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Hello, everyone. I'm Natasha. Um We're just gonna be talking about stroke today from an A&E perspective. Um I'll just get everything ready in a second. So can you guys see this? You see my little Rainbow Wheel? It's a bit awkward. That's great. Same. I've just got my ipad beside me. So I if you have any questions at any point, just drop them in the chat box and I'll try and uh just give you answers and just go through it as we go along this presentation itself. So we're gonna be talking about stroke today and we're gonna be talking about it from an A&E perspective. What are we going to learn today? We're gonna recognize some of the common presentations of an acute stroke, how to investigate and manage an acute stroke and understanding your basic anatomy and how to correlate it with the presentation and obviously being aware of the mimics and any differentials. So, in a pre alert situation, when the person comes in, for, for instance, we've got a 5553 year old male that's coming as fast. Positive. So this is Peter doesn't really look like he's fast. Positive to be honest, but we shall find out and the paramedics have handed over that he was found at home. Fast positive. He's got a G CS of 15 out of 15 and it's been 45 minutes since onset of symptoms. So, just starting out right here, what do you think actually matters the most out of this history? So, would it be his age, would it be his, the symptoms that he's had? Query? He's F positive? Is his G CS concerning or is it the duration? Yeah, so we've got a split. So over there, what it matters is that obviously false positive, important but equally as important or even more important as the minutes of duration. And we'll get through to why that is. So obviously, BFAs is a campaign to improve awareness among nonmedical folk or just in the community to be more aware of signs of a stroke and it's actually improved recognition by about 60 to 70% in the community. So it is a really good campaign. Now, coming back to Peter, you actually see Peter in one of your examination rooms and PETA doesn't look so good to be honest. Um that does actually look like false positive symptoms. So what do you do immediately with this gentleman? So I'd like you to think about in a perspective, something that we just rehash on and on and on and on. How would you examine a patient in a and a and potentially something to just help you think about is, you know, what would be the most important part of your clinical work up for this patient? I don't think, I haven't forgotten. I still want you to list out the way and how you would go about examining a patient on A&E. Mhm. Anybody else? So, we've got a patient here that's come in as fast. Positive. And I want you to think about their clinical work up. What would be the most important tool or you think about that will be very important in your examination, blood CT head, a neuro exam, all your scoring tools. So we've got, we've got CT head as the most important now. Yes, I agree. Obviously, your CT head is gonna give you answers or sometimes it might not give you answers. And the reason I say that is because your neurological examination is probably the most important thing, reason being and we'll go through it. Stroke does not always have to be a radiole, a radiological evidence, guided diagnosis. It's actually more clinical findings that guide you. You treat them based on the symptoms that you actually see and test based on your physical examination. So while I was getting out, I'm really disappointed in you guys, I wanted you to say A to e always do an A to e in any, any patient in A&E is the most efficient way to examine anyone and obviously take a detailed history for this patient. Obviously, it's really important. Concentrate on your neuro exam. These tiny little things that you will pick up and do is so pertinent in these cases. Put him in a Mon Bay. You don't really want him Peter looking like this being actually stayed out there in the waiting room right now. It's not the best, is it? And are there any scoring tools that you can think of for stroke actually? And this is a bit of an interesting one cause not many people actually know it. So what do you think it would be? I've just put up another pole over there being a bit po heavy today. So we've got different types and then you can choose what you think or what you may have known or what you may not have known. And that's the reason for this and we'll go through them together. So yes, people have put on Rosiere and that is literally recognition of strokes in the emergency room. So you want to cannulate and take some blood and you wanna, obviously, if you're suspecting a stroke, you wanna be conscious of your duration, you wanna get a CT head as quickly as possible under guidelines. Get an E CG as a baseline, obviously, uh BMS to make sure and we'll go through why that was so important. And Aspirin 300 mg of that, you, you would already find that a lot of paramedics that would have already questioned a stroke would have given this en route to the hospital, but it's good to clarify and if not prescribe it and speak to your stroke coordinator. So if you're in a district general like myself, you'll just be speaking to a str a stroke coordinator over the phone. And obviously, if it's um in your own hospital, you'll go to the appropriate channels yourself. So great. You think it is a stroke? So, what do you think differentials wise? What do you think it could be? And I don't wanna call out anyone. So we're not gonna do that. But these are some of the most common stroke mimics that you will see according to our chem. What do you think would be the most common ones in your understanding? And I'll give you guys just 10 seconds. Let's make it 20 seconds. So different types of differentials that I want you to think of for a stroke. It would be things like hyperglycemia, migraines with auras, simpler things like vertigos, seizures, um space occupying lesions, brain tumors, sepsis, shock, syncope, electrolyte, imbalances and um facial nerve palsy. And it's a bit of a interesting one when we think about facial nerve palsy because if you wanna compare facial nerve palsy, which is a cranial nerve palsy compared to stroke, there is something that is so important that you need to remember and you need to ask yourselves which one is forehead sparing. So for sparing is that obviously the forehead is not affected by it. Can anyone try to remember what they think of it and just try and think which one do you think would be a lower motor neuron or an upper motor neuron condition? Yeah, perfect. So, stroke is a upper motor neuron and it spares your forehead. Whereas cranial palsy is a lower motor neuron and it takes complete side, upper and bottom part of your face. Ok. So we've talked a little bit about stroke mimics and this is just our thing. And you'd actually find that there 7% of it would actually go down to vertigo dementia's eve with migraines just because of how they present atypical migraines, migraines with auras and the others as you can see in their own percentages. Now, coming back to our scoring tools, we have few that we're gonna talk about. So we've got Rosea, it's recognition of stroke in the emergency room. Now, it is not the most specific. It just basically helps you kind of just understand whether you think it's more of a differential rather than a stroke doesn't really give you any more quantity than that. But it is something to be helpful if you're a little bit stuck talking about the N I HSS. But this is your National Institute of your health stroke scale. And when do you actually use it? You use it when you want, when it actually gets to help physicians to objectively rate how severe ischemic strokes are gonna be, it determines your prognosis. It helps determine rehabilitation. So, as you can imagine, um it helps with 30 day mortality. So the larger the number is, I think your maximum that you can go to is 42. Um So a score between 22 to 42 gives you a 30 day mortality of over 50%. So it's a very good indicative prognosticator for example. And you can always repeat it through someone's um stroke that actually us all. So coming back to Peter, what's his story? His wife noticed that he had a left sided facial droop after waking up and his left arm felt weaker. It was not resolving and they called the ambulance. So he's got type two diabetes hypertension. He's a nonsmoker. He's got some family history of a few things and in terms of a systemic inquiry, it's just fairly unremarkable apart from the neurological findings. So important question number one, did this resolve because you wanna find and you'll soon find and we'll talk about it later. Like TI A s, you want to ensure that these neurological findings are not just resolve themselves. And because that does not mean does not lead, lead you down the road of stroke, it leads you down TI A S. And the second thing to think about when you're taking your history with someone, when we were doing clinical work up with someone with stroke is what are the risk factors? Because this is so important to actually underlying stroke management or the cause of the stroke itself. And for him, we've got a few things. We've got hypertension, we've got diabetes. Uh, we've got family history of ischemic heart disease. Does he actually have? It may have a borderline one, we'll find out. So, examination and this is the most crucial part when you think about someone that has a stroke is the one obviously get a set of OB S for them go through your at e. So fairly general, interesting A to e in the sense that he's stable and all those parameters. But then where does it actually come up when you do your neurological examination? Why? Because you're gonna be doing your tone, your power, your reflex, your sensation, so be great. Bear in mind the first time it comes up, just go and refresh yourself and geeky medics however you need to. But it's so important that you do a detailed neurological examination, especially if you want to speak to your stroke coordinator. These findings will be absolutely more useful than so important. Look at your inspection, use this common acronym swift. Um and go through what we talked about earlier. Tone power reflex sensation, proprioception coordination and of course your cerebellar signs. Another acronym to lovely remember is your uh danish for cerebellar and your cranial nerve examination. If you guys have any problems whatsoever, you have any questions, just let me know. OK, so now you come to the idea that this person has a stroke right now. Obviously you've done a CT head. Well done. Yeah, we're branching out to two different types of stroke, an ischemic stroke where you've got a lack of oxygen through a clot part of the brain, or you've got a hemorrhagic stroke where there's a bleed in the brain. Let's go down the ischemic part of the stroke. So there is a very, very important cut off time that I need you to think of. And sorry, I was just putting up the pole. So this cutoff time is actually indicative as to when you can trombol someone. Oh, people were absolutely on the ball there. Yes. 4.5. You've heard it all. That's great. So 4.5 is your cut off. So what is thrombolysis? Now, I've already said that in an ischemic stroke, you've got a clot in the brain. And how are you gonna get rid of a clot? You are gonna dissolve it with a blood thinner. This is more systemic blood thinner, thrombolysis with a um ulcer place, which is basically a tissue plasminogen activator. So it catalyzes plasminogen into its active form, which is known as plasmin. And this basically is a major enzyme for clot breakdown. And after you do Trombolysan, we'll go through the eligibility criteria for that. You want to make sure that 24 hours later, another repeat ct head has been done to exclude hemorrhagic transformation. Now, if it's over 4.5 hours, you can consider a trom that also has its own select criteria that changes constantly according to stroke guidelines as well. So it's always really good to remember that. But for trom, there are new guidelines sometime last year that said that the stroke windows between 6 to 16 hours. So again, always just remember, but you won't be making that decision by yourself. So you don't have to worry about that. But obviously 4.5 hours, if you're considering troms is extremely important. Now, when you go under the hemorrhagic a blade in the brain stroke in that pathway, it's really important. You'll be obviously using our famous thing here in the northeast or just around England is obviously our refer a patient. Um But also it's really important to maintain your BP at that point and be aware of the ad coagulant history. So Trom sis who is eligible. So number one ischemic stroke, an onset of symptoms under 4.5 hours and if they're over 18, so does anybody really care why it's 4.5 hours? I went through this little um it was very unfortunate rabbit hole to try and find out why. 4.5. Exactly. And it's basically because there were a lot of meta analysis, there were a lot of systemic reviews that basically showed in conclusion this 4.5 hours, anything above this had a higher risk of hemorrhagic transformation. And this was all collective studies that were probably done for over like four or five years ago. So this was the reason and it just had a slightly higher mortality rate over um for those that had trauma lysis over 4.5 years ago, 4.5 hours. And this was done a couple of years ago in terms of systemic reviews. Now, things are always constantly changing and you notice that policies can also change. And consultants can also vary in terms of their advice and when they do it, so things are obviously clinically based. So take things as they go. But what happens when you don't know the exact time of the stroke? When do you take it? And it's very easy. You just basically take the time as to when the patient was at their last like um normal neurological baseline. And that's the time that you'll take it except for wake up strokes. This is a bit of an interesting one. So if a person just woke up in the morning and said that, oh, my arm just felt extremely there. I couldn't move it at all. You would take it from the time that they woke up because there was no clinical, there's been no clinical evidence to actually show that um that they would have had a stroke in their sleep in that time before because clinical evidence might have shown that they've actually woken up because of the stroke. So that's the only exception for that. Now, who's excluded from thrombolysis. So this is a very chunky exclusion re uh exclusion list. But I want you to just remember a few things, severe head trauma, any other head bleeds, head surgeries and upper gi bleeds. Those are the most important and also uncontrollable BP. Those five things, the rest of them can just be lightweight reading if you want to do them later. But also you've got the weird and wonderful hematological conditions to think about if their platelet counts were under a certain amount. If they are on, obviously, anticoagulant use with prolonged IRS and PT S and need to have like specific reversal agents before moving on. This is just how a trampy works. If you think about how a PCI works, it's effectively similar where they basically put a tube all the way through your groin and it goes to the brain and it is either removed through suction or it's actually broken off into small pieces and then removed. So what's more important is that if your patient is not for acute management? As in like, for example, thrombolisis thrombectomies, what exactly happens to them? Number one, you continue that aspirin for about two weeks and then after that, you think about secondary prophylaxis and this is when you need to think about the cause of the stroke as well. So you either take them into uh two lines, clopidogrel, 75 mg and that goes online or the DOAC if they've had new presentation of AF which some of the times they might do on uh ECG S and if you have AF as well, you need to go through and just, you know, do chat fast score and counsel them things like this. Always think about hyperlipidemia. That's why you start people on statins. It's really good to look at their lipid profile. The type of bloods that you do for these patients are also really important. Um So stroke bloods and young stroke bloods. So stroke bloods that you would do. Just apart from your usual S and LFT S, you do a lipid profile. TSH A coag an E SR and an HBA1C. Again, if you think about risk factors, the bloods would also like would make sense with this. And if you think about young stroke blood. So for somebody who has had a stroke at 40 years old, um sometimes it might not just be all due to risk factors, there might be some hypercoagulable state like for example, Lupus. So they have another big chunk of blood or just that, that you will do. So this could be Lupus bloods, protein C protein S anticardiolipin. Now this changes policy to policy and protocol. So always just remind yourself before ordering anything. But if you think about a more hypercoagulable state and why you're ordering it makes it easier to remember in terms of management, you will, you know, in terms of investigation? Sorry, you might think about ultrasounds of your carotids. A ct of your angio arch and your intracranial MRI head for further evidence and things that could be done as an outpatient. For, for example, if a cause was not actually put down a 72 hour tape to find out whether there are any rhythm irregularities like af and an echo to look for any intramural thromboses or any valvular pathologies. Seven, we've got Peter and Pizza does this and we know that pizza has a stroke. What do you think? Do you think you can drive? I'm sorry, I was just putting up another pole there for you. Yeah. No, we don't think you can drive. And what the advice is about this is that you advise them while they're there in the hospital, you advise them that they're not allowed to drive because Tibe obviously has his own protocols, but it's something to be mindful about. So you wanna tell them that they're not allowed to drive until they're reviewed in clinic most of the time you, well, the process is that at least a month after they discharged from the hospital, they need to see whether they have any residual weakness or what exactly their symptoms are before being seen in clinic and before talking to the D VLA about learning to drive again again, very person to person based and clinical based. Now road to recover. Sorry, you've gone down the route with P where you've given him lots of aspirin, you've changed it to Clopidogrel. He is stable in himself, but he obviously still has this left sided weakness. He is not talking as well. He's got a little form of expressive dysphasia. How does he get better? And that is true. Rehabilitation. So, rehab is such an important part of stroke um because they work as an MD et and you relearn everyday skills. So people that you know they swallow has been infected, obviously the mobility gaining the confidence, understanding what's the best way for them to actually immobilize. Now, continence communication and how their cognitive state will be and obviously nutritional status and hydration. One of Peter's symptoms actually did resolve after 30 minutes. Now, I've given you the answer already and that is, oh OK. But I want you to think about a transient ischemic attack and we'll go through that in our seizure presentations at some point in this series. So please join us for that too. But what is the scoring tool that we need to use for that? And I mentioned it earlier. Now, there's a poll over there. I'll give you that answer. It's basically your ABCD two and it's a great tool to use for TI A S. But again, like I said, we'll cover it in our seizure presentation. But this is just a nice overview of what our referral form looks like from uh Derham Darlington. Trust and how useful it is when we're referring you on for a tia. A give me a second. Oh, well done. Yes. ABCD two. So, just talking a little bit more about stroke in itself. What is stroke? It's basically an interruption of your blood supply to a focal part of your brain that's caused a loss of neurological function or your death. Got about 80,000 admissions in England and Wales due to an acute stroke. And what's actually very surprising but also interesting is that stroke is actually the second most common cause of mortality and the most common cause of disability. So to me, take account about how common this incidence of stroke is among, you know, people in the UK. So we've already a little bit covered about this, but we've got two different types of strokes. Um We've got an ischemic stroke that could be due to thrombosis. You know, I think about your carotids, it could be embolic, it could be um dissections and it's basically a lack of perfusion inside a focal part of your brain or multiple parts and a brain hemorrhage, which could either be an intracerebral hemorrhage or a subarach. What's important to know is that 85% of strokes are more likely to be ischemic than they are hemorrhagic. But obviously, it's very difficult to um predict in the beginning. Some books and theory might state that if a patient was complaining of a headache prior this could have some relevance to it becoming a hemorrhagic um stroke or a bleed. But again, this is not very inconclusive. This is why your CT head is extremely important. Because as we said before you give them aspirin earlier, you would notice that you'd have to be extremely careful. Um, you want to make sure that it's not a hemorrhagic stroke before giving them, you know, for example, thrombolysis especially. So, just talking about brain ischemia, what it is is that obviously you've got your ischemic core where the core your brain tissue is basically is about to die. But the area around it is known as the ischemic pen Umbria and this is actually just um excitable but viable cells um and they actually can be saved if they are perfused again. So I think something that's actually very interesting that I learned about this was understanding how many neurons actually get lost in a minute. A stroke goes untreated. Sorry guys, I'm just technical issues trying to see my pole station again. So what do you think? Oh yeah, 100% people got it right. 1.9 million, 1.9 million is the answer for the neurons that get lost in a minute. A stroke goes untreated. So extreme amount to be honest, if you think about it and it's quite crazy. But coming back to risk factors for an ischemic stroke, you wanna think about things like af age, smoking, hyperlipidemia, um hypertension. Oh sorry, I wrote smoking twice. But yes, smoking is a huge, huge, huge risk factor type two diabetes. And obviously think about your family history coming up to hemorrhage. As simple as that. We've got a bleed in our brain. Um, it just depends where, what are your risk factors here? You want to think about age hypertension, any av malformations, any anticoagulants and tumors vasculitis or basically just simple trauma. So this is something quite fun and I'm not gonna pick out on anybody. But if someone remind ourselves and forget about it, just basic brain ANAs quite nice to remind ourselves. So we're gonna talk about the front of our brain and surprise, surprise. This is the frontal lobe. What does your frontal lobe actually do? It helps you with your motor control, your concentration, your problems solving the way your speech is over that. I think it's just basically trying to represent what Broca's area is. Now, we're talking about the very top of our head, almost like the parents of our head just closing a little bit more of that pressure and that's your parietal lobe. So what it does is go take touching pressure in your taste and your awareness of what you're doing. Now, just talking about the sides of our heads, like giving me a headache just about here, near my temples and this is your temporal lobe. And what does your temporal lobe do? It helps you with your hearing and your facial recognition, you know, just moving on to the back of your brain, which we know is where your occipital lobe is. And this helps with obviously your sight, your vision and right at the bottom, we've got a cerebellum which helps us with coordination. This little area over here is your Wernicke's area to help you with language and reading. Very important to remember. Your broker's area over here is basically language production. Whereas your Wernicke's over here is your language comprehension. So problems in either one of those areas will then result in basically um expressive or receptive aphasia. No, my favorite bit that tends to be a little bit more confusing is stroke by anatomy. Where is this lesion? So we've got diagrams here, right? And it looks really, really traumatic looking to be honest. But what I'm gonna do is I'm just gonna take a pause from sharing everything. Oops, sorry guys. And I'm just actually going to draw out a few things for you. So I think it's actually really, really helpful. So we're just gonna talk about anatomy of it and I'll try my best to make it as big as possible. But what I want you to think about is the heart and bear in mind. My drawing is not very useful. OK? And I wanna think about the arch of aorta. So we've got tree spouts here. We've got our subclavian spelt. So this is your right subclavian artery and then you've got your left common carotid and then you've got your left circling. So let's focus on this middle one, your left common carotid. So it goes all the way up and then it becomes your left internal carotid and then it goes to your brain. But how and that's two the cycle of that that we're gonna do. Sorry. That's a bit inverse obviously. But his eye made you think about this. So this is your internal carotid arteries? Ok. So these are your internal carotid arteries. I want you to remember two things. It pops into your middle cerebral arteries. And now important things to remember. There's always an anterior part of everything. Say we've got our anterior cerebral arteries and how they connect to each other. Very similarly anterior communicating artery, simple as that where there's an anterior, there is a posterior. So go down, go down. How does it connect that as your posterior communicating arteries? And these two branches coming out is your posterior cerebral arteries. Now, we're talking about the back posterior. So what's actually at our back is our spine? So if you draw your little spine here, this is your, this is the artery and you think about your back, we've got our let your grow arteries. I hope that makes a little bit more sense. Um Things there are a little bit more detailed that you can potentially think about uh things like your, this is your anterior inferior cerebellar arteries and your pus. So these are basically some of the vessels that can cause things like lateral medullary syndrome locked in syndrome, things like that in your pontine arteries here. So I hope that makes all a little bit more sense. The final thing I wanna talk about, which will be in my next slide is basically correlation to your middle cerebral artery, your anterior ce liberal artery and your posterior liberal artery to your body. Like where does it actually? And what does it actually control? So just very quickly, if you think about a these are your legs, so your anterior cerebral artery controls your legs and then these are your hands, which is your middle cerebral artery. So your middle cerebral artery controls your torso and also your mouth because it's an M. So it controls your lip as well. And then if you give this person funny glasses, which is an angry pea, that's basically your posterior. And that helps things like your sight and it helps things like your cognition and it helps things like your balance. So if you think about it like that, so I hope that makes a little bit more sense. Um Let's go back and finish this presentation. Give us a second. So we talked about that and I, and it's basically just a bit of a rehash, but I hope that makes a little bit more sense. So what scans do we order and why do we order them? So, I just want you to think about two things. Number one is obviously your ultrasound of your carotid arteries over here and your ct of your intracranial arch and your um the ct intracranial aorta aortic arch. And that's just because of the circle of Willis. So you're wanting to look for any clots or any um more types of ischemia that might be there as well. This is basically that little stick man that I was talking about about which arteries actually have a relationship with which motor functions. So different types of stroke and we all know this. So basically what it mean is basically ts packs pox and lacuna in fugs and how do we break them down is basically through the Bamford classification. So what the criteria is is either unilateral hemiparesis or hemisensory loss or uh homonomous hemiopia. Uh high cognitive dysfunction. Can anybody give me some examples of what higher cognitive dysfunction could be like anything at all? Just one example. And I kinda mentioned them earlier as well? Ok. Well, that's fine. So things like nausea, dysphasia, sensory inattention in a visual field defect. Yeah, perfect. Yes, memory can be one of them. So this is basically how you classify them. So based on the criteria, taxus three of the criteria which is total pax is partial. So to the above lacuna can be a different things because it's the arteries that actually surround your internal capsule in your thalamus and your basal ganglia. So it can present with one of the following which either is a poor, a pure sensory stroke, pure motor stroke and a toxic hemiparesis. This arteria or it's just a combination of sensory motor and pox is basically a vertebra bacillar arteries and they preserve one of the following cerebellar or brain stem syndrome. Um isolated homonymous hemi utopia and what is a very, very dangerous and common finding um complication with an MCA stroke is a malignant MCA infarct malignant MCA syndrome. So, about 5% of these strokes can result from this complication. And about all of them have been found to have been caused by an embolic occlusion of your proximal middle cerebral artery. And it basically is a very rapid sudden neurological deterioration due to cerebral edema that's caused herniation in an MCA territory stroke. And it's something to always be vigilant by, by simple clinical signs such as acute confusion, acute deterioration, um worsening of their stroke side symptoms. These are things to be just be a bit mindful of, especially if they had an MCA territory stroke. Um What you can see at the bottom there is basically how they've dealt with it because they may require urgent decompressive hemocrine omy. And you can see how uh swollen it just needed some space for that. Now, this is just a very quick slide about mini strokes. Um This is just a transient ischemic attack and what it is is a transient episode of neurological dysfunction caused by any focal brain, spinal cord or even retinal ischemia without any acute infarction. The clinical features are unilateral weakness or sensory loss, aphasia, dysarthria, um moments of ataxia, feeling vertigo, loss of balance or visual problems. The most important part is that they have resolved themselves at a specific duration of time. A very quick overview of management is number one ABCD two Aspirin AC head, an MRI and you discuss with stroke. But what you would find is most important is actually their clinical history of what they were doing. How did the symptoms present? How did they resolve themselves in terms of secondary prevention? You think about clopidogrel and statins? So I hope that was all right. Um I think we made really good time of that today. If you have any questions, just pop it down below, but thank you so much for coming. I do appreciate it. Go and have a lovely, lovely Friday. If you have any questions, just let me know. Thank you very much for your time. Just don't forget to see our feedback. I'd really appreciate it.