Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Acute Stroke Jihad Gasmelseed ST3 Neurology Plymouth university NHS trustAcute Stroke • Acute stroke is defined as the acute onset of Definition focal neurological findings in a vascular territory as a result of underlying cerebrovascular disease. • The 5th cause of death , 1st cause of disability worldwideType of stroke • Ischemic stroke 85%: • TOAST classification: • 1)Large vessel disease • 2) small vessel disease (lacunar) • 3)embolic stroke • 4)cryptogenic stroke• Haemorrhagic stroke: 15% • 1)ICH • 2)SAH • HTN • DM • Hypercholesteremia • Smoking • AF Causes of stroke • Heavier drinking • Sedentary lifestyle • Genetic (young age) clotting disorder, vasculitis, dissection. Mechanism of stroke • Cut of bloods supply to to arterial closure regardless of the cause. • When an arterial blockage occurs, the immediately adjacent neurons lose their supply of oxygen and nutrients. The inability to go through aerobic metabolism and produce ATP causes the Na+/K+ ATPase pumps to fail, leading to an accumulation of Na+ inside the cells and K+ outside the cells. The Na+ ion accumulation leads to cell depolarization and subsequent glutamate release. Glutamate opens NMDA and AMPA receptors and allows for calcium ions to flow into the cells. A continuous flow of calcium leads to continuous neuronal firing and eventual cell death via excitotoxicity Lacune • Lacunes may be defined as small subcortical infarcts (< 15 mm in diameter) in the territory of the deep penetrating arteries; these lesions may present with specific lacunar syndromes or they may be asymptomatic. Lacunes occur most frequently in the basal ganglia and in the internal capsule, thalamus, corona radiata, and pons • 1.Pure Motor • 2. Pure Sensory • 3.ataxic hemiparesis Types • 4. dysarthria/clumpy • 5. mixed sensory motorLarge vessel Disease Features of • Contralateral hemiparesis and hypesthesia (Weakness of arm& face is worse than in the middle cerebral lower limb) artery stroke: • Gaze towards to side of lesion • Ipsilateral hemianopsia • Receptive or expressive aphasia is dominant hemisphere is affected • Agnosia • Inattention, neglect Features of • Speech is preserved but there is disinhibition • Mental status is altered anterior cerebral artery stroke: • Judgment is impaired • Contralateral cortical sensory deficits • Contralateral weakness greater in legs than arms • Urinary incontinence • Gait apraxia Posterior • Cortical blindness cerebral artery • Contralateral homonymous hemianopsia • Altered mental status stroke: • Visual agnosia • Memory impairmentVertebral/basilar • Nystagmus artery stroke: • Vertigo • Diplopia and visual field deficits • Dysarthria • Dysphagia • Syncope • Facial hyperesthesia • AtaxiaEmbolic stroke Time is brain. Acute stroke With each one minutes of large vessel Storke two millions neurons dies. Stroke call • Call from the nurse, • Dr The patient become confused/drowsy • Dr this patient had fall can you come and asses. • Dr this patient slumped in the chair • Dr patient become slurred • Dr patient said lost some part of his vision Assessment ABCD A Airway B breathing C irregular heart rate AF?dd text D GCS ,abnormal posture, upgoing planter, unequal pupil Essential • Onset of symptoms, duration • OBs: BP: High , PR: Fast AF • BM ! • ECG • Routine bloods (FBC, U&E, Coag ) • Stop anticoagulation • Stroke team • CTH/CTANIHSS Absolute contraindication • >4.5 hours since know onset of symptoms, or time of onset not known. • Known haemorrhagic stroke. • Strong suspicions of SAH • Arterial puncture of non compressible site • Or LP within last 7 days • Recent major surgery • Ulcerative gastroenteritis disease in the last three months, sever liver disease, oesophageal varices• Sever head injury at the time of stroke, ICH< 3 months • Any history of previous primary /spontoeus ICH • AVM , malignant brain neoplasm, recent neurosurgery. • Endocarditis , recent MI, Aortic aneurysm or ventricular system • Trauma with fracture or internal injuries within previous 4 weeks • Warfarin INR>1.7 • Platelets <100 • BM<3 or>22mmol/l-can lyse if corrected • BP >185 systolic or 110 diastolic –can lyse if corrected • Radiological evidence of ICH • CTH already showing expensive acute changes of infarction• Current treatment with dabigatran, rivaroxiban, apixbana, edoxaban • Current Heparin treatment is not an exclusion if the APTT ration is normal • Current treatment with theraputic dose low molecular weight heparin Relative contraindications • Intracranial aneurysm • Benign brain tumour • Previous ICH due to trauma >3 months • Neurosurgery>3 months • Ischemic stroke < 3 months • Seizure at onset • Coma • Rapidly resolving symptoms • INR 1.4-1.6 Thrombolysis • HOB • Closely monitored • 0.9/kg alteplase • 10% bolus • 90% infusion over one hour • BP <180/100 • Repeat NIHSS score in 2, 24 hours • Any drop GCS or worsening neurology STOP infusion and repeat CTHThrombectomy • Monitored closely OBS, Neuro. • NIHSS score 2 hours and 24 hours post thrombolysis • Any drop in neurology or drop in GCS • 1. stop infusion Post thromolysis • 2 Repeat CTH • 3.Request FFP • 4. Takes blood, FBC, COAG, Fibrinogen Post thrombolysis care • Post thrombectomy Aspirin 300 mg. • HASU or ITU • Hourly neuro Obs • Monitor for worsening neurology/drop GCS • 1.Tranexamic acid 1g iv stat. CTH : Blood • 2.FFP (12-15mls/kg round to nearest 250ml=1 unit) • 3.Discuss with haematology cryo or fibringogen preciptate if fibrnogen low. • 4. Neurosurgical discussion( hematoma evacuation) • 5.Consider mannitol 20% at 0.5g/kg if for surgery or ITU. • 6. Hourly obs. • 1. Seizures. • 2.recurrent ischemic stroke. • 3.PE CTH: Normal • 4.Extrancrnial bleed. • 5.Drug reaction. • 6.Metabolic upset. • 7. OthersICH • Stop anticoagulation • Tight BP control : <140/80 • Neurosurgical referral • Close neuro obs in high setting • Reverse coagulopathy • DVT prophylaxis • Carotid doppler. • 24-72 Hrs Cardiac Tape Stroke work up • Echo • Lipid ,HbA1c • Stroke in young • MRI brain • Antiplatelet • statin Inpatient • Feeding • DVT prophylaxis • OT/PT/SLT • Antiplatelet. • Statin • Control risk factor (DM, HTN, Smoking, drinking) Stroke • DVLA secondary • Discharge destination prevention • 1. Pneumonia • 2.bed sore • 3. depression Long term • 4.contracture complications • 5. disability • 6.neuropathic pain • 7.Malignant MCA • 8.Post stroke seizure Malignant MCA is the term used to describe rapid neurological deterioration due to the effects of space occupying cerebral oedema following middle cerebral artery (MCA) territory stroke. Early neurological decline and symptoms such as headache and vomiting should alert the clinician to this syndrome, supported by radiological evidence of cerebral oedema and mass effect in the context of large hemispheric infarction.Malignant MCA Management URGENT NEUROSURGICAL DECOMPRESSIVE REFERAL CRANIECTOMY• The prognosis is generally poor , and death usually occurs as a result of transtentorial herniation and brainstem compressionQUESTION?