Stroke

Clinical

History: Sudden onset of focal neurological deficit for > 24h.
Risk factors: CVS risk factors
ΔΔ: TIA, hypoglycaemia, migraine, extradural/subdural (trauma, alcohol abuse), subdural/tumour (progressive onset), meningitis/encephalitis (fever, neck stiffness), Todd's paresis & cerebral vasculitis
Pathology: 80% are infarcts and 20% haemorrhages

Investigations

• Urgent BM: exclude hypoglycaemia
• Bloods: Glucose, protein C/S/Leiden factor (in the young), prothrombin time/platelets (in case its a bleed), syphilis serology
• ECG: prolonged QT, AF/SVT, ST Δs
• CXR, echo heart (embolus)
• CT: Within 2-5d. 50% infarcts are not visible on CT. Urgent CT if: < 3h (thrombolysis considered), unconsciousness, likely non-stroke
• Urine: drugs, infection, vasculitis, infective endocarditis
• Doppler carotids: now routine in most patients

Location

TACI (Total anterior cerebral Infarct)

Middle/anterior cerebral artery. 60% die in a year. All of:

1. Ipsilateral hemiparesis w 2 of 3 body parts (face, arms, legs)
2. Homonymous hemianpoia
3. New cerebral dysfunction: dysphagia, neglect, visuospatial

PACI (Partial anterior cerebral Infarct)

Same territory. Either of:

1. 2 out of 3 TACI
2. New higher cerebral alone
3. Motor/sensory deficit more restricted than TACI

POCI (Posterior circulation Infarct)

Brainstem/cerebellar signs:

• Cerebellar ischaemia: DANISH = dysarthria, ataxia, nystagmus, intention tremor, slurred speech, hypotonia
• Brainstem ischaemia with cranial nerve signs: diplopia, dysphagia, dysphonia
• Midbrain ischaemia with a combination of anterior/posterior signs.

LACI (Lacunar Infarct)

Commonly asymptomatic. Pure motor/sensory/sensorimotor deficit/ataxic hemiparesis/dysarthria & clumsy hand. Excluded by higher cortical involvement or disturbance of consciousness.

Prognosis

Bad for TACI. 1 year mortality is 10-20% for the rest.

Treatment

The gold standard is to treat in a specialied stroke unit.

Initial treatment

See also the emergency page.

• ABC, recovery position.
• O2.
• IV access.
• Nil by mouth until SALT assessment.
• Avoid glucose infusions because it causes potassium to enter cells.
• If glucose > 10mmol/l put on asliding scale
• Thrombolysis: if infarct proved by CT in < 3h can use T-PA, although this rarely happens in the UK
• Anticoagulation prophylaxis: TEDS, mobilization, hydration. Aspirin 300mg (once bleed excluded). Add an anticoagulant after 2 weeks if ischaemic stroke/AF/heart valve lesion/thrombophilia.

Continuing management

• Avoid catheters unless retention (infection)
• Pressure sores: air mattresses
• Avoid & treat hypotension: can continue antihypertensives, but no new ones for 2 weeks unless hypertensive encephalopathy
• Carotid endarterectomy if stenosis >70%
• Treat CVS risk factors: hypercholesterolaemia, AF, hypertension, obesity
• Feeding: if swallow is unsafe feed with NG tube progressing to PEG (percutaneous endoscopic-gastrostomy) if NG is needed long-term

Prognosis

Recurrence: In the week following the stroke 10% recur. At one month 20% recur.
Mortality: 10%
Negative prognostic signs: unsafe swallow (leads to aspiration pneumonia), loss of consciousness (80% mortality), incontinence, pyrexia, hyperglycaemica