Sudden onset of focal neurological deficit for > 24h.
CVS risk factors
TIA, hypoglycaemia, migraine, extradural/subdural (trauma, alcohol
abuse), subdural/tumour (progressive onset), meningitis/encephalitis
(fever, neck stiffness), Todd's paresis & cerebral vasculitis
80% are infarcts and 20% haemorrhages
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)
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
TACI (Total anterior cerebral Infarct)
Middle/anterior cerebral artery. 60% die in a year. All of:
Ipsilateral hemiparesis w 2 of 3 body parts (face, arms, legs)
New cerebral dysfunction: dysphagia, neglect, visuospatial
PACI (Partial anterior cerebral Infarct)
Same territory. Either of:
2 out of 3 TACI
New higher cerebral alone
Motor/sensory deficit more restricted than TACI
POCI (Posterior circulation Infarct)
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)
asymptomatic. Pure motor/sensory/sensorimotor deficit/ataxic
hemiparesis/dysarthria & clumsy hand. Excluded by higher cortical
involvement or disturbance of consciousness.
Bad for TACI. 1 year mortality is 10-20% for the rest.
The gold standard is to treat in a specialied stroke unit.
See also the
ABC, recovery position.
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.
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
if swallow is unsafe feed with NG tube progressing to PEG (percutaneous
endoscopic-gastrostomy) if NG is needed long-term
In the week following the stroke 10% recur. At one month 20% recur.
Negative prognostic signs:
unsafe swallow (leads to aspiration pneumonia), loss of consciousness (80% mortality), incontinence, pyrexia, hyperglycaemica