
Epidemiology
- Stroke is the 3rd commonest cause of death in the UK (11% all deaths) and the most common cause of neurologic disability
- Every 5 minutes someone in England will have a stroke; approximately 110 000 strokes and a further 20, 000 TIAs occur in England each year
- Although the incidence of stroke doubles for every decade over the age of 45 years, 1/4 of strokes occur in people <65 years
- People of African-Caribbean ethnicity are at twice the risk of stroke
Risk factors
- Non-modifiable: Age, male sex, ethnicity, previous history of stroke/TIA
- Modifiable: Hypertension, Diabetes Mellitus, Hyperlipidaemia, Smoking, Cardiac disease
Types
- Primary intracerebral haemorrhage, typically resulting from vascular rupture
- Ischaemic stroke, typically resulting one of 3 main aetiologies:
1. Large artery atherothromboembolism (extracranial and intracranial)
2. Small vessel arterial disease
3. Embolism from a cardiac source - Other causes include carotid or vertebral artery dissection, hypercoagulable states, sickle cell disease or ‘undetermined’ aetiology
Symptoms and Signs (Bamford Classification)
Depend on location of brain damage:
- LACS (lacunar): Motor or sensory deficit only
- PACS (partial anterior artery stroke): 2 of following: motor or sensory deficit; higher cortical dysfunction; hemianopia
- TACS (total anterior artery stroke): All of: motor or sensory; cortical; hemianopia
- POCS (posterior circualtion stroke): Isolated hemianopia; brain stem signs; cerebellar ataxia
- Note: 'acute confusion' and 'collapse? cause' without new neurological signs are NOT a usual presentation of stroke or TIA
Key questions
- "When did the problem start?"
- "Have you had any headacche or neck stiffness? Does the light hurt your eyes?"
- “What were you doing at the time?”
- “Was it like that at the beginning, or did it take some time?”
- "Was there a sudden change in speech/vision/strength/feeling?"
Investigation
Blood
- FBC, U+E, Bone, LFTs, Coagulation, Glucose
Other
- ECG, CXR
- CT head: urgently if suspected haemorrhage or suitability for thrombolysis
Key Investigation (CT head)
L middle cerebral artery infarction
Specialist Investigations
- Brain MRI
- CTA/MRA Head/Neck (to investigate for arterial dissection/stenosis)
- CTV/MRV (to investigate for cerebral venous sinus thrombosis)
- Carotid Duplex ultrasound (to investigate for carotid artery stenosis)
- Echocardiography (to investigate for sources of cardiac embolism); 40% pts <55y have patent foramen ovale, but it is unclear whether closure is of benefit (see references)
- Thrombophilia screen for patients <55 years; auto-antibodies (ANA/DsDNA; ANCA; Anti-cardiolipin antibody), Homocystine, B12/Folate, Lipoprotein A ± Syphilis serology
Differential Diagnoses
- SOL (incl SDH)
- Seizure
- Migraine
- Hypoglycaemia
- Multiple Sclerosis
- Radiculopathy/Neuropathy
- Somatisation
- Metabolic derangement: sodium, calcium
Note: do not forget encephalitis, its treatable
Treatment
Treatment (medical)
- Admission to Stroke Ward for skilled multidisciplinary management of hydration, nutrition, oxygenation, temperature, positioning, and prevention of pressure sores and DVTs
- If symptoms <4.5h, assess for suitability for FAST Pathway ie thrombolysis with IV ALTEPLASE (rt-PA) (0.9 mg/kg (maximum 90 mg); 10% bolus over 1 to 2 min, then rest over 1 hour as infusion)
- If thrombolysis is indicated, current recommendation is that 'door-to-needle' time is no more than 30 minutes - which needs to include CT scanning in addition to clincial assessment
- Thrombolysis is now evidence-based practice and in all Stroke guidelines. Even though it has no effect on mortality, but is useful, in terms of morbidity (see Cochrane review in references)
- Stop antithrombotics and reverse high INR if intracerebral haemorrhage
- Antithrombotic treatment for ischaemic stroke:
PO ASPIRIN 300 mg od for 2 weeks, after CT head.
After 2 weeks:
Change Aspirin to 75 mg od + add PO DIPYRIDAMOLE MR 200 mg bd
(If patient is intolerant of aspirin, use PO CLOPIDOGREL 75 mg)
OR
Replace aspirin with warfarin (if not contraindicated) if stroke is cardioembolic. - Secondary prevention to include optimisation of vascular risk profile (BP, glucose, lipid control)
Treatment of Hypertension
- Hypertension is not recommended to be treated for the first week after stroke (in view of impaired cerebral autoregulation) unless BP>185/110 mm Hg or hypertensive encephalopathy or hypertension-induced LVF exists
Treatment (surgical)
- Neurosurgical intervention should be considered for posterior fossa haemorrhage, peripheral lobar haemorrhage, intraventricular haemorrhage and hydrocephalus
- Hemicraniectomy should be considered for malignant ischaemic stroke (large MCA infarction with decreased conscious level) in patients <60 years
- Carotid endarterectomy should be considered for symptomatic carotid artery stenosis (70-99%)
Prescribing issues
- Do not give first dose ASPIRIN until you have seen CT head (unless there will be a significant delay in obtaining the scan)
- Do not give sc LMWH routinely
Key management decision
- Suitability for thrombolysis in hyperacute stroke
Admit?
- Usually, but only if direct to stroke ward (within 4h); or via brief visit to medical admission ward
- There is evidence that treatment at home is better than a general medical (non-stroke) ward
- High risk TIAs should be treatment like an acute stroke, with direct admission to a stroke ward
- Low risk TIAs should go to a TIA clinic within 48h
Bed plan
- Stroke ward
Referrals
Medical
- Neurology SpR
- ± Neurosurgery SpR? (if bleed or SOL)
Nursing
- Stroke nurse
The Rest
Maxim
- "Time is brain"
Complications
Cerebral
- Seizures, cerebral oedema, hydrocephalus, haemorrhagic transformation of infarct, SIADH
Systemic
- Infection (UTI, LRTI), DVT/PE, depression, contractures, constipation, pressure sores
Follow-up
- Stroke rehabilitation programme
Risk stratification
- ABCD2 for high risk TIA
Prognosis
- Few stroke survivors make a complete recovery; 15% are left with speech problems, 25% are unable to walk, 50% have residual weakness and 25-50% remain dependent on carers for day to day activity
- Risk of recurrent TIA/stroke is greatest early after the first event: about 2-3% of survivors of a first stroke have a recurrent stroke within the first 30 days, about 10% in first 6 months and 10-15% within one year, which is about 15 times greater than the risk in the general population of the same age and sex
- After the first year, the average annual risk of recurrent stroke for the next 4 years falls to about 5%
- This risk is about 9 times the risk of stroke in the general population of the same age and sex
- Mortality after first ever stroke (all types combined) is about 10% at 7 days, 20% at 30 days, and 30% at 1 year. With thrombolysis, there appears to be an increased risk of early and late death, mostly from intracranial hemorrhage (see Cochrane) but this is outweighed by the benefits of the treatment
- Deaths occurring within the first week after stroke are mostly due to the direct effects of cerebral damage
- Later on, the complications of immobility (for example, bronchopneumonia, venous thromboembolism) and cardiac events become increasingly common
2° Prevention + Health promotion
- Refer to stroke rehabilitation programme
- Stop smoking
- Control DM, BP. Get BP down, by whatever method
- Take ACEi, HMG CoA reductase inhibitor ('Statin') and aspirin/dipyridamole (or warfarin)
Don't forget
- Admit patient directly to Stroke Ward, via CT; they improve mortality
- Time is brain – assess patients for suitability for thrombolysis within 4.5h of symptom onset
- Stroke and TIA are not common causes of 'collapse?cause' or 'acute confusion'
- Patients with high risk TIAs should be managed aggressively to prevent early stroke
- Watch out for aspiration pneumonia and seizures
- Do NOT give a sc LMWH (eg ENOXAPARIN) routinely
Red flags
- Deteriorating conscious level
