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Stroke(

A!neurologic!event!of!vascular!origin,!whereby!there!are!rapidly!developing!clinical!signs!of!focal!or!
global!disturbance!of!cerebral!function,!lasting!>24hrs,!or!leading!to!death!with!no!obvious!cause!
other!than!of!vascular!origin.!

Causes:((

A. Ischaemic((85%)( (
(
1. Thrombosis?in?situ!!
[Due!to!atherosclerosis,!dissection,!or!fibromuscular!dysplasia]!
Atherosclerosis!is!by!far!the!commonest!cause.!Usually!at!the!carotid!bifurcation,!the!MCA!
origin!and!the!ends!of!the!basilar!artery.!
Blood!and!coagulation!disorders!are!an!uncommon!primary!cause!of!stroke!and!TIA,!but!
should!be!considered!particularly!in!younger!patients,!those!with!a!known!clotting!
dysfunction,!previous!cryptogenic!stroke…!
!!
2. Embolism!!
Embolic!infarctions!more!common!than!those!caused!by!in?situ?thrombosis.!The!territory!of!
the!middle!cerebral!artery!is!most!commonly!affected!by!embolic!infarction,!as!this!vessel!is!
the!direct!continuation!of!the!internal!carotid!artery.!!
!
o heart!emboli!(AF,!valvular!vegetations!of!SBE/IE,!valvular!disease,!prosthetic!valves,!
MI,!aneurysms,!external!cardioversion)!
o atherothromboembolism!(e.g.!from!carotids)!
o from!cardiac!surgery!e.g.!CABG!
o paradoxical!emboli.!
!
3. Systemic!Hypoperfusion!
There!is!systemic!hypoperfusion,!causing!diffuse!brain!dysfunction!(not!focal!like!other!
types).!The!reduced!perfusion!can!be!due!to!e.g.!cardiac!arrest,!arrhythmia,!MI,!PE,!
pericardial!effusion.!Hypoxaemia!may!further!reduce!the!amount!of!oxygen!carried!to!the!
brain.!
Symptoms!of!brain!dysfunction!typically!are!diffuse!and!nonfocal!in!contrast!to!the!other!
two!categories!of!ischemia.!Most!affected!patients!have!other!evidence!of!circulatory!
compromise!and!hypotension.!The!neurologic!signs!are!typically!bilateral,!although!they!may!
be!asymmetric!when!there!is!preexisting!asymmetrical!craniocerebral!vascular!occlusive!
disease.!
The!most!severe!ischemia!may!occur!in!border!zone!(watershed)!regions!between!the!major!
cerebral!supply!arteries!since!these!areas!are!most!vulnerable!to!systemic!hypoperfusion.!
The!signs!that!may!occur!with!borderzone!infarction!include!cortical!blindness,!or!at!least!
bilateral!visual!loss;!stupor;!and!weakness!of!the!shoulders!and!thighs!with!sparing!of!the!
face,!hands,!and!feet!(a!pattern!likened!to!a!"man?in?a?barrel").!

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TOAST!classification!of!Ischaemic!Stroke?!Five!Subtypes!
1. Large!artery!atherosclerosis!
2. Cardioembolism!
3. Small!vessel!occlusion!
4. Stroke!of!other!determined!aetiology!
5. Stroke!of!undetermined!aetiology!

B.(Haemorrhagic((15%)(

CNS!bleeds.!Subdivided!into!Intracerebral!haemorrhage!and!SAH.![excludes!SDH!and!
haemorrhage!into!a!tumour]!
?ICH:!The!most!common!causes!are!hypertension,!trauma,!bleeding!diatheses,!amyloid!
angiopathy,!illicit!drug!use!(mostly!amphetamines!and!cocaine),!and!vascular!malformations.!
SAH:!The!two!major!causes!are!rupture!of!arterial!aneurysms!that!lie!at!the!base!of!the!brain!
and!bleeding!from!vascular!malformations!that!lie!near!the!pial!surface.!Bleeding!diatheses,!
trauma,!amyloid!angiopathy,!and!illicit!drug!use!are!less!common.!

C.(Rarer(Causes:([Think!of!these!in!young!people!in!particular]!

1. Sudden!BP!drop!>40mm!Hg!(causing!a!watershed!infarction)!
2. Vasculitis!
3. Venous!sinus!thrombosis!
4. Carotid!artery!dissection!
5. Thrombophilia!

Risk(Factors(!

• Age!
• Sex:!males!>females!
• Ethnicity:!probably!higher!in!Blacks!and!Asians!
• Positive!family!history!
• Past!TIA/!Stroke!
• Hypertension!
• Diabetes!mellitus!
• Heart!disease,!PVD!
• Atrial!fibrillation!
• Carotid!stenosis!
• Hyperlipidemia!
• Obesity!!
• Physical!inactivity!
• Smoking!
• Alcohol!(J?shaped)!
• Polycythemia!
• Oestrogens!e.g.!OCP,!HRT!
• Hypercoagulability!!

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(i.e.!same!for!other!vascular!disease,!but!relative!risk!differs!e.g.!smoking!a!bigger!risk!for!IHD,!
hypertension!a!bigger!risk!for!stroke).!

Stroke(Burden(

0.5?1.2%!of!the!population.!Over!2/3s!of!strokes!occur!in!the!over!65s.!!

The!third!most!common!cause!of!death!after!coronary!artery!disease!and!cancer.!Following!a!first!
stroke,!death!occurs!within!one!week!in!10%!of!cases,!within!a!year!in!30%!of!cases!and!within!five!
years!in!60%!of!cases.!

Some(points(for(history(

− Risk!factors!
− Deficit:!focal?!
− Onset:!Did!it!come!on!suddenly!or!was!there!progression?!(maybe!tumour?).!Activity!at!the!
onset!or!just!before!the!stroke.!Sudden!onset!or!progression!over!hours!is!typical.!A!space?
occupying!lesion!(e.g.!tumour,!SDH)!should!be!suspected!if!onset!is!over!days.!
− Associated!symptoms!
− Headache!or!drowsiness?!(haemorrhage!more!likely)!
− Fall!or!other!head!trauma?!(subdural?...!request!urgent!scan)!
− Dominant!hand?!
− Co?morbidities!
− Social!history…!ADLs,!lives!alone?,!premorbid!cognition!and!function.!
− Assess!pre?stroke!and!current!functional!status:!!
o Speech,!hearing,!vision,!memory,!baseline!mental!state.!!
o Washing,!showering,!dressing,!toileting.!
o Appetite,!diet,!weight!loss.!
o Transferring,!mobility!inc!stairs,!falls.!
− Note:!Lightheadedness/faintness!not!stroke/TIA;!same!for!isolated!
confusion/incontinence/drop!attacks.!

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Signs(

On!Exam:!Go!through!systems.!Especially!neuro!(cranial!nerves!inc!sight!and!swallow;!speech?!
dysphasia,!dysarthria;!limbs;!gait;!neglect…)!and!cardiovascular!(including!peripheral!vascular!exam).!

Focal!signs!correspond!with!the!territory!of!the!compromised!vessel!(issue!clouded!by!collateral!
supply).!!

>Cerebral(hemisphere(infarcts((50%)(

Cerebral(artery(territories(

ICA:!Occlusion!may!at!worst!cause!total!(and!usually!fatal)!infarction!of!the!anterior!two?thirds!of!the!
ipsilateral!hemisphere!and!basal!ganglia!(lenticulostriate!arteries).!More!often,!the!picture!is!similar!
to!an!MCA!occlusion.!

Cerebral!arteries:!ACA,!MCA,!PCA!form!the!circle!of!Willis.!ACA!and!MCA!arise!from!the!internal!
carotid!while!PCA!arises!from!the!basilar!artery.!

>ACA:!Supplies!the!frontal!and!medial!part!of!the!cerebrum.!Occlusion!may!cause!weakness!in!the!
contralateral!leg!(±!milder!arm!symptoms).!The!face!is!spared.!!

>MCA:!Supplies!the!lateral!part!of!the!hemisphere.!Occlusion!may!cause!contralateral!hemiparesis,!
hemisensory!loss!(esp.!face!and!arm),!contralateral!homonymous!hemianopia,!cognitive!change!
(including!dysphasia!with!dominant!hemisphere!lesions;!visuo?spatial!disturbance!with!non?
dominant!hemisphere!lesions).!

>PCA:!Supplies!the!occipital!lobe.!Occlusion!gives!contralateral!homonymous!hemianopia!(often!with!
macular!sparing).!

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[Most!of!the!medial!aspect!of!the!motor!cortex!maps!to!the!lower!limb,!whereas!the!more!lateral!
areas!map!to!the!upper!limb!and!face].!

>Brainstem(infarcts((25%)(

Quadriplegia,!disturbance!of!gaze!and!vision,!locked?in!syndrome!(aware!but!cannot!respond…!
ventral!pontine!infarct),!lateral!medullary!syndrome!(arises!from!blockage!of!the!arterial!supply!to!
the!lateral!medulla,!most!commonly!of!the!vertebral!artery,!also!of!the!PICA).!

The!vertebrobasilar!circulation!supplies!the!cerebellum,!brainstem,!occipital!lobes.!Occlusion!may!
cause!symptoms!of!one!or!more!of!these!regions.!

>Lacunar(infarcts((25%)(

A!lacuna!refers!to!a!small,!deep!cerebral!infarct!in!the!brain!or!to!a!cavity!that!has!developed!
following!resorption!of!the!necrotic!tissue.!It!has!a!diameter!of!<1.5cm!and!a!volume!of!<3.4cm3!

A!lacunar!infarct!arises!from!deficient!blood!supply!of!a!single!deep!penetrating!artery,!typically!
affecting!the!basal!ganglia!(lenticulostriate!arteries),!internal!capsule!(recurrent!artery!of!Huebner),!
thalamus!or!pons.!!

These!peforating!vessels!are:!

– End!arteries!
– Have!no!collaterals!
– Have!no!pressure!reduction!system!
– Supply!critical!areas!
– Present!in!brain!stem!
– Design!fault!

Causes:!atherosclerosis,!accumulation!of!eosinophils!in!the!vessel!wall!(lipohyalinosis),!
microembolism,!rupture!of!a!Charcot?Bouchard!aneurysm!!

The!deep!cerebral!location!of!these!infarcts!means!the!absence!of!‘cortical!signs’.!Generally,!the!
patient!does!not!experience!seizures,!loss!of!consciousness!or!coma!and!has!a!more!successful!
recovery!than!with!a!larger!cortical!infarction.!There!is!clear!unilateral!motor/sensory!deficit!clearly!
involving!two!of!three!areas!(face,!arm,!leg)!with!the!whole!of!one!limb!being!involved.!

There!are!five!classic!lacunar!syndromes:!

1. Pure(Motor(Stroke(

This!is!the!most!common!lacunar!syndrome.!The!arm!and!leg!are!paralysed!on!one!side,!or!
experience!heaviness.!The!lower!face!may!also!be!similarly!affected.!There!are!no!accompanying!
sensory!or!other!deficits.!!

Usually!due!to!an!infarct!in!the!posterior!limb!of!the!internal!capsule.!!

2. Pure(Sensory(Stroke(

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The!patient!experiences!transient!or!persistent!numbness!and!partial!sensory!loss!on!one!side!of!the!
body!e.g.!they!may!feel!hot/cold/numb/itchy!over!the!affected!region.!There!are!no!accompanying!
motor!or!other!deficits.!!

The!VPL!region!of!the!thalamus!is!the!site!of!the!infarct.!

3. Sensorimotor(Stroke(

This!lacunar!syndrome!has!both!motor!and!sensory!deficits,!being!essentially!a!combination!of!pure!
motor!stroke!and!pure!sensory!stroke.!

It!arises!when!an!infarct!affects!both!the!ventral!posterolateral!region!of!the!thalamus!and!the!
adjacent!posterior!limb!of!the!internal!capsule.!

[In!the!above!three,!there!is!clear!involvement!of!two!of!the!three!areas!(face,!arm,!leg)!with!the!
whole!of!one!limb!being!involved].!

4. Ataxic(Hemiparesis(

This!syndrome!is!a!combination!of!motor!and!cerebellar!symptoms.!There!is!significant!weakness!
and!clumsiness!on!the!same!side!of!the!body,!in!the!leg!more!so!than!the!arm.!!

Common!sites!of!injury!are!the!pons,!corona!radiata!and!the!anterior!limb!of!the!internal!capsule.!!

5. ClumsyPHand(Dysarthria(

This!is!the!least!common!lacunar!syndrome.!Patients!experience!weakness!of!the!tongue!and!face,!
and!their!speech!is!slurred.!They!complain!of!hand!clumsiness!which!impairs!fine!movements!e.g.!
writing,!playing!an!instrument.!There!are!no!accompanying!motor!or!other!deficits.!

Lacunar!infarcts!of!the!ventral!pons!or!internal!capsule!are!the!most!common!in!this!syndrome.!

DDx(for(Stroke(or(TIA((all!for!stroke!but!*!for!TIA!really)!

− Head!injury!
− Subdural!haemorrhage!
− Hypoglycemia*!!
− Hyperglycemia!
− Intracranial!tumours!
− Hemiplegic!Migraine!(migraine!aura)*!
− Epilepsy!(Todd’s!palsy:!limb!weakness!following!seizure!but!recovery!<24hrs)*!However,!NB!
that!status!epilepticus!can!cause!CNS!infarcts!
− CNS!lymphoma!
− Wernicke’s!Encephalopathy!
− Hepatic!Encephalopathy!
− Drug!overdose!!
− Peripheral!nerve!lesions!(vascular!or!compressive)!
− Hyperventilation!
− Retinal!bleeds( !

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Potential(tests(and(rationale(

− Pulse,!BP:!AF,!hypertension!(also!retinopathy),!acutely!raised!BP!common!in!early!stroke.!
− FBC:!anaemia!or!polycythemia;!↑WCC;!high!or!low!platelet!count!
− U&E:!dehydration?;!assess!fluid!replacement!
− Fasting!Glucose:!diabetes;!hyperglycemia!(stress!response);!hypoglycaemia!(may!mimic!
stroke)!!
− Fasting!Lipids!
− ECG:!AF;!IHD,!MI,!hypertension!!
− CXR:!aspiration,!cardiomegaly!!
− CT/MRI!brain.!Immediate!CT!if!any!of!following!criteria:!

o Thrombolysis!candidate!
o On!anticoagulant!treatment!
o Known!bleeding!tendency!
o Depressed!consciousness!(GCS!<13)!
o Unexplained!progressive!or!fluctuating!symptoms!
o Papilloedema,!neck!stiffness!or!fever!
o Severe!headache!at!onset!or!suspected!SAH.!

! ! For!all!other!situations,!CT!should!be!performed!within!24hrs.!

CT!distinguishes!stroke!from!non?stroke!such!as!tumour.!Identifies!likely!cause!and!territory.!
Blood!is!white!in!early!CT.!Small!infarcts!might!not!be!seen!and!so!diagnosis!is!made!clinically!
i.e.!a!normal!CT!does!not!exclude!a!stroke.!

MRI!should!be!available!as!a!problem!solver!in!cases!such!as!delayed!or!atypical!clinical!
presentation,!and!in!addition,!where!there!is!still!diagnostic!uncertainty!after!CT!scanning.!

Posssibly!MRI!Brain!with!Diffusion!Weighted!Imaging!(MRI?DWI)/MRV/MRA/MR?neck!
vessels/MR?perf.!

MRI!with!DWI!is!very!sensitive!and!relatively!specific!in!detecting!acute!ischaemic!stroke.!
DWI!findings!have!shown!high!levels!of!diagnostic!accuracy;!however,!studies!have!
demonstrated!that!small!brainstem!lacunar!infarcts!may!escape!detection.!Normal!DWI!in!
patients!with!stroke?like!symptoms!should!trigger!further!investigation!for!a!non?ischaemic!
cause!of!the!symptoms.!DWI!looks!at!the!microscopic!random!motion!of!the!water!molecule!
protons.!

− Troponins,!INR!
− Telemetry!
− Transthoracic!Echocardiography/TFTs:!Multiple!infarcts,!AF,!recent!MI!to!look!for!thrombus,!
where!there!is!murmur,!LAH!as!a!source!of!thrombus.!
− Carotid!Doppler:!carotid!artery!stenosis!!

Possible(additions(

− Liver(function(tests:(co4morbidity?(
− ESR:(Vasculitis((e.g.(giant(cell(arteritis);(sepsis((inc.(endocarditis)(
− CRP:(sepsis((e.g.(aspiration(pneumonia)(

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− Iron,(B12,(folate(
− Creatine(kinase:(muscle(breakdown?((prolonged(lie(on(floor)(
− Blood(cultures:(sepsis(
− Urinalysis:(diabetes,(vasculitis,(urinary(infection(
− SPEP:(Serum(protein(electrophoresis(e.g.(multiple(myeloma,(amyloidosis(
− (Genetic(tests(e.g.(Fabry’s,(CADASIL)(
− If(<55yrs(old(consider:(

o Lupus(anticoagulant/Anticardiolipin(antibody(
o ANA/ANCA(
o Thrombophilia(screen(
o Syphilis(serology(
o TOE(

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Stroke(Management:(Acute(

1. Airway:!Ensure!patent!airway!to!avoid!hypoxia!or!aspiration.!Oxygen!saturation!should!be!
kept!above!94%.!O2!supplementation!is!only!necessary!for!hypoxic!patients.!
2. Blood!glucose:!Monitor!and!keep!at!4?11!mmol/L.!
3. BP:!Monitor.!Do!not!lower!unless!extreme!(>220),!encephalopathy!or!aortic!dissection,!as!
this!may!cause!cerebral!hypoperfusion!as!autoregulation!is!impaired.!If!needed,!IV!labetalol!
is!first!choice.!?For!long?term!attention.![BP!targeting!in!stroke!is!a!controversial!area!and!
can!vary!significantly!by!consultant]!
4. Investigations!above!
5. Thrombolysis:!See!note!below.!
6. Nil!by!mouth.!Until!swallowing!is!assessed.!
7. Keep!hydrated.!Don’t!overhydrate!as!may!cause!cerebral!oedema.!
8. Explain!what!has!happened.!
9. Secondary!Prevention!of!Stroke:!See!Below…!Antiplatelets,!Statins!
10. Others!
???If!haemorrhagic!stroke,!normalize!INR.!Consider!for!surgery!e.g.!if!hydrocephalus.!
???If!SAH,!give!oral!nimodipine!60mg!four!hourly!unless!there!are!specific!contraindications.!

11. Consider!VTE!prophylaxis!with!LMWH!unless!CI.!Graduated!compression!stockings!are!not!
recommended.!!
12. Get!patient!to!an!acute!stroke!unit!as!soon!as!possible.!Grade!1A!recommendation.!

Others!

• Avoid!centrally!acting!drugs!e.g.!sedatives!
• Lower!pyrexia!(fan,!paracetamol,!sponging).!
• Stop!HRT!(hypercoagulability)!
• Keep!skin!dry!and!change!position!to!avoid!bed!sores.!

Thrombolysis(!

The!recanalisation!of!a!vessel!which!has!become!occluded!by!a!thrombus/embolus!

• For!use!in!patients!18?80yrs!with!definite!ischemic!stroke!who!present!within!3hrs!of!the!
onset!of!symptoms!(or!4.5hrs!based!on!ECASS!study;!possible!role!up!to!6hrs).!Give!as!soon!
as!possible,!not!simply!within!the!timeframe.!The!benefit!of!intravenous!thrombolysis!
decreases!continuously!over!time!from!symptom!onset.!Time!is!brain.!
• Recombinant!tissue!plasminogen!activator!is!the!most!frequently!used!agent!!
• Only!one!third!of!those!who!receive!thrombolysis!will!show!functional!benefit.!
Numbers!Needed!to!Treat!(NNT)!!
t!_To!Cure!if!within!90!minutes!1!in!8!!
t!_To!Cure!if!within!3!hours!1!in!10!!
t!_To!Cure!if!within!4.5!hours!1!in!14!!
t!_To!derive!some!benefit!1!in!2?3!!
Numbers!Needed!to!Harm!(NNH)!!
t!_To!do!worse!1!in!35!!
t!_To!kill!or!leave!permanently!disabled!1!in!100!!

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• Exclusion!criteria:!Many.!Includes:!major!infarct/haemorrhage!on!CT;!mild!deficits;!previous!
CNS!haemorrhage;!seizures!at!presentation;!impaired!coagulation;!recent!surgery,!trauma,!
child!delivery;!aneurysm;!portal!hypertension;!thrombocytopenia;!BP!>220/130!
• A!5?fold!excess!in!death!due!to!intracranial!haemorrhage!compared!to!placebo!but!fewer!
deaths!overall.!
• Second!CT!head!24h!post?thrombolysis!to!identify!haemorrhage.!Urgently!if!any!signs!or!
symptoms!of!intracranial!haemorrhage!e.g.!headache,!acute!hypertension,!nausea!and!
vomiting,!!
seizure.!
• Complications!of!thrombolysis!
o Haemorrhage!(intracranial/extracranial)!
o Anaphylaxis!
o Hypotension!
o Uncontrolled!hypertension!(target!BP!is!<180/105)!
(

Stroke(Management:(Rehabilitation(

Stroke!units:!Unit!with!MDT!with!expertise!in!stroke.!!Lower!death,!dependency!and!institutional!
care!compared!to!general!ward!care!(doctor,!nurse,!pharmacist,!therapists!above…).!

All!patients!should!receive!an!initial!physiotherapy,!speech!and!language,!nutrition!and!occupational!
therapy!assessment!within!24?48hrs!of!admission,!with!a!full!assessment!completed!within!5!
working!days.!

Guidelines:!Patients!should!receive!a!minimum!of!45!minutes!daily!of!each!therapy!that!is!required.!!

• Food!(dietician):!Watch!swallowing!small!amount!of!water:!signs!of!aspiration!(cough/voice!
change)!>!make!nil!by!mouth!for!some!days;!use!IV!fluids!then!semi?solids.!NG!tube!and!then!
PEG!feeding!if!continued!swallowing!difficulty.!
• Optimal!management!bowel!and!bladder!movements!
• Avoid!early!catheterisation.!Could!prevent!return!to!continence.!
• Emotional!lability!(e.g.!unprovoked!sobbing)…!tricyclics!may!help.!Screen!for!depression!
(present!in!a!third)!
• Position!so!as!to!minimise!spasticity.!Botulinum!toxins!may!be!helpful.!!
• Tests:!draw!a!clock!face!(apraxia),!copy!a!pattern!(spatial!ability),!selecting!and!naming!
objects!(agnosia)!
• Occupational!therapy!e.g.!washing!and!dressing,!supply!of!home!aids.!Barthel’s!Index!of!ADL.!
• Speech!and!language!therapy!e.g.!dysarthria,!dysphasia!
• Physiotherapy.!Potentially!constrain!good!limb…!constraint?induced!movement!therapy)!
• Psychology.!Screen!for!mood!disorders!
• Long?term!care!team!
• End?of?life!decisions!
• Early!supported!discharge!teams!should!target!stroke!survivors!with!mild!to!moderate!
disability.!!
• Follow?up!following!discharge!for!adaptation,!complications!etc.!

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Complications(

• Contractures!(elastic!tissues!replaced!by!inelastic!tissues!e.g.!muscle/tendon!shortening!
leading!to!joint!rigidity).!
• Faecal!incontinence!(immobility,!neurological!impairment).!Regulate!with!high!fibre!diet,!
frequent!fluids!and!toileting.!May!be!a!need!for!an!enema!(liquid/gas!injection!into!rectum!
to!expel!contents)!or!deliberate!constipation!with!codeine).!
• Urinary!incontinence:!Pads!and!toileting.!May!require!catheterisation.!!
• Infection:!Commonly!chest!or!urine.!
• Muscle!spasm:!Common!on!affected!side.!Exacerbates!arthritis.!May!require!antispasmodics.!
• Pain:!Commonly!shoulder!pain!in!a!paralysed!arm!e.g.!joint!subluxation!+!spasm/arthritis.!
• Dysphagia!
• Aspiration!pneumonia!!
• Pressure!sores:!Skin!necrosis!from!pressure?induced!ischemia!!
• Psychological!problems:!Low!mood!(a!third!are!depressed)!
• Thromboembolism:!Especially!with!immobility.!
• Dehydration;!malnutrition!
• Delirium!and!dementia!

Discharge(from(Hospital(and(Returning(to(the(Community(

• Discharge!planning!is!an!ongoing!process!and!should!commence!as!early!as!possible!
following!admission.!!
• A!home!assessment!should!be!carried!out!by!specialist!therapists,!typically!an!occupational!
therapist,!to!ensure!safety!and!community!access.!Optimal!independence!will!be!facilitated!
through!home!modification!and!adaptive!equipment.!
• After!leaving!hospital,!stroke!survivors!must!have!access!to!specialised!stroke!care!and!
rehabilitation!services!appropriate!to!their!needs.!!
• Stepdown!unit!in!Merlin!Park!
• Early!supported!discharge!services!should!be!supplied!by!a!specialist!multidisciplinary!team.!
!
( (

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Stroke(Management:(Prevention(
(
European!Guidelines!on!Cardiovascular!Disease!Prevention!in!Clinical!Practice.!
(
Primary(Prevention((

• Control!risk!factors!e.g.!diet!!
• Lifelong!anticoagulation!with!left?sided!rheumatic!or!prosthetic!valves.!!
• Warfarin!with!chronic!AF.!Post?TIA!prevention.!

Stroke(Management:(Secondary(Prevention((

• Control!risk!factors.!BP!control!crucial!in!particular.!!
• ‘Patients!should!be!encouraged!to!take!responsibility!for!their!own!health!and!be!supported!
to!identify,!prioritise!and!manage!risk!factors.”!
• Achieve!moderate!physical!activity!(sufficient!to!become!slightly!breathless)!for!20?30!
minutes!each!day.!!
• Patients!who!have!had!an!ischaemic!stroke!benefit!from!daily!antiplatelet!agents!(aspirin!±!
dipyridamole),!daily!statins,!daily!ACEi!and/or!thiazide.!!
• Note:!Warfarin!is!effective!for!primary!and!secondary!prevention!of!ischemic!stroke,!
reducing!the!risk!by!68%.!Aim!for!an!INR!of!2.0?3.0.!Stroke!risk!is!twice!as!much!for!those!
with!an!INR!of!1.7!as!opposed!to!2.!Adding!aspirin!to!warfarin!does!not!confer!additional!
protection.!

??????!

>Antiplatelet(therapy(

Antiplatelet!therapy!for!TIA!or!ischemic!stroke!in!first!14!days!
− Antiplatelet!therapy!(Aspirin)!if!ischaemic!stroke!and!patient!not!thrombolysed!!Give!300mg!
aspirin!daily!for!14!days.!Give!orally!if!not!dysphagic;!via!enteral!tube!or!rectally!if!dysphagic.!
− If!aspirin!intolerant,!commence!Clopidogrel!300mg!PO!stat!and!75mg!thereafter.!
− If!intolerant!of!both!aspirin!and!clopidogrel,!then!dipyridamole!200mg!BD!should!be!
considered.!
− Give!PPI!alongside!aspirin!if!acute!ischaemic!stroke!or!if!dyspepsia!previously!reported!with!
aspirin!use.!
!
Antiplatelet!therapy!in!first!14!days!stroke!occurred!while!already!on!aspirin!therapy.!
− Add!dipyridamole!200mg!daily!for!7!days.!Then!increase!to!200mg!BD!thereafter!and!
continue!aspirin!75mg!daily.!
− Or!change!to!clopidogrel!monotherapy!75mg!and!stop!aspirin!after!5!days!of!clopidogrel!
therapy.!
!
Long?term!anti?platelet!therapy!
− Aspirin!and!Dipyridamole!MR!combination!therapy,!Aspirin!monotherapy,!or!Clopidogrel!
monotherapy!are!acceptable!options!for!long?term!secondary!prevention.!!
− If!aspirin!is!used!as!monotherapy,!the!dose!may!be!kept!at!300mg!daily.!Otherwise,!the!dose!
is!generally!reduced!to!75mg.!
!
!

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>Anticoagulation(
!
Oral!anticoagulation!after!cardioembolic!TIA!or!Ischaemic!Stroke!with!Atrial!Fibrillation!or!Flutter.!
− Recommended!for!both!paroxysmal!and!persistent!atrial!fibrillation!or!flutter,!unless!specific!
contraindications!exist!e.g.!falls,!alcohol!dependence.!
− Use!dose?adjusted!warfarin;!target!INR!of!2.5!(range!2?3).!
!
>Statins((
(
Cholesterol?lowering!therapy!following!TIA!and!Ischaemic!Stroke!
− Recommended!if!total!cholesterol!is!>3.5mmol/L.!!
− Optimal!time!of!commencement!of!statins!is!unknown.!No!evidence!to!support!it!in!the!
acute!phase!(48hrs).!
− Reasonable!to!commence!statins!approximately!4wks!after!the!event![SPARCL!trial].!
− Simvastatin!40mg!PO!nocte!if!total!cholesterol!>3.5mmol/L!and!no!haemorrhage!on!CT!
brain.!!
− Use!pravastatin!if!patient!is!already!stabilised!with!warfarin,!as!warfarin!interacts!with!
simvastatin.!
− Statins!poorly!tolerated/CI!then!use!ezetimibe.!
!
Statins!should!be!avoided!after!primary!intracerebral!haemorrhage,!unless!risk!of!further!ischaemic!
events!outweighs!the!risk!of!recurrent!haemorrhage.!!
!
>AntiPhypertensives( (
!
− There!is!evidence!that!modest!reductions!in!blood!pressure!significantly!reduce!risk!of!
recurrent!stroke.!This!is!the!case!even!in!subjects!who!were!within!normotensive!limits!at!
time!of!presentation.!!
− Recommended!blood!pressure!treatment!goals!are!systolic!blood!pressure!<135/85!mmHg!
for!non?!diabetic!subjects!and!<130/80!for!diabetic!subjects.!!
− Care!needs!to!be!taken!in!subjects!with!known!severe!bilateral!carotid!stenosis.!Blood!
pressure!in!this!group!should!not!typically!be!actively!reduced!below!140/90!mmHg.!!
!
>Carotid(Endarterectomy((
!
• Not!always!possible!to!establish!a!relationship!between!symptoms!and!carotid!disease.!It!is!
ultimately!a!clinical!judgment.!Intervention!is!indicated!for!patients!with!focal!cerebral!
events!in!the!carotid!territory!or!transient!monocular!blindness!(amaurosis!fugax).!!
• Patients!with!symptomatic!severe!(≥!70%!by!NASCET!criteria)!carotid!artery!stenosis!should!
be!considered!for!carotid!endarterectomy,!unless!contraindicated.!
• Intervention!for!patients!with!symptomatic!moderate!(50?69%)!carotid!stenosis!should!be!
discussed!on!a!case!by!case!basis.!
• Surgery!is!not!indicated!in!patients!with!symptomatic!carotid!disease!with!<50%!stenosis.!!
• Guidelines:!Greatest!benefit!if!surgery!is!performed!within!2wks!of!symptom!onset,!but!this!
may!not!be!appropriate.!
• For!asymptomatic!patients,!carotid!endarterectomy!should!be!considered!on!a!case?by?case!
basis.!

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Transient(Ischemic(Attack!

A!fully!reversible!focal!neurological!deficit!of!vascular!origin,!generally!lasting!no!more!than!a!few!
minutes,!but!may!be!up!to!24!hours.!Unlike!in!stroke,!the!clots!in!TIAs!dissolve!naturally!under!the!
action!of!the!plasmin!system!before!any!lasting!neurological!defect!can!develop.!

?Carotid!territory:!Contralateral!weakness/numbness,!dysarthria,!dysphasia,!homonymous!
hemianopia,!amaurosis!fugax!(transient!monocular!visual!loss!due!to!deficient!blood!supply!to!the!
retina).!

?Vertebrobasilar!territory:!Hemiparesis,!hemisensory!loss,!bilateral!weakness!or!sensory!loss,!
diplopia,!vertigo,!deafness,!tinnitus,!vomiting,!dysarthria,!ataxia.!

Causes(

• Atheroembolism:!From!carotids!(chief!cause)!or!heart…!check!for!carotid!bruit!(absence!
does!not!rule!out!carotid!source!of!emboli,!tight!stenosis!may!have!no!bruit).!
• Hyperviscosity!e.g.!polycythemia,!sickle?cell!anemia,!myeloma.!
• Vasculitis.!
• Ddx:!See!above!

Tests(!

As!above!

Treatment(

• Control!stroke!risk!factors!
• Antiplatelet!drugs:!Low?dose!aspirin!for!life!(75mg/day)!and!dipyridamole!for!2yrs.!
Dipyridamole!increases!cAMP!and!decreases!thromboxane!A2.!!
• Warfarin!indications!include!AF,!mitral!stenosis!
• Carotid!endarterectomy!(CEA):!The!removal!of!atheromatous!material!inside!the!carotid!
artery!to!correct!stenosis!(NICE!recommends!it!within!two!weeks!for!patients!with!>70%!
stenosis.!Benefit!for!50?70%!stenosis!should!be!assessed!on!a!case?by?case!basis!e.g.!if!the!
team’s!peri?operative!stroke!rate!is!low.)!

Prognosis(in(TIAs(

A!medical!emergency!as!20%!of!TIAs!will!be!followed!by!a!stroke!in!the!next!90!days.!The!risk!is!
highest!early!on…!In!stroke!patients!who!had!a!preceding!TIA,!70%!of!the!TIAs!were!in!the!previous!7!
days.!

ABCD2(scoring(system:(Predicts!the!90?day!risk!of!recurrent!TIA!or!stroke.(

Age!>60yrs…!1!point!

BP!>140!for!SBP!or!>90!for!DBP…!1!point!

Clinical!features:!1!point!for!speech!disturbance!w/out!weakness.!2!points!for!unilateral!weakness!

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Duration!of!symptoms:!1!point!for!10?59mins,!2!points!for!>60mins!

Diabetes!Hx:!1!point!

0?3:!Low!stroke!risk!in!next!90days!
4?5:!Moderate!
6?7:!High!(40?50%!risk)!
Random(Notes(

The!brain!receives!15%!of!the!resting!cardiac!output!and!accounts!for!20%!of!the!total!body!oxygen!
consumption.!Cerebral!blood!flow!remains!constant!over!a!wide!range!of!blood!and!intracranial!
pressures!because!of!autoregulation!of!vascular!resistance.!!

PGlobal(cerebral(ischemia(

Widespread!ischemic/hypoxic!injury!occurs!with!a!generalised!reduction!in!cerebral!perfusion,!
usually!with!a!systolic!pressure!of!less!than!50mm!Hg,!seen!in!cardiac!arrest!and!shock.!!

Neurons!are!much!more!sensitive!to!hypoxia!than!glial!cells.!Furthermore,!certain!populations!of!
neurons!have!a!greater!susceptibility!to!ischemia!of!short!duration,!namely!the!pyramidal!cells!of!the!
Sommer!sector!of!the!hippocampus,!the!Purkinje!cells!of!the!cerebellum!and!the!pyramidal!neurons!
of!the!neocortex.!!!

Individuals!who!survive!severe!global!cerebral!ischemia!are!often!deeply!comatose!(being!in!a!
persistent!vegetative!state)!or!may!meet!the!clinical!criteria!for!brain!death.!The!brain!is!swollen,!
with!widened!gyri!and!narrowed!sulci.!There!is!poor!demarcation!between!grey!and!white!matter.!!

Border?zone!(watershed)!infarcts!are!wedge?shaped!areas!of!infarction!that!occur!in!the!most!distal!
fields!of!arterial!perfusion.!They!are!highly!sensitive!to!hypotensive!episodes,!with!the!border!
between!the!territories!of!the!ACA!and!MCA!having!particular!risk!of!damage.!!

PFocal(cerebral(ischemia(

Cerebral!arterial!occlusion!leads!to!focal!ischemia!of!the!territory!of!the!compromised!vessel.!This!
progresses!to!infarction!with!sustained!occlusion.!The!extent!of!collateral!flow!is!the!greatest!
determinant!of!damage,!with!the!circle!of!Willis!being!the!major!source.!The!deep!penetrating!
vessels!of!the!brain!have!little/no!collateral!flow!(e.g.!to!the!thalamus,!basal!ganglia).!!

!‘Brain!attack’:!Being!used!to!describe!the!full!spectrum!of!disease!severity!from!TIA!to!fatal!stroke.!
Early!intervention!similar!to!that!of!myocardial!salvage.!

Cognitive(Communication(Disorders(resulting(from(NonPdominant(Hemisphere(Stroke((
!
Although!language!centres!are!found!in!the!dominant!(typically!left)!cerebral!hemisphere,!cognitive!
deficits!following!non?dominant!hemisphere!stroke!can!affect!attention!(including!visuospatial!
neglect),!memory,!problem!solving,!reasoning,!organising,!planning!and!awareness!of!deficits.!These!
may!impact!on!communication!by!decreasing!the!efficiency!and!effectiveness!of!comprehension,!
expression!and!pragmatics.!Specific!language!deficits!often!affect!non?literal!language,!alternative!
meanings!and!other!subtleties!of!language.!

15!
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