Emergency medicine: Stroke Cases Quiz Quiz Dr Shuaib Siddiqui, - - PowerPoint PPT Presentation

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Emergency medicine: Stroke Cases Quiz Quiz Dr Shuaib Siddiqui, - - PowerPoint PPT Presentation

Oct 28, 2023 478 likes •885 views

Emergency medicine: Stroke Cases Quiz Quiz Dr Shuaib Siddiqui, MB BChir MRCP, FY3 doctor (1) Emergency series Content reviewed on 12/05/2020. Case 1 History You are working in A&E. You see a 70-year-old man who is brought in by

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Emergency series

Dr Shuaib Siddiqui, MB BChir MRCP, FY3 doctor

Content reviewed on 12/05/2020.

Quiz

Emergency medicine: Stroke

Cases Quiz

(1)

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History You are working in A&E. You see a 70-year-old man who is brought in by ambulance after his son noticed he was slurring his speech. This started 3 hours ago. On examination, you note he has 3/5 power of both his left upper limb and 4/5 power of his left lower limb. Observations HR 90, BP 155/89 mmHg, RR 18, SpO2 97%, Temp 36.8

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Case 1

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Question 1

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History You are working in A&E. You see a 70-year-old man who is brought in by ambulance after his son noticed he was slurring his speech. This started 3 hours ago. On examination, you note he has 3/5 power of both his left upper limb and 4/5 power of his left lower limb. Observations HR 90, BP 155/89 mmHg, RR 18, SpO2 97%, Temp 36.8

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Case 1

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Question 2

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Pathophysiology

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Definition: sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death (NICE)

Pathophysiology

Ischaemic (85%) Thrombotic

  • Atherosclerosis
  • Prothrombotic state

Embolic

  • AF
  • Paradoxical embolus
  • Infective endocarditis

Lacunar

  • HTN

Hypoperfusion

  • Reduced blood pressure

Haemorrhagic (15%) Intracerebral

  • Trauma
  • HTN
  • Cerebral amyloid

Subarachnoid

  • Trauma
  • Berry aneurysm
  • AVM
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Pathophysiology

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Definition: sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death (NICE) Epidemiology

  • 11% of people die from a first stroke
  • Incidence of ~ 120,000 per year in the UK

Risk factors

  • Age: risk doubles every decade after the age of 55
  • Family history
  • Smoking
  • Diabetes
  • Hypercholesterolaemia
  • Carotid artery stenosis
  • Prothrombotic state

Pathophysiology

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Pathophysiology

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Stroke vs TIA

Stroke TIA Definition Sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death Transient neurological symptoms lasting less than 24 hours

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Pathophysiology

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Stroke vs TIA

Stroke TIA Definition Sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction Imaging Infarction No infarction Tissue Hypoxic damage No changes

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Question 3

History You are working in A&E. You see a 70-year-old man who is brought in by ambulance after his son noticed he was slurring his speech. This started 3 hours ago. On examination, you note he has 3/5 power of both his left upper limb and 4/5 power of his left lower limb. Observations HR 90, BP 155/89 mmHg, RR 18, SpO2 97%, Temp 36.8

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Question 4

History You are working in A&E. You see a 70-year-old man who is brought in by ambulance after his son noticed he was slurring his speech. This started 3 hours ago. On examination, you note he has 3/5 power of both his left upper limb and 4/5 power of his left lower limb. Observations HR 90, BP 155/89 mmHg, RR 18, SpO2 97%, Temp 36.8

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Pathophysiology

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(2)

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Pathophysiology

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(3)

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Pathophysiology

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Territory Signs

Anterior cerebral artery Contralateral hemiparesis and sensory loss

  • Lower limbs affected more than upper limbs

Middle cerebral artery Contralateral hemiparesis and sensory loss

  • Upper limbs affected more than lower limbs

Contralateral homonymous hemianopia Aphasia (dominant hemisphere) Hemispatial neglect (non-dominant hemisphere)

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(4)

MCA infarct

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Hemispheric dominance

  • Broca’s and Wernicke’s area: dominant hemisphere
  • Spatial processing: non-dominant hemisphere

(5) (6)

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Hemispheric dominance

  • Broca’s and Wernicke’s area: dominant hemisphere
  • Spatial processing: non-dominant hemisphere

(7)

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Question 5

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Pathophysiology

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Territory Signs

Posterior cerebral artery

  • Contralateral homonymous hemianopia with macular sparing
  • Contralateral loss of pain and temperature due to thalamic

infarction Vertebrobasilar artery

  • Cerebellar signs - DANISH
  • Reduced consciousness
  • Quadriplegia or hemiplegia
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Pathophysiology

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(8) (6)

PCA infarct

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Pathophysiology

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(6)

Vertebrobasilar infarct

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ROSIER score

Feature Score

Loss of consciousness or syncope

  • 1 point

Seizure activity

  • 1 point

New, acute onset: Asymmetric facial weakness + 1 point Asymmetric arm weakness + 1 point Asymmetric leg weakness + 1 point Speech disturbance + 1 point Visual field defect + 1 point

  • Recognition of stroke in the emergency room
  • Score > 0 suggests possible stroke requiring further investigation
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Bedside

  • Blood glucose: rule out hypoglycaemia
  • ECG: assess for AF

Bloods

  • U&Es: rule out hyponatraemia
  • Screen for risk factors: HbA1c, lipids, coagulation profile

Imaging

  • Brain imaging: urgently within 1 hour
  • Non contrast CT head
  • CT angiogram
  • MRI head
  • CXR: if swallow compromised
  • Echocardiogram
  • Carotid doppler

Investigations

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Question 6

History You are working in A&E. You see a 70-year-old man who is brought in by ambulance after his son noticed he was slurring his speech. This started 3 hours ago. On examination, you note he has 3/5 power of both his left upper limb and 4/5 power of his left lower limb. Observations HR 90, BP 155/89 mmHg, RR 18, SpO2 97%, Temp 36.8

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Question 6

(9)

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Management

Thrombolysis: <4.5 hours of symptom onset

  • Alteplase
  • Must rule out intracranial haemorrhage prior to commencing
  • Aim for BP <180/110

Thrombectomy: <24 hours of symptom onset

  • Angiogram demonstrates proximal anterior or posterior circulation strokes
  • Limited infarct core on imaging

Antiplatelets: all patients

  • Aspirin 300mg 2 weeks followed by clopidogrel 75mg lifelong
  • If the patient has had thrombolysis, commence antiplatelets on the following day

Anticoagulation: only if the cause is AF

  • Commence Aspirin 300mg for 2 weeks
  • After 2 weeks, stop aspirin and consider anticoagulation
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Management

Absolute contraindication Relative contraindication

Intracranial haemorrhage on CT Major surgery or serious non-head trauma in the previous 14 days Neurosurgery, head trauma or stroke in past 3 months Recent lumbar puncture (usually in the past 7 days) History of intracranial haemorrhage History of major haemorrhage within the past 21 days Active internal bleeding Pregnancy Bleeding diathesis HTN >185 mmHg SBP or >110 mmHg DBP

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Question 7

History You are working in A&E. You see a 70-year-old man who is brought in by ambulance after his son noticed he was slurring his speech. This started 3 hours ago. On examination, you note he has 3/5 power of both his left upper limb and 4/5 power of his left lower limb. Observations HR 90, BP 155/89 mmHg, RR 18, SpO2 97%, Temp 36.8

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Management

Risk factor modification

  • Smoking cessation
  • Statin: atorvastatin 80mg
  • Treat diabetes and HTN

Driving

  • No driving for 1 month
  • HGV drivers must not drive for 1 year
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Management

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Management

Haemorrhagic stroke

  • Admit to NCCU: consider need for intubation and hyperventilation
  • Control BP: aim for SBP 130-140mmHg (NICE)
  • IV hypertonic saline if evidence of raised ICP
  • Surgery
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Management

TIA

  • No need for CT imaging routinely
  • Do not use ABCD2 (NICE)
  • Commence on Aspirin 300mg
  • Review in TIA clinic within 24 hours if symptoms < 1 week ago, otherwise TIA clinic within

7 days

  • Echocardiogram
  • Carotid doppler
  • MRI brain
  • Lifelong clopidogrel
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Pathophysiology

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Complications

Complication DVT Aspiration pneumonia Neurological sequalae

  • Seizures
  • Weakness
  • Immobility
  • MCA syndrome

Nutritional support

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Question 8

(1)

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History A patient is brought in by ambulance. He is drowsy and was witnessed to have a tonic clonic seizure in the street. On examination you notice a significant right sided hemiparesis. He is struggling to maintain his airway but this improves upon a chin lift maneuver.

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Case 2

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Top-decile question

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Pathophysiology

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Recap

  • Stroke results in neurological impairment with infarction
  • TIA results in transient symptoms and is not associated with infarction
  • Urgent imaging must be performed within 1 hour
  • Thrombolysis should be commenced urgently if within 4.5 hours of symptom onset
  • Thrombectomy must be considered if presenting within 24 hours of symptom onset
  • Patients should be on aspirin 300mg for 2 weeks followed by lifelong clopidogrel
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Further information

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References

1) Lipothymia [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0/)] 2) Circle of Willis. Rhcastilhos [Public domain] https://commons.wikimedia.org/wiki/File:Circle_of_Willis_en.svg 3) mailto:ralf@ark.in-berlin.de / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) 4) Miquel Perello Nieto / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) 5) OpenStax College / CC BY (https://creativecommons.org/licenses/by/3.0) 6) derivative work: Frank Gaillard (talk)Brain_stem_normal_human.svg: Patrick J. Lynch, medical illustrator / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 7) Dhru4you / Public domain 8) derivative work: Frank Gaillard (talk)Brain_human_sagittal_section.svg: Patrick J. Lynch, medical illustrator / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 9) INFARCT.jpg: Lucien Monfilsderivative work: W2eK / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

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