Stroke

The Basics (Part 1)

Ivan Wiggam MD FRCP

Consultant Physician in Stroke Medicine, Royal Victoria Hospital Belfast
Honorary Clinical Lecturer, Queen’s University, Belfast
Learning Objectives (Part 1 & 2)

 Diagnosis
 Medical treatment of acute stroke
 Relevant neuroanatomy
 Multidisciplinary treatment of stroke
 Stroke prevention
 Mr John Smith
 79 year old man
 Gets up to turn off TV at 14:30h and falls
to floor
 Wife, in another room, hears him fall
 He can’t move his left side….

 What should she do?

Call 999
Mr Smith arrives in ED at 16:31 h
(pre-alert)

 Is it a stroke?
 Is reperfusion therapy an option?
 Is it a stroke?
(a) Is the patient at risk of a stroke?
 age
 hypertension
 smoking
 diabetes
 cholesterol
 presence of other vascular disease

(b) Does it look like a stroke?

 onset
 course
 focal vs general symptoms
 “negative” symptoms (loss of function)
 Conditions which can look
like a stroke
 Migraine
 Epilepsy
 Structural brain lesions (SDH, Tumour, abscess)
 Metabolic/toxic disorders (hypoglycemia)
 Vestibular disorders
 Functional weakness
 Demyelination
 Mononeuropathy
 Mr Smith
 Should he have thrombolysis?
 Clear time of onset
(licensed window 4½ h, but “late lysis” possible up to 9h if advanced
imaging demonstrated salvagable tissue )

 No contra-indications
 Infarct v haemorrhage
 Mr Smith
 Walked to bathroom, about 15 min before he fell
 Background history of hypertension, and atrial
fibrillation
 On warfarin and anti-hypertensives
 INR 1.3 (has missed warfarin for a few days)
 Examination
 BP 160/98 mmHg, Capillary blood glucose 5.4
mmol/l
 Dense left hemiparesis
 Neglecting left side – eyes deviated to right
 Left homonymous hemianopia

 NIHSS – 18

NIHSS certification
https://secure.trainingcampus.net/uas/modules/trees/windex.aspx?rx=nihss-
english.trainingcampus.net
What brain imaging is needed
and when?
“Belfast BAP”
 Brain – NCCT
 Angio – CTA (if thrombectomy potentially
indicated)

 Perfusion – CTP (if delayed presentation

and reperfusion potentially indicated)

When?
 Now! (if lysis being considered)
 All cases ASAP, at most within1h
(even if minor stroke, especially if on anticoagulant
therapy)
NCCT at 16:45 h

ASPECTS 7
 Imaging – ASPECTS
www.aspectsinstroke.com

Examine all the images at the

ganglionic and supra-ganglionic
levels.

Take off 1 pt from 10 for every

region that is affected

ASPECTS
8-10 Small core

6-7 Moderate core

0-5 Large core

2023-09-19 www.escapetrial.org
 Should he have
thrombolysis?

 no contra-indications

 What about the risks?

 Types of haemorrhagic
transformation
More confluent
Small petechiae
petechiae within
along margins
infarct, no space
occupying effect

HT* Type 1 HT* Type 2

Blood clot <30%

of infarct with Clots >30% infarct
mild space size with
occupying effect substantial space
occupying effect

PH** Type 1 PH** Type 2

* HT = haemorrhagic transformation
Courtesy of R. von Kummer, Dresden, Germany. ** PH = parenchymal haematoma
Percentage of patients who benefit and are harmed by tPA

Maarten G. Lansberg et al. Stroke. 2009;40:2079-2084

Copyright © American Heart Association, Inc. All rights reserved.

 IV
thrombolysis
 IV bolus at 16:47 h
 DTN 16 minutes
CTA at 16:51
CT perfusion at 16:55
rtPA in large vessel occlusions
Early Recanalization after IV Thrombolysis
(<3h)

Stroke 2016, 47; (9): 2409-2412

So what about thrombectomy?
 ESCAPE Outcomes

2015-02-11 www.escapetrial.org
Time to Treatment With Endovascular Thrombectomy and
Outcomes From Ischemic Stroke: A Meta-analysis

Saver et al. JAMA. 2016;316(12):1279-1289

Back to Mr Smith

 ED arrival 16:31
 NCCT 16:45
 IV lysis 16:47
 CTA 16:51
 CT Perfusion 16:55
 Groin puncture 17:09
 Recan (TICI 3) 17:35

 Last angio run 17:37

Before After
17:24 17:37
 After reperfusion therapy

 Improvement of neglect
 Good return of power (minor drift left arm
and leg)
 Homonymous hemianopia resolved
 Mr Smith arrives on ward..
You are asked to do his clerk in……
 Needs full history and examination
1. Check what has been done….if carotid stenosis has stent been
left in situ?
2. Include social history (smoking/driving)
 Treatment plan
1. Fluids – can he swallow?
2. Flowtrons – complete VTE prophylaxis on kardex
3. “F”armacy – no blood thinners for 24h, think about his other
medications
4. Follow up scan – book repeat CT for 24h (or earlier if planned).
Request virtual non-contrast (VNC scan) to remove contrast
staining.
 5 things to know about Antiplatelet
therapy after Stroke & TIA
1. Standard treatment – Asprin 300mg for 2 weeks (or until
discharge) then clopidogrel 75mg lifelong
2. For minor stroke (NIHSS less than ~5 but depends on size of
infarct) or TIA – DAPT – warn small risk of serious bleed
 Load with aspirin 300mg AND clopidogrel 300mg (if not already on)

 Then prescribe aspirin 75mg AND clopidogrel 75mg for 3 weeks - after 3 weeks, stop
aspirin and continue clopidogrel 75 mg long-term

 Co-prescribe lansoprazole while on DAPT

3. After reperfusion therapy, hold all antiplatelets until after 24h

scan (unless advised otherwise – eg if carotid stent)
4. If symptomatic intracranial stenosis – DAPT for 3 months
5. If AF, usually give antiplatelet agent first (unless TIA) and
then switch to anticoagulant (timing depends on size of
infarct)
 Mr Smith: Follow-up CT at 24h

24h NIHSS 5

Started aspirin 300mg

 Mr Smith
 24h after admission……he is still on IV
fluids
 His son has brought him in a pizza as he
is “hungry and hospital food is terrible”

 Are you happy for him to have a pizza?

 Swallow Screen
 Level of Consciousness
 Swallowing
 Water swallow test / NOT GAG REFLEX

 If concerns, ask SLT to see

Please be a thinking doctor!
 5 questions to ask for every
“stroke patient”
1. Is it a stroke?
2. What sort of stroke is it?
3. Which part of the brain is involved?
4. Why did it happen? (and what do I need
to do to prevent another one?)
5. What problems does this patient have as
a result?
 What part of the brain is
affected?
 Left or right
 Anterior (carotid) or Posterior
(vertebrobasilar)
 Cortex or deep white matter
 Left or Right?
 Crossing of sensory and motor fibres
 corticospinal tracts - lower medulla
 spinothalamic fibres - spinal cord
 dorsal columns - upper medulla
 The “dominant hemisphere”
 Language function localises to left hemisphere
 Awareness of body localises to right hemisphere
 Visual pathways
 monocular vs homonymous deficits
 Cerebellar and cranial nerve lesions
 result in ipsilateral deficits
 Anterior or Posterior?

The carotid system supplies The vertebro-basilar system

most of the hemispheres and supplies the brain stem,
cortical deep white matter cerebellum and occipital lobes
The Cortex?
Subcortical?
 Stroke Subtypes
Anterior circulation
 TACS Total anterior circulation
syndrome
 PACS Partial anterior circulation
syndrome
 LACS Lacunar syndrome

Posterior circulation
 POCS Posterior circulation syndrome
 TACS

1. New higher cerebral

dysfunction
 dysphasia
 neglect / visuospatial
disorder

2. Hemiparesis /
hemisensory loss
 at least 2 of face / arm /
leg

3. Homonymous
hemianopia
 LACS
 pure motor stroke
 pure sensory stroke
 sensori-motor stroke
 ataxic hemiparesis

At least 2/3 of face,

arm, leg
 PACS
 2 of 3 components of
TACS
 higher disturbance of
cerebral function
alone
 restricted motor /
sensory loss
 one limb
 face + hand, but not
whole arm
 POCS
 ipsilateral cranial nerve
palsy with contralateral
motor/sensory deficit
 bilateral simultaneous
motor/sensory loss
 cerebellar dysfunction
 isolated visual field
defect
 TACS, PACS, LACS and POCS – what
does that tell you?

Outcome at 30 days
Independent Dependent Dead

LACS 62% 36% 2%

TACS 4% 56% 39%
PACS 56% 39% 4%
POCS 62% 31% 7%
All 50% 39% 10%
 How does this help you?
 Helps you understand likely stroke
mechanism (hence relevant investigations
and treatment)
 Helps you provide information on
prognosis
 Helps you plan rehabilitation / LoS

 Helps you know what you’re doing