Physiology

 
 

 
Face/arm (MCA) or arm/leg (ACA) hemiparesis
 

 
 
 
Stroke
 Def:
o Rapid onset focal neurological deficit due to vascular lesion (infarct or
bleed) lasting > 24 hours
 Ax:
    
o Ischaemic (85%)
 Atherothromboembolic (40%)
 Large artery atherosclerosis (20%) - MCA
 Small vessel disease (20%) - perforating arteries off
MCA/PCA
 5% monogenic Cadasil - smooth
muscle hypertrophy, hyalinosis
 Cardioembolic (25%)
 AF - mostly
 Cardiac tumour
 ASD e.g. PFO
 VSD
 Other (20%)
 Cervical artery dissection
 Vasculitis
 Hypoperfusion
 Watershed stroke: sudden ↓ BP
 Strokes of unknown causes (15%)
 Haemorrhagic (15%)
 Hypertension - deep structures → small vessel disease
 Oral anticoagulant
 Structural lesion - cortical e.g. AV malformation, tumour mets,
cavernoma
 Amyloid angiopathy - cortical
 Drugs - cocaine
 Trauma
 Haemorrhagic transformation of infarct
 RF - non-modifiable:
o ↑ age
o Male
o Afro-Carribbean > Asian > European
o PHx vascular event
o Hereditary
o Sickle cell disease
 RF - modifiable:
o BP
o Cigarette smoking
o Hyperlipidaemia
o DM
o Heart disease: AF, CCF, IE
o EtOH XS
o Oestrogen containing drugs: OCP, HRT
o Polycythaemia
 Types -ischaemic - Oxfordshire Community Stroke Project/Bamford classification:
o
 TACS 3 H's MCA
CL hemiparesis (motor or ACA
Large sensory)
infarct Higher cortical dysfunction
ICA/MCA HHemianopia
/ACA
 
PACS Isolated higher cortical Branch
dysfunction OR MCA
ICA/MCA 2 of 3 H's
/ACA  
LACS/l 1. Perforati
acunar motor/s ng
Small ensory/ arteries
infarct sensori around
around motor IC,
basal of thalamu
ganglia, face/ar s, BG
Clumsy
IC, m,
hand-
thalamus arm/leg
dysarthria
and pons or face,
(motor
Deep arm leg
deficit)
penetrati 2.
HTN
ng sensory
arteries stroke
3.
hemipa
resis
POCS 1. Vertebr
hhemia obasilar
Infarct in nopia arteries
veretebr 2.  
obasilar /cerebr
territory ellar
OR PCA syndro
OR me
cerebella 3. Nystagmus
r   , ataxia
perforati Ipsilateral CN
ng palsy
arteries Contralateral
motor/sensory
 Types - haemorrhagic:
o SAH
o ICH
 CF - symptoms:
o Unilateral weakness
o Speech disturbance: dysphasia, dysarthria
o Visual deficit
 o Visuo-spacial dysfunction
o Ataxia
o Headache
o Seizure
o Coma
 CF - signs:
o
Hemiparesis Face/arm (MCA) or arm/leg (ACA) hemiparesis
(opposing) Leaning to one side
Higher cortical Dominant:
dysfunction  Broca's - expressive dysphasia,
left frontal lobe, motor front
 Wernicke's area - receptive
dysphasia, left temporal lobe, sensory
back
Non-dominant:
 Attention and neglect
Abbreviated mental test
Dyspraxia
Hemianopia Lose 2 right (L nasal, R temporal) or 2 left (L temporal,
(opposing) R nasal) sides of visual fields
Cerebellar Past-pointing, nystagmus
signs
o Cardio: mitral stenosis, AF, carotid bruit, pulmonary oedema
o Motor: muscle bulk, abnormal posture/movement, tone, ↓ strength,
pronator drift, brisk reflexes, extensor plantar
o Gait: ataxic, hemiparetic
Ischaemic Haemorrhagic
Carotid bruit Meningism
AF Severe headache
Past TIA Coma
IHD
 Scores:
o Oxford Community Stroke Project
o Modified Rankin Score
o NIHSS
 Ix - acute:
o ABCDE
 A:
 GCS < 8 - intubate, risk of aspiration
 NBM until swallow test
 ?NGT
 B:
 RR
 O2 sats
 Creps R side → swallow impairment →
aspirate
 Ix: CXR and ABG
  C:
 BP - hypoperfusion can lead to stroke
 IV access
 Ix: ECG - embolic AF
 D
 E
 Neuro exam
 Glucose
o FAST scoring
o Bloods:
 Glucose - see if hypoglycaemia → HbA1C
 FBC (polycythaemia), U&E, LFT
 Lipids and cholesterol
 Coagulation - ?haemorrhagic
o CT head
 Rule out haemorrhagic stroke
 Rule out tumours
o Swallow test within 24 hours
 Ix - subacute:
o Bloods:
 ESR - ?vasculitis
 ANCA - ?vasculitis
 Thrombophilia screen
 Thrombocytopenia
o MRI brain - DWMRI
 Most sensitive - subtle changes
 Late presentation
o MRA/CTA/CT perfusion/dwMRI
 Assess if thrombectomy
o ECG telemetry - ?paroxysmal AF
o CT head again after 24 hours
 Evaluate lesion
o Carotid doppler - >70% stenosed → endarterectomy within 2 weeks
o ECHO - ?PFO if DVT leading to stroke
o Genetic testing - CADASIL
o LP - ?SAH
 Do 12 hours after CT head
 Ddx:
o HI +/- haemorrhage
o ↑/↓ glucose
o Infection: encephalitis, abscesses, toxo, HIV
o Drugs: opiate overdose
 Rx - acute:
o Acute stroke unit - prevent aspiration, coordinated care, DVT
prophylaxis, early mobilisation
o ?ischaemic:
 IV thrombolysis - alteplase - within 4.5 hours of symptom
onset
 NIHSS score for risks and benefits of
thrombolysis
 CI:
  Recent head trauma
 Recent head surgery
 GI bleed
 PHx bleed
 Coagulopathic
 ↑ ICP
 ↓ platelets
 Thrombectomy - within 6 - 8 hours of symptom onset
 Up to 24 hours (including wake-up) if
confirmation of ischaemic penumbra on CT
perfusion/dwMRI
 Aspirin 300 mg +/- PPI
 Evaluation for decompressive hemicraniectomy
 Carotid endarterectomy
o ?haemorrhagic: BP control
 Evaluation for neurosurgery
 Rx - longer term:
o A - antiplatelet, antilipid, anticoagulation
 Statins - after hyperacute phase
 Aspirin/clopi 2 weeks 300 mg
 Then clopidogrel 75 mg lifelong
o B - blood pressure rx
o C - smoke cessation, carotid endarterectomy (>70% stenosis)
o D - DM, diet
o E - exercise
 Rehab - MENDS:
o M - MDT: physio, SALT, dietician, OT, specialist nurses, neurologist,
family
o E - eating: swallow screen, MUST
o N - neurorehab: speech and physio, botulinium
o D - DVT prophylaxis
o S - sores avoided @ all costs
 OT:
o Impairment, disability, handicap
  Driving:
o 4 weeks
 
 
TIA
 Def:
o Sudden onset focal neurology due to temporary occlusion of cerebral
circulation lasting < 24 hours
o Now: transient neuro dysfunction secondary to ischaemia without
infarction
 Ax:
o Atherothromboembolism from carotids
o Cardioembolism: post-MI, AF, valve disease
o Hyperviscosity: polycythaemia, SCD, myeloma
 CF:
o Crescendo TIA - ≥2 TIA within 1 week → high risk developing into stroke
o Symptoms
  Brief symptoms
 Mimic CVA in same distribution
o Signs
 Carotid bruits
 ↑ BP
 Heart murmur
 AF
 Ix:
o Bloods:
 FBC, U&E, ESR, glucose, lipids
o CXR
o ECG
Echo
o Carotid doppler +/- angiography
o DWMRI
 Score:
o ABCD2 - risk of developing into stroke
Age >60
BP >140/90
CF Unilateral weakness (2)
Speech disturbance w/o weakness
Duration >1 h (2)
10 - 59 min
DM  
 High risk - admit
 Low risk - discharge and stroke clinic within 3 days
 Ddx:
o Vascular: CVA, migraine
o Epilepsy
o Hyperventilation
o Hypoglycaemia
 Rx:
o Antiplatelet/anticoagulate
 Aspirin/clopi 300mg/d 2 weeks
 Then 75mg/d lifelong
 Warfarin if cardiac emboli: AF, MI, MS after 2 weeks
o CV RF control
 BP, lipids, DM, smoking, exercise, ↓ salt
o Assess risk of subsequent stroke: ABCD2
o Specialist referral to TIA clinic
o ?Carotid endarterectomy if > 70% symptomatic stenosis within 2 weeks