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Adult-acquired Neurology - Stroke

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ness37's version from 2018-04-30 12:26

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DefinitionInterruption of blood supply to brain = neurones are deprived of oxygen + nutrients (glucose). Sudden onset, no warning, neurones seize to function within seconds, pathological changes within minutes (symptoms last 24 hours+)
Types of strokeIschemic (80-90%) or Haemorrhagic (10%)
Ischemic Fragment of material (embolus - blood clot, tumor, bacteria) travels through the blood vessel to a point of narrowing and blocks blood flow or blood clot (thrombus) forms somewhere else in body and travels to brain artery
HaemorrhagicBlood vessel in brain ruptures (accumulation of blood in neural tissue) which may need surgery to remove build up (shunting - draining) not suitable for blood thinners = important to find out which one it is)
TIAMay precede Ischemic stroke, symptoms last for seconds or minutes but less than 24 hours
Risk factorsSmoking, hypertension, increasing age, diabetes, heart disease, excess alcohol, high cholesterol, fast/irregular heart beat, previous stroke/s
DiagnosisNeed to consider: where stroke has occurred, what type of stroke have they had, risk factors and functional effects = needs to be quick. Brain imaging (MRI and CT scan)
Prognosis20% will die within 30 days of onset, death usually results from bleeding in the brain. Subsequent deaths are usually due to pneumonia.
RecoveryRapid recovery = first 4-6 weeks. Recovery may be slow after then. Approx 50% of survivors will be dependant at 1 year post stroke
Bamford SystemClassification system for bedside diagnosis of region of brain affected (allows for prediction of prognosis) TACS, PACS, LACS and POCS
TACS and PACSMCA infarct, aphasia, executive dysfunction, disinhibition, lack of insight, visual field deficit, motor and sensory deficit.
LACSUnilateral weakness, sensory loss, may have dysarthria, no cognitive signs
POCSMotor deficits (damage same side as stroke) dysphagia and dysarthria
Treatment for Ischemic strokeAnti-platelets e.g. Asprin (reduce chance of another clot forming) Anticoagulants, carotid stent (surgery to unblock artery) Thrombolysis - meds to disperse clot (within 4 1/2 hours stroke onset) or Thrombectomy - emergency procedure to remove blood clot
Treatment for Haemorrhagic strokeSurgery (to remove blood, stop bleeding and relieve pressure) or craniotomy (small piece of skull removed to get to brain)
MDTOrganised stroke unit care: go to hyperacute stroke unit (0-72 hrs) to prevent death, reduce disability and reduced need to institutionalised care. Specialised MDT = coordinated assessment, rehab, goal setting and discharge plan
Implications for speechUnilateral UMN dysarthria - tends to be relatively mild, tongue deviates to weaker side, articulation (most likely affected). Spastic dysarthria - lips and tongue movements restricted, often co-occurs with dysphagia, voice and speech affected (mono-pitch, mono-loudness, hypernasality, reduced speech rate) Flaccid dysarthria - affects speed, range and accuracy of movement, depends on cranial nerve affected (Articulation = Trigeminal V, Facial VIII and Glossopharyngeal XII
Implications for languageAphasia - Broca's (expressive) or Wernicke's (receptive) 33% of people who survive a stroke will have it
Implications for swallow Impaired in 50% of cases. May resolve or persist. 3x more likely to develop pneumonia. Short term NG tube (consider PEG if NBM for more than 2 weeks)
NICE guidelinesRehab goal = minimum therapy 5 days for 45 mins per week. Dysphagia = hydration and swallow assessed within 4 hours. Aphasia = SLT assessment for diagnosis (within 1 week), opportunity to practise language and communication skills (first 4 months) Dysarthria - Assessed by SLT to diagnose type, communication partners training, AAC (if required)
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