Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Stroke

Stroke - Key Features

1. In patients presenting with symptoms and/or signs suggestive of stroke, include other diagnoses in the differential diagnosis (e.g., transient ischemic attack [TIA], brain tumour, hypoglycemia, subdural hematoma, subarachnoid bleed).

2. In a patient presenting with a stroke, differentiate, if possible, hemorrhagic from embolic/thrombotic stroke (e.g., through the history, physical examination, and ancillary testing, such as scanning and electrocardiography), as treatment differs.

3. Assess patients presenting with neurologic deficits in a timely fashion, to determine their eligibility for thrombolysis.

4. In a patient diagnosed with stroke, involve other professionals as needed (e.g., a physical therapist, an occupational therapist, social service personnel, a physiatrist, a neurologist) to ensure the best outcome for the patient.

5. When caring for a stroke patient with severe/serious deficits, involve the patient and her or his family in decisions about intervention (e.g., resuscitation, use of a feeding tube, treatment of pneumonia).

6. In patients who have suffered stroke, diagnose “silent” cognitive deficits (not associated with sensory or motor symptoms or signs, such as inattention and impulsivity) when they are present. 7. Provide realistic prognostic advice about their disabilities to stroke patients and their families.

8. In stroke patients with disabilities, evaluate the resources and supports needed to improve function (e.g., a cane, a walker, home care).

9. In the continuing care of stroke patients with deficits (e.g., dysphagia, being bedridden), include the prevention of certain complications (e.g., aspiration pneumonia, decubitus ulcer) in the treatment plan, as they are more common.

10. In patients at risk of stroke, treat modifiable risk factors (e.g., atrial fibrillation, diabetes, hyperlipidemia, and hypertension).

11. In all patients with a history of TIA or completed stroke, and in asymptomatic patients at high risk for stroke, offer antithrombotic treatment (e.g., acetylsalicylic acid, clopidogrel) to appropriate patients to lower stroke risk.

STROKE
Definition

• An acute neurological injury that occurs due to either brain ischemia or brain hemmorrhage

Types

1. Ischemic (87%)

a. Thrombotic

b. Embolic

c. Hypoperfusion related

2. Hemorrhagic

a. Intracerebral(10%) b. SAH(3%)

History

• Typically sudden onset of sx

• Weakness, esp unilateral

• Confusion

• Aphasia

• Visual deficit/diplopia

• Dizziness, gait disturbance, ataxia

• Sudden severe HA with no known cause

• Atypical sx

• SOB

• LOC or syncope

• Sudden pain in chest, arms, legs

• Seizure

• Sudden hiccups, fatigue, palpitations

• Altered mental status

• Risk Factors

• HTN

• DM

• CAD

• A-fib

• Valve replacement

• Recent MI

• Bleeding diathesis (i.e anticoagulation)

Physical Exam

• Assess ABCs

• GCS

• Screening neurological exam assessing visual, motor, sensory, coordination, and language functions

Work Up

• Capillary blood glucose

• CBC, lytes, BUN, Cr

• INR, PTT

• ECG

• Consider: LP, tox screen, CXR (for aspiration) depending on presentation

• Imaging

• Emergent non-contrast CT head

• Most acute ischemic strokes are not visualized by non-contrast CT in early hours of a stroke

• Role of CT is primarily to exclude intracranial bleeding, tumour, and other stroke mimics

• Remember to do LP if suspicion of SAH and normal CT

Management

• Hypertension in ischemic stroke

• If no thrombolytic therapy, should treat if SBP >220 or DBP >120, or if serious other comorbidities (i.e. ACS, AKI, HF etc)

• Cautiously lower BP by 15% within first 24h

• Can restart previous antihypertensives at ~24h if neurologically stable

• Stricter control if thrombolysis being considered or has been done

• Hyperglycemia

• Less favourable outcomes in the setting of hyperglycemia, so it should be treated if >10

• Thrombolysis

• Need to determine time of symptom onset!defined as last moment patient was at baseline

• Thrombolysis not recommended if time of onset unclear

• Inclusion criteria

• Acute ischemic stroke

• 18-80 y/o

• Onset of symptoms 3-4.5h before rtPA administration (time varies between institutions/guidelines)

• Stroke sx present for at least 30 minutes without significant improvement

• Exclusion Criteria

• Lengthy list, but includes ICH, coagulopathy, seizure at onset, significant HTN, or unclear dx

• Antiplatelet therapy (for ischemic stroke)

• ASA 325mg w/I 24-48h after stroke onset (does not interfere with thrombolysis)

• Other considerations

• Aspiration risk

• NPO until swallowing assessment

• May need NG or PEG feeds!discuss wishes w/ pt/family

• Elevated head of bed to 30 degrees if concerned about increased ICP, aspiration, oxygen desaturation

• Maintain normothermia

• Pneumonia most common cause of fever w/I 1st 24h

• DVT prophylaxis with UFH or LMWH in patients w/ ischemic stroke and limited mobility (wait 24h if thrombolyzed)

• Urinary incontinence common

• Most commonly d/t detrusor hyperrflexia from loss of inhibitory input from CNS

• Beware of bedsores

• Frequent repositioning q2h ideally if bed bound

• Pressure reducing products

• High rates of post-stroke depression (18-61%)

• Multi-disciplinary approach

• Involve OT, PT, SLP, stroke rehab if available

• D/C planning-consider need for home support, assisted living, placement

Secondary Prevention

• Antiplatelet therapy for non-cardioembolic stroke/TIA

• ASA 81mg od OR

• Clopidogrel 75mg od OR

• ASA + Aggrenox (ER Dipyridamole)

• Clopidogrel vs ASA

• Clopidogrel slightly more effective (5.3% vs 5.8% rate of stroke, MI, vascular death annually), but marginal benefit may be offset by cost (CAPRIE Trial)

• Slighly lower rates of GI bleeding w/ clopidogrel vs ASA

• Don’t use ASA and clopidogrel together-no benefit and increased rates of adverse events-unless there is some other indication (i.e ACS, PCI etc)

• Dyslipidemia/Statin Therapy

• Conflicting evidence, some suggestion that dyslipidemia is not a strong risk factor for stroke but...

• Atorvostatin 80mg po od for anyone with TIA or ischemic stroke of atherosclerotic origin

• ARR of fatal/nonfatal stroke at 5 years = 2.2%

• ARR of any coronary event 6.5% (SPARCL trial)

• Consider combining statin with niacin or gemfibrozil if HDL <1

• Treat DM2 and HTN

• Lifestyle modification

Primary Prevention

• Lack of data for ASA in mod –high risk patients (Framingham risk >10%), so use clinical judgement

TRANSIENT ISCHEMIC ATTACK
Definition

• A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction

• Duration (i.e. <24h) no longer included in definition

Prognosis

• Increased risk of stroke (up to 17% 90 day risk)

• Predictor of imminent stroke (4-10% risk w/i 48h)



Clinical Manifestation

• Low flow (i.e. secondary to carotid stenosis, vertebrobasilar lesion etc)

• Usually brief (i.e. minutes), recurrent

• Carotid stenosis/MCA lesion

• Usually stereotyped

• Hand, face, arm, leg numbness/weakness

• Aphasia if dominant hemisphere

• Vertebro-basilar circulation

• Not stereotyped

• Brainstem and cerebellar sx

• Dizziness w/ or w/o vertigo

• Dysarthria

• Diplopia, ptosis

• Arm/leg numbness or weakness-can be bilateral

• Facial numbness

• Embolic

• Typically last hours

• Sx as above, but if in PCA distribution may include

• Ataxia

• Hemianopsia

• Hearing loss

• Crossed face and body numbness

Work-Up

• ABCD2 score

• Prognostic scoring tool designed to identify patients at high risk of ischemic stroke in the first two days after a TIA

• Can be used to determine inpatient vs outpatient therapy

• Imaging

• CT or MRI brain recommended ASAP, w/i first 24h

• Neurovascular evaluation

• Most patients will get a duplex u/s of carotids initially, or possibly CTA/MRA

• Cardiac evaluations

• ECG

• ECHO if no cause for TIA found on w/u

Management

• Risk factor reduction-see recommendations for secondary prevention of stroke

• Carotid Endarterectomy (CEA)

• Symptomatic and > 50% stenosis, with life expectancy >5 years --> refer to vascular surgeon

• CEA usually recommended in patients w/ recently symptomatic carotid stenosis of 70-99% with a life expectancy of >5 years

• Symptomatic stenosis 50-69%-CEA usually recommended in men but not women

• <50% stenosis-medical management

• Near occlusion-CEA not beneficial

• Ideally CES should be done w/I 2 weeks of last event

*Note-Above table does not include metabolic causes (i.e. hypoglycemia, other metabolic disturbances), encephalopathy

Study Guide

Stroke

Resources

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