Stroke

Definition

Stroke is a clinical syndrome characterised by sudden onset or rapidly developing focal or global neurological disturbance which lasts more than 24 hours.

Prevalence

In the UK, first ever stroke occurs in 2.3/1000 people per year and first-ever TIA in 0.5/1000 people per year.

Types of stroke

85% ischaemic 15% haemorrhagic

 
Rhcastilhos / Public domain Commons Wikimedia

Rhcastilhos / Public domain Commons Wikimedia

Dr. Johannes Sobotta / Public domain Commons Wikimedia

Dr. Johannes Sobotta / Public domain Commons Wikimedia

 

Bamford classification (or Oxford classification) system

 

Total anterior circulation stroke (TACS)

Anterior cerebral arteries
Middle cerebral arteries

All three:

  • Unilateral weakness (and/or sensory deficit) of the face, arm and leg

  • Homonymous hemianopia

  • Higher cerebral dysfunction (dysphasia, visuospatial disorder)

Partial anterior circulation stroke (PACS)

Middle and anterior cerebral arteries

Two of the following:

  • Unilateral weakness (and/or sensory deficit) of the face, arm and leg

  • Homonymous hemianopia

  • Higher cerebral dysfunction (dysphasia, visuospatial disorder)

 

Lacunar syndrome (LACS)

A lacunar syndrome (LACS) involves a subcortical stroke that occurs secondary to small vessel disease. There is no loss of higher cerebral functions (e.g. dysphasia).

  • Pure sensory stroke

  • Pure motor stroke

  • Senori-motor stroke

  • Ataxic hemiparesis

 

Posterior circulation syndrome (POCS)

Posterior circulation (e.g. cerebellum and brainstem)

Any of:

  • Ipsilateral cranial nerve palsy and a contralateral motor/sensory deficit

  • Bilateral motor/sensory deficit

  • Conjugate eye movement disorder (e.g. horizontal gaze palsy)

  • Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)

  • Isolated homonymous hemianopia

 
 

Diagnosis

  1. The person presents with sudden onset, focal neurological deficit which is ongoing or has persisted for longer than 24 hours

  2. Use a validated tool
    FAST (Face Arm Speech Test), outside hospital
    ROSIER (Recognition of Stroke in the Emergency Room) in the emergency department.

  3. Exclude hypoglycaemia

 

Suspect stroke if:

  • Confusion, altered level of consciousness and coma

  • Headache – sudden, severe and unusual headache which may be associated with neck stiffness.
    Sentinel headache(s) may occur in the preceding weeks.

  • Weakness − sudden loss of strength in the face or limbs.

  • Sensory loss – paraesthesia or numbness.

  • Speech problems such as dysarthria.

  • Visual problems – visual loss or diplopia.

  • Dizziness, vertigo or loss of balance — isolated dizziness is not usually a symptom of TIA.

  • Nausea and/or vomiting.

  • Specific cranial nerve deficits
    Unilateral tongue weakness
    Horner’s syndrome (miosis, ptosis, and facial anhidrosis).

  • Difficulty with fine motor co-ordination and gait.

  • Neck or facial pain (associated with arterial dissection).

  • Posterior circulation strokes may be difficult to diagnose
    acute vestibular syndrome —
    vertigo, nystagmus, nausea or vomiting, head motion intolerance, and new gait unsteadiness.

Management of acute stroke

  1. Admit to specialist stroke unit

  2. Non-enhanced CT Brain

Acute ischaemic stroke (intracranial haemorrhage has been excluded by brain imaging)

  1. Thrombolysis with alteplase if within 4.5 hours of onset of stroke symptoms.
    Staff in emergency departments, if appropriately trained and supported, can administer alteplase.

  2. Thrombectomy +/- intravenous thrombolysis if:

    i) occluded proximal anterior circulation and within 6h of onset of symptoms
    ii) occluded proximal anterior circulation and 6h-24hr of onset of symptoms and potential to salvage brain tissue
    iii) occluded proximal posterior circulation (basilar or posterior cerebral artery) and <24hr of onset of symptoms and potential to salvage brain tissue.

  3. Aspirin 300mg daily for 2 weeks.
    If dysphagia then give aspirin 300mg rectally or by enteral tube
    Thereafter, switch to definitive long-term antithrombotic treatment.
    Patients already receiving anticoagulation for a prosthetic heart valve who experience a disabling ischaemic stroke and are at significant risk of haemorrhagic transformation, should have their anticoagulant treatment stopped for 7 days and substituted with aspirin.

  4. Proton pump inhibitor

Acute haemorrhagic stroke

Recommend reversal of anticoagulation treatment in people with a primary intracerebral haemorrhage who were receiving warfarin before their stroke and have elevated international normalised ratio.
Warfarin effect can be reversed by IV prothrombin complex concentrate and vitamin K.

Acute venous stroke

Recommend full-dose anticoagulation treatment (initially full-dose heparin and then warfarin) in people diagnosed with cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage).

Surgical treatment of acute stroke

Indications for neurosurgery include:

  1. Primary intracerebral haemorrhage complicated by hydrocephalus

  2. Severe stroke involving infarction of the middle cerebral artery
    Decompressive hemicraniectomy within 48 hours of symptom onset for people with acute infarction in the territory of the middle cerebral artery AND severity criteria (>15 score on National Institutes of Health Stroke Scale (NIHSS) scale, decreased level of consciousness, infarct affecting >50% MCA territory, infarct volume >145cm³)

On-going medical, nursing and rehabilitation care

  • Supplemental oxygen therapy, if sats<95%

  • Blood pressure control for people with acute intracerebral haemorrhage if acutely hypertensive (systolic blood pressure between 150 and 220 mmHg) within 6 hours of symptom onset

  • Blood pressure control for people with acute ischaemic stroke only if hypertensive emergency or in those patients considered for thrombolysis.

  • Assessment of swallowing function
    Oral nutritional supplementation
    Hydration
    Avoiding aspiration pneumonia

  • Nutrition and hydration

  • Optimal positioning and early mobilisation

  • Blood sugar control (4 to 11 mM)

Secondary prophylaxis

 

24hr ECG Tape

Carotid artery ultrasound

Cardiac echocardiogram

Atrial Fibrillation

Carotid Artery Stenosis

Cardiac thrombus

 

Ischaemic stroke or TIA without Atrial fibrillation
Aspirin 300mg daily for 2 weeks,
then,
1st line: Clopidogrel 75mg daily (licensed for use in ischaemic stroke, off-label use in TIA)
2nd line: Aspirin 75 mg daily AND modified-release dipyridamole 200 mg twice daily

Consider initiating dual therapy (Aspirin and clopidogrel) for the first three months following ischaemic stroke or TIA due to severe symptomatic intracranial stenosis or for another condition such as acute coronary syndrome.

Ischaemic stroke or TIA AND Atrial fibrillation
Aspirin 300mg for 2 weeks
then,
start Warfarin or DOAC (direct thrombin or factor Xa inhibitor). Adjusted-dose warfarin (target INR 2.5, range 2.0 to 3.0)

 

Cardiovascular co-morbidities

  • Hypertension (aim to achieve a target systolic blood pressure below 130 mmHg (or 140–150 mmHg in people with severe bilateral carotid artery stenosis)

  • Diabetes

  • Atrial fibrillation (rate control; target resting heart rate <110 bpm)

  • Hypercholesterolaemia: high intensity statin (such as atorvastatin 20–80mg daily)
    Immediate initiation of statin treatment is not recommended in people with acute stroke
    Continue statin treatment in people with acute stroke who are already receiving statins

  • Heart failure

  • Obstructive sleep apnoea

 

Influenza immunization

Driving (Group 1)

Stroke: Must not drive, driving may resume after 1 month if there has been satisfactory clinical recovery

TIA: Must not drive, driving may resume after 1 month if there has been satisfactory clinical recovery

Multiple TIAs: Must not drive for 3 months, driving may resume after 3 months if there have been no further TIAs.

Dr Rajesh Varmastroke