STROKEPriyanca Patel and Fil Sianos

What is a stroke?A neurovascular deficit of cerebrovascular

cause that persists beyond 24hrs or is interrupted by death within 24hrs

What are the 2 main types of stroke?• Ischemic

• Something is reducing the blood flow eg. Thrombi, emboli

• Hemorrhagic• Rupture of a vessel eg. Aneurysm

Stroke risk factors

• Hypertension • Hypotension• Hypercholesterolemia• Obesity• Atrial fibrillation• Due to clot formation from erratic flow

and pooling of blood in the atria

How can we recognise a stroke?Face weakness

Arm weakness

Speech problems

Time to call 999

Oxford stroke classification

• Total Anterior Cerebral Infarct (TACI)

• Partial Anterior Cerebral Infarct (PACI)

• Lacunar Infarct (LACI)

• Posterior Cerebral Infarct (POCI)

TACI (aka. TACS)

• DEATH: common• Higher dysfunctions (cognitive, emotional and

issues with defecation and micturition)• Dysphagias• Visuo-spatial problems• Homonymous hemianopia• Motor/ sensory deficits

PACI (aka. PACS)- 2/3 similar to TACI- Partial motor/ sensory deficits- Higher dysfunction alone

LACI (aka. LOCS)- Pure motor or sensory or sensorimotor loss- focal- Common in brainstem regions and deep cerebral white

matter

POCI (aka. POCS)

- Cranial nerve palsy and contralateral motor/sensory deficit

- Bilateral motor or sensory deficit- Cerebellar signs - DANISH- Eye movement deficits/ isolated homonymous hemianopia

Motor

Sensory

Watershed infarctsDue to a rapid drop in cerebral perfusion caused by a systemic drop in blood pressure • Occurs in boundaries of the arterial supplies• These areas are supplied by a fine network of vessels

Eg. Carotid artery occlusion ACA-MCA- Loss of motor function

(sometime identical sensory loss) in:- TRUNK- PROXIMAL UPPER LIMBS

MCA-PCA- Problems with visual processing Man in a barrel

syndrome

Transient Ischaemic Attacks (TIA’s)Transient loss of perfusion to an area with full recovery within 24hrs- Often results in lacunar infarcts - A key warning sign, if lest untreated 10% of cases will progress

into a full stroke within 1yr- Often causes of TIA are

- Carotid insufficiency- Vertebrobasilar insufficiency

Amourosis fugax: a transient loss of vision (usually in one eye). This is a characteristic type of TIA caused by loss of perfusion in the retinal or ophthalmic arteries

How can we assess the risk of an individual having a stroke?

There are a number of scaling systems that can be used to assess the risk of an individual having a stroke:

• ABCD2

• CHADS2

• CHA2DS2-VASc

ABCD2

• Does the patient require urgent specialist stroke assessment- ie. After having a TIA?

• Score between 0 and 7• Score > or = 4 are at a HIGH risk of stroke and need immediate

assessment • <4 should be given 300mg of aspirin/day, risk reduction discussed

and referred to a TIA clinic within a week

A: Age (> or = 60yrs: 1 point)

B: Blood pressure at presentation (> or = 140/90mmHg: 1 point)

C: Clinical features (unilateral weakness = 2 points, speech disturbance without weakness: 1 point)

D: Duration of symptoms (> or = 60mins: 2 points, 10-59mins: 1 point)

D: Diabetes (1 point)

CHADS2 and CHA2DS2-VASc• Risk of stroke in patients with atrial fibrillation• Used to determine whether treatment with anticoagulant or

antiplatelet therapy is required• Clinically has been superseded by the CHA2DS2-VASc:

C: Congestive heart failure (1 point)

H: Hypertension (1 point)

A2: Age >75yrs (2 points)

D: Diabetes mellitus (1 point)

S2: Prior stroke or TIA or thromboembolism (2 points)

V: Vascular disease (eg. peripheral artery disease, MI, aortic plaque)

A: Age 65-74yrs (1 point)

Sc: Sex category (ie. Female- 1 point)

Stroke ManagementKEY: Rapid identification and treatment to reduce damage and disability

Determine whether the stroke is ISCHAEMIC or HAEMORRHAGIC:1. Urgent scan- CT and sometimes DWI (secondary for ischaemic

stroke but takes longer- tells you how far the ischaemia has gone)2. Signs of blood? YES: Haemorrhagic (get neurosurgery in as they may need to stop the bleed/ evacuate)NO: Ischaemic need to get blood flow back so proceed with thrombolysis

NB: Current recommendation is 4.5hrs for thrombolysis (ALTEPLASE)

CT imaging/ MRI• CT – fast, easy to spot

haemorrhage

• DWI – best for ischaemic damage

Long Term Management of stroke• Blood thinners eg. aspirin or clopidogrel • Lifestyle changes

Long-term COMPLICATIONS of STROKE:• Post-stroke pain • Burning pain with sharp components • Hyperalgesia• Allodynia• Treat as neuropathic pain eg. AMITRIPTYLINE

Thank You! Any Questions?