MEDICAL STUDENTS STROKE MEDICINE SUMMARY

Stroke Types Ischaemic (80%) Intracerebral Haemorrhagic Subarachnoid Haemorrhage (5%)

(15%)
CT/MRI May be normal Always CT done within 6 hrs
Appearance initially or may abnormal 99% sensitive for SAH.
show dense hyperdense Blood most dense
vessel, loss of blood initially around aneurysm.
grey white so a normal Acomm Artery,
differentiation scan rules MCA, Pcomm
loss of insular out ICH. Artery, Basilar
ribbon. Later Blood goes
artery
hypodense. with time
over weeks.
MRI: CTA: Aneurysm on R
Gradient MCA
Echo/T2*
and SWI
show blood
as black

MRI: DWI/ADC show L MCA infarct

Risks Age, AF, HTN, IHD, Lipids, Diabetes, smoking, Male sex, Age, HTN, race, alcohol excess Genetics, Smoking, HTN
alcohol excess
Causes Cardioembolism: AF, Endocarditis, Valves, Hypertension, Cerebral Amyloid Berry (Saccular) Aneurysms, AV Malformation,
Mural, myxoma, Atheroma plaque rupture angiopathy (age>70), Anticoagulants Perimesencephalic (Normal DSA benign), Trauma,
e.g. carotid stenosis. Dissection. Small vessel Exclude trauma as well as Bleed from Anticoagulants
(lacunar) disease. Rare: Vasculopathies AVM, Cavernoma, Tumours
Investigations FBC, ESR, U&E, LFT, lipids, Glucose, ECG FBC, ESR, U&E, LFT, lipids, Glucose, ECG FBC, ESR, U&E (Low Na is common), LFT, lipids,
(AF/MI/LVH), CXR. Carotid Doppler: Non- (LVH), CXR, Coagulation check INR Glucose, ECG, CXR
disabling anterior circulation strokes or TIA. MRI/A at 6-12 weeks to look for LP needed after 12 hrs if thunderclap headache and
Transthoracic Echo: Murmur, Cardiac persisting structural causes normal CT after 6 hrs to look for RBCs and
symptoms, abnormal ECG, Endocarditis. Xanthochromia. Cerebral angiography to look for
Strokes < 45 and no cause: MRA, aneurysms or AVM
Thrombophilia screen, Vasculitis screen,
Bubble echo
Management Admit HASU. ABC. Check BM. Consider Admit HASU, Consider ITU if GCS < 9. Those with suspected bleeding from
Thrombolysis: Some ITU if GCS < 9. ABCs. IV fluids if NBM or IV fluids if NBM or poor intake or aneurysms or AVM are admitted under
Contra-indications : poor intake or dehydrated. dehydrated. ABCs, Control BP Neurosurgery/ITU. Intubate/ventilate if low
any increased risk of
bleeding, On Thrombolysis: Alteplase 0.9 mg/kg if acutely. Aim for SBP of 140 mmHg GCS. Direct measure of Measure ICP.
anticoagulants, BP > within 4.5 hours of onset and no but not lower. Avoid Nitroprusside. Lower SBP < 160 mmHg with Labetalol may
185/110mmHg, contraindications (see left) Consider IV Labetalol 10-20 mg slow reduce rebleed risk.
recent surgery, plts
< 100, INR > 1.7,
Mechanical Thrombectomy < 6 hrs of IV over 2 mins which may be Clipping or coiling of aneurysms.
NIHSS> 25, Coma, onset, Large vessel occlusion (M1, repeated. Amlodipine 5 mg PO/NG Main risk is rebleeding and vasospasm.
Recent GI/GU bleed, Carotid T) on CTA and NIHSS > 6 (+/- or ACEI PO. Monitoring. Surgical Nimodipine is given to prevent vasospasm
Epistaxis, Arterial Alteplase) (<24 hrs with Clinical-core consult. OT/PT/SLT Hydration. IV fluids
Puncture of Non-
compressible Vessel, mismatch on CTP or MRI) Reverse Any Anticoagulation Long term Rehabilitation as needed. These
Brain AVM, Stroke < Malignant MCA: Decompressive Warfarin: 4 factor PCC + IV Vitamin patients do not usually come to the stroke
3 months, Any hemicraniectomy K team.
Haemorrhagic
stroke. No complete
Antiplatelets : Aspirin 300 mg PO/PR 2 Dabigatran: Praxbind 5 g IV or Clip inserted after Coil inserted endovascularly by
craniectomy by Interventional
Side effects: weeks then Clopidogrel 75 mg od haemodialysis.
neurosurgeon neuroradiologists into the
Anaphylaxis, BP control: Labetalol 10-20 mg slow IV Rivaroxaban, Apixaban, or aneurysm and causes
Angioedema, which can be repeated if BP > 220 Edoxaban: 4 factor PCC (e.g. thrombosis
Intracranial and
extracranial mmHg or > 185/110 mmHg and for Octaplex,Beriplex)
haemorrhage alteplase. Surgical management: refer all
Diabetic control: VRIII if needed to keep patients. Cerebellar haematoma > 3
Glucose 5-15 mmol/l. Exercise, Stop cm, hydrocephalus needing EVD,
Smoking, Statins, Warfarin or DOAC for cortical bleeds near brain surface
AF, 7 day SLT,OT,PT. and low GCS Long term
Rehabilitation
Arterial Syndromes and Aetiology Right Sided Stroke (Side of the brain Left Sided Stroke(Side of the brain pathology)
pathology)
Middle cerebral Cardio-embolism, carotid disease with artery Left HP (FAL Arm weakest), Left HS, Right HP (FAL arm weakest), Right HS loss
artery (MCA) to artery embolism, local atherosclerosis. Left HH (can’t see to left), Left Right HH (can’t see to right)
Hemineglect/anosognosia Aphasia (language)
Anterior Cerebral Cardio-embolism, carotid disease with artery Left HP (FAL leg weakest) Right HP (FAL leg weakest) urinary incontinence,
Artery(ACA) to artery embolism, local atherosclerosis. Abulia, urinary incontinence Aphasia, Change personality

Posterior Cerebral often Cardio-embolism e.g. AF or posterior Left HH, cognitive and other memory Right HH, cognitive, memory issues, aphasia
artery(PCA) circulation (subclavian/vertebral/basilar) issues
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 atherosclerosis and artery to artery
Basilar and Supplies Brainstem (Midbrain (3/4) Pons R cranial nerve palsies. R cerebellar signs L cranial nerve palsies L cerebellar signs
Vertebral arteries (5/6/7/8) Medulla (9/10/11/12) and R Horner’s if R lateral medulla. Left HP L Horner’s if L lateral medulla. Right HP
cerebellum Pontine: locked in syndrome Pontine: locked in syndrome

Bamford Classification: useful clinically HP = hemiparesis HS = hemisensory loss HH = Homonymous hemianopia

Brain is supplied by 4 vessels : R/L Internal Carotid arteries (anterior circulation) and R/L Vertebral arteries (Posterior circulation)

Stroke Type HP or Dysphasia or Vertigo, dysphagia,

HH Notes
(All = red, some = green) HS loss hemi neglect diplopia, cerebellar signs

Total anterior circulation Yes Yes Yes No Large cortical stroke in

(TACS) 20% MCA/ACA areas.

Partial anterior circulation Yes/No Yes/No Yes No 2 out of 3. Smaller cortical

(PACS)35% stroke in MCA/ACA areas

Lacunar stroke (LACS) 25% Pure motor No No No Subcortical stroke due to

Pure sensory small vessel disease
Ataxic HP Subcortical/pons

Posterior circulation (POCS) 25% Yes/No Yes/No NO Yes Cerebellar or brainstem

syndromes

Stroke Complications: Prevention is key

Complications Prevention and Management

General Good positioning and support weight of affected arm to protect shoulder. Good nursing care. Skin protection. Catheter care.
7-day OT and PT to work on physical and functional goals to optimise return of function. SLT for speech, language and
swallowing. Psychology for mood and cognition issues. Multidisciplinary teamworking and stroke care saves lives and reduces
disability. Early supported discharge where possible.
Ischaemic Stroke Use of Aspirin 300 mg acutely. Long term stroke prevention – antiplatelets, anticoagulate AF after CHADSVASC HASBLED risk
recurrence assessed. Statins. All strokes - manage BP. avoid alcohol, stop smoking, exercise
Cerebral Oedema Fall in GCS after MCA infarct at 24-72 hours. Use IV N-saline not Dextrose CT diagnostic. Referral to neurosurgeons for
discussion on Hemicraniectomy
Enlarging Fall in GCS. Cerebellar Haematoma > 3 cm. Superficial supratentorial bleeds. CT diagnostic. Referral to neurosurgeons for
Haematoma discussion on haematoma evacuation and/or decompressive Surgery +/- External ventricular drainage for hydrocephalus.
Manage SBP to 140 mmHg
Obstructive Bleed into ventricles or oedema obstructs the ventricles CT diagnostic. Referral to neurosurgeons for discussion on Surgery +/-
Hydrocephalus External ventricular drainage for hydrocephalus
Seizures/status Lorazepam for status epilepticus. IV Phenytoin/Equivalent. Some may need long-term anticonvulsants e.g. Levetiracetam.
epilepticus Always consider Non-convulsive status in any patient with hypoactive delirium
DVT/PE Early mobilisation, Intermittent Pneumatic compression, LMWH selected cases IPC for all who are immobile. If PE suspected
then CTPA diagnostic. If DVT needs USS. Anticoagulation. Consider IVC filter for those we cannot anticoagulated due to ICH
with VTE
Swallow Swallow Screening Assessment acutely before oral intake. If problems identified then Speech and language therapy
assessment. Aspiration pneumonia IV antibiotics, chest physiotherapy, Sitting out as tolerated

Nutrition Encourage oral intake when possible. If unsafe swallow or other reasons consider NG feeding. Involve dieticians. Weigh patient
so can be monitored.

Falls Falls can be the price to pay for mobilisation but we should try to prevent. See if you can Identify those at risk and try to
prevent. Implement strategies. Close supervision.
AF/Heart failure Avoid fluid overload. PO or IV Beta blockers, PO or IV Digoxin for fast AF. Furosemide for fluid overload.
Anticoagulate AF at 10-14 days in Ischaemic stroke with DOAC usually. Assess CHADSVASC and HASBLED scores.
Continence Manage constipation. Catheter for retention and TWOC when possible. Start a toileting regimen.
UTI: Oral or IV antibiotics short course. Try to ensure privacy when toileting.
Skin Keep skin dry and protected and 2 hourly turns to prevent pressure sores.
Review by nurses and doctors and specialist teams. Nutrition important.
Mood Assess using validated tools and support psychological needs. Be sensitive to needs. Supportive empathetic care. Consider
antidepressant and monitor.
Mortality: 30-day mortality Acute Ischaemic stroke 15% SAH 35% ICH 40%. Haemorrhage worse outcomes. Determine what would have
been wishes of patient. Coma on presentation a bad prognostic sign. Follow NICE guidance. Trials of fluids as appropriate.
DNACPR forms after discussion with patient or those close to patient. Prepare family. Compassionate care. Palliative care
team. Empathy.
TIA Syndromes
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A TIA is in theory a clinical “stroke-like” syndrome due to a temporary transient arterial occlusion that warns that an acute ischaemic
stroke may be imminent. Most resolve within 10-20 mins though definition is < 24 hrs. Refer to TIA clinic – to make the right diagnosis
from TIA mimics (migraine/syncope/TGA/hypoglycaemia etc), diagnose AF and anticoagulate, find carotid stenosis needing
endarterectomy and to start best medical therapy (clopidogrel + statin) and advise about lifestyle (smoking/exercise/alcohol) and
driving – stop for 28 days. See all asap but urgently (Same day) if Age > 60 (+1), Duration > 10-59 min (+1) > 60 mins (+2), Unilateral
weakness (+2), Loss of speech no weakness (+1), BP ≥ 140/90 mmHg (+1) Diabetes (+1) and score >3. If score 6-7 then 2-Day Stroke Risk:
8.1%, 7-Day Stroke Risk: 11.7% and 90-Day Stroke Risk: 17.8%

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