Module 4 Logbooks - Stroke (Ischaemic And Haemorrhage)

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Module 4 - logbooks 5-6: definition (stroke)

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Disruption of blood supply to the brain, characterised by rapidly developing signs of focal or global disturbance of cerebral functions, lasting for more than 24 hours or leading to death

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Module 4 - logbooks 5-6: definition (PACS)

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Two of: Unilateral weakness, homonymous hemianopia, higher cerebral dysfunction (dysphagia/visuospatial disorder)

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Module 4 - logbooks 5-6: epidemeology

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150,000 strokes, 20,000 TIAs and 50,000 deaths. Lacunar 25%

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Module 4 - logbooks 5-6: aeitology

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(Atherosclerosis) thrombus, emboli, bleed

Young: vasculitis/carotid artery dissection

Old: Thrombus (carotid), emboli (heart (AF)) and hyper/hypotension

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Module 4 - logbooks 5-6: risk factors

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Hypertension, Smoking, Diabetes mellitus., Heart disease (valvular, ischaemic, atrial fibrillation), Peripheral vascular disease, Post-TIA, carotid bruit, Combined oral contraceptive pill, Hyperlipidaemia, Excess alcohol, Clotting disorders

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Module 4 - logbooks 5-6: common presentation

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ACUTE ONSET. Anterior: face, arm, speech, hemianopia

Posterior/brainstem: eyes, balance (ataxia), co-ordination (cranial nerves)

Lacunar: pure motor, pure sensory, mixed motor and sensory signs

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Module 4 - logbooks 5-6: investigations

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CT head in short term. MRI after time. FBC looking at hrpoglycemia, ECG and carotid duplex

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Module 4 - logbooks 5-6: pathophysiology (lack of oxygen (haemorrhage increase in pressure and break down in auto-regulation)

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Inability to maintain ion gradients. Increased calcium >> disordered release of enzymes. Increased sodium >> oedema

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Module 4 - logbooks 5-6: anatomy (Circle of Willis)

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Circle of Willis: Posterior - Vertebral arteries >> Basilar artery >> >> posterior cerebral >> communicating arteries >> internal carotid

Anterior: Internal carotid >> middle cerebral and anterior cerebral. Anterior cerebral have communicating artery

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Module 4 - logbooks 5-6: prognosis

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Most people survive first stoke but have significant morbidity. Mortality is 20% at one month and then 5-10% per year thereafter

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Module 4 - logbooks 5-6: management (acute)

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Thrombolysis if not contraindicated and < 4.5 hours. Then antiplatelet therapy. Haemorrhage has no current treatment (potentially anti hypertensives or diuretics). Possibly surgery to relieve pressure

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Module 4 - logbooks 5-6: drugs - CLOPIDOGREL

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Antiplatelet. Prevents ADP binding to platelet receptor reducing clotting factor production. Also reduces fibrinogen binding to platelets

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Module 4 - logbooks 5-6: drugs - LANSOPRAZOLE

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PPI - supresses gastric acid inhibiting H+K+ ATPase enzyme system

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Module 4 - logbooks 5-6: drugs - AMLODIPINE

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Calcium channel blocker. Inhibit influx of calcium ions through L type channels. Calcium >> calmodulin >> MLCK >> contraction

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Module 4 - logbooks 5-6: drugs - LOSARTAN

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AT II receptor antagonist. Stops vasoconstrictive properties of AT I

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Module 4 - logbooks 5-6: drugs - SALBUTAMOL

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Beta 2 agonist. inhibits phosphorylation of myosin and leads to bronchial dilation

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Module 4 - logbooks 5-6: drugs - BECLOMETASONE

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Steroid - inhibits Leukocyte infiltration >> decrease in inflammatory response

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Module 4 - logbooks 5-6: anatomy (Brain regions)

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Frontal lobe - executive function, LT memory Broca's area and social norms

Parietal lobe - integrates space and navigation

Occipital lobe - visual cotrex

Temporal lobe - semantics in speech and vision

Cerebellum - co-ordination and motor control

Brain stem - midbrain, pons and medulla

Thalamus - sensory information

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Module 4 - logbooks 5-6: drugs - BACLOFEN

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Muscle relaxant - GABA receptor agonist

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Module 4 - logbooks 5-6: drugs - FLUOXETINE

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SSRI - Blocks reuptake >> more circulating serotonin

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Module 4 - logbooks 5-6: drugs - METFORMIN

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Anti-diabetic. AMP-activated protein kinase - improves insulin binding

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Module 4 - logbooks 5-6: drugs - PARACETAMOL

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COX 1, 2 (and 3?) inhibitor. Raises pain threshold by decreasing prostaglandins

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Module 4 - logbooks 5-6: stroke mimics

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Ss - Somatisation, subarachnoid haemorrhage, subdural haemorrhage, sepsis and stroke history

Abscess, dementia, hypothermia, hypoglycaemia, tumour, epilepsy, MG, Bell's and MS

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Module 4 - logbooks 5-6: hemianopea

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Homonymous = same field affected in both eyes most commonly seen hemianopia in stroke.

Heteronymous = different field affected in both eyes.

Superior = upper half of field of vision affected

Inferior = lower half of field of vision affected.

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Module 4 - logbooks 5-6: Screening

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Swallowing (bedside swallow test), malnutrition (MUST), ADLs (OT), depression and shoulder subluxation

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Module 4 - logbooks 5-6: drugs - SIMVASTATIN

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Enzyme inhibitor - HMG coA reductase. Reduces mevalonic acid, precursor of cholesterol

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Module 4 - logbooks 5-6: Hemiparesis

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Weakness on the contralateral side of the infarct

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Module 4 - logbooks 5-6: Hemianaesthesia

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Loss of sensation on the contralateral side of the infarct

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Module 4 - logbooks 5-6: Hemianopia

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Decreased vision/blindness in one half of the visual field of one or both eyes, typically on one side of the midline

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Module 4 - logbooks 5-6: Dysphasia

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Impairment in language and divided into receptive and expressive dysphasia - Wernicke's area

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Module 4 - logbooks 5-6: Dysarthria

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Impairment in speaking due to paralysis and loss of co-ordination of speech muscles

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Module 4 - logbooks 5-6: Dyspraxia

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Impairment in learning new movements

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Module 4 - logbooks 5-6: Dysphagia

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Difficulty in swallowing due to paralysis and loss of co-ordination of muscles involved in swallowing

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Module 4 - logbooks 5-6: Diplopia

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Double vision often due to nystagmus and loss of eye muscle control

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Module 4 - logbooks 5-6: Ataxia

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Wide-based gait with truncal instability

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Module 4 - logbooks 5-6: Apraxia

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A disorder of learned movements (e.g. don't know which steps to do first for teeth cleaning)

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Module 4 - logbooks 5-6: Glasgow coma score

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Eye opening, motor response and verbal response. 13-15 minor. 9-12 moderate. 8 or less severe

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Module 4 - logbooks 5-6: Lacunar infacrt aeitiology

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Atheroma and Lipohyalinosis (vessel disease) vessel wall thickening and a resultant reduction in luminal diameter.

Occlusion of a single deep penetrating artery. Affecting basal ganglia, internal capsule, thalamus and pons. Intact cognition/conciousness

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Module 4 - logbooks 5-6: acute management NICE guidelines

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Alteplase (thrombolysis) - within 4.5 hours if not contra-indicated

ASPIRIN 300mg for 2 weeks - then long term treatment

Haemorrhage:

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Module 4 - logbooks 5-6: Berry anneurysm treatment (surgery)

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Clip (open) or coil (endovascular)