Stroke

Stroke

Classified into two types:

1) Ischaemic

2) haemorrhagic


Ischamic stroke:
=====================
is either - thrombotic or embolic

thrombotic - from ahterosclerosis

embolic - from heart or from aneurysm

Symp:
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monocular vision loss, visual field loss
unilateral (facial/limb) weakness
aphasia (impaired language function - sign of dominant hemispheric ischaemia)
ataxia
{symp mem tip below}

Test:
----------------
CT brain (mainly to exclude hemorrhagic stroke. CT brain may be normal within first few hours of ischaemic stroke.


Rx:
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presentation within 3 hrs and no contraindication to thrombolytics -> tPA (ateplase)
presentation after 3 hrs -> aspirin 300 mg dly

cerebral venous sinus thrombosis -> heparin / warfarin

DVT prophylaxis


haemorrhagic stroke
=====================

Symp:
----------------
Headache ("most severe headache of my life" suggests subarachnoid haemorrahge)
Neck stiffness
Visual impairment (hemianopia(half visual field defect), diplopia), photophobia
Unilateral (face/limb) weakness
Seonsory loss
Aphasia (impaired language function - sign of dominant hemispheric ischaemia)
Dysarthria, ataxia
Nausea/vomiting (uncommon)
Altered level of consciousness/confusion (uncommon)
{symp mem tip below}

Test:
----------------
CT brain
INR


Rx:
----------------
-Airway protection (Intubate if GCS <= 8)
-Sedation (with propofol/midazolam/barbiturate - e.g. in ICU setting - midazolam 0.1 mg/kg (typically 5 mg) ivi as a loading dose,

then 0.1 mg/kg/hr)
-Anticonvulsant (phenytoin 15 mg/kg over 20 min loading, then 3 mg/kg 12hrly)
-Antipyretic (paracetamol)
-BP control ( pt often have sys BP > 180. keep sys BP just below 160 using labetalol. CAUTION - too low BP may worsen the

damage)
-Treat hyperglycemia (if serum glucose > 10 mmol/L)
-Head 30 degree elevated at bed.
-Mannitol 1g/kg IV bolus, maintenance 0.25 ~ 0.5 g /kg every 6 hrs.
-Correct coagulopathy if it exists.

Neurosurg consult

{mem tip:
Airway, Sedation, -ABC
Head 30 degree, mannitol, -압력 낮춰 공급높이고
Hypertension, Diabetes, Epilepsy  -대사활동 줄여 소모줄이고
}

{symp mem tip:

//////////////
Cincinnati prehospital stroke scale:
==================================

- Facial drop (seen by asking the pt to - "show me your teeth")
- Arm drift ( hold out two arms with palms up and eyes closed for 10 sec. one arm drifts down)
- Abnormal speech ( have the pt say "you can't teach an old dog new tricks" - pt slurs words/uses wrong words/can't speak)

if one of the above positive - 75 % chance of stroke
if all three positive - more than 85 % chance of stroke
/////////////


stroke (both hemorrhagic & ischaemic) - cincinnati scale 에 시력/시야 검사 더함.

Visual impairment:
-ischaemic stroke: monocular blindness, visual field defect
-hemorrhagic stroke: hemianopia(half visual field defect), diplopia

Hemorrhagic stroke 에는 다음과 같은 특징이 더함.

Characteristic of hemorrhagic stroke:
-Headahce (common but may be absent)
-Neck stiffness (common)
-nausea/vomiting (uncommon)
-altered level of consciousness (uncommon)
즉,
마치 memnigitis 같이 - neck stiffness, headache, nausea vomitting
바보같은 radiologist 는 GCS 15/15 은 hemorrhage 아니라고 하겠지만 hemorrhagic stroke 가 꼭 혼수상태일 필욘 없음.
다만 GCS 가 낮으면 mortality 가 높아짐. Haemorrhage size 가 커도 mortality 높아짐