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Stroke (The Basics) Part 1 2023
Stroke (The Basics) Part 1 2023
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….
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
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)
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
ASPECTS
8-10 Small core
2023-09-19 www.escapetrial.org
Should he have
thrombolysis?
no contra-indications
* HT = haemorrhagic transformation
Courtesy of R. von Kummer, Dresden, Germany. ** PH = parenchymal haematoma
Percentage of patients who benefit and are harmed by tPA
2015-02-11 www.escapetrial.org
Time to Treatment With Endovascular Thrombectomy and
Outcomes From Ischemic Stroke: A Meta-analysis
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
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
24h NIHSS 5
Posterior circulation
POCS Posterior circulation syndrome
TACS
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
Outcome at 30 days
Independent Dependent Dead