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Acute Stroke

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					                            Acute Stroke                                       Anatomy of stroke
                                                                               - Carotid territory stroke – hemiplegia, language dysfunction, rt-lt
                                                                                  disorientation
Learning Objectives:                                                           - MCA territory – hemiplegia, hemianesthesia, hemianopia, coma
- What is stroke?                                                              - Vertebrobasilar – diplopia, dysartria, dysphagia, amnesia,
- To know its pathophysiology                                                     unsteadiness
- To know the current medical management guidelines                               MCA = middle cerebral artery
- To know current status of intervention
                                                                               Manifestation
What is stroke?                                                                - Hemiplegia (loss of motor functions in 1 half)
A clinical syndrome consisting of rapidly developing clinical signs of focal   - Focal higher cerebral dysfunction - aphasia
(or global in case of coma) disturbance of cerebral function lasting more      - Hemianopia (loss of vision in 1 half)
than 24 hours or leading to death with no apparent cause other than a          - Hemisensory loss
vascular origin.                                                               - Brain stem symptoms
- Focal cerebral dysfunction
- Happens instantaneously                                                      Differential diagnosis
- Symptoms persistent more than 24 hours                                       - Primary cerebral tumour
                                                                               - Metastatic cerebral tumour
Global Burden                                                                  - Subdural hematoma
- Stroke is now the second most common cause of death globally and             - Cerebral abscess
   the major cause of disability                                               - Demyelination (MS)
- Up to 20 million stroke events occur yearly worldwide                        - Hypoglycaemia
                                                                               - Encephalitis
Classification                                                                 - Migranous aura
- TIA (transient ischemic attack)                                              - Focal seizure
- Stroke                                                                       - Todds palsy
- Stroke in evolution-symptoms worsen after 1st present                        - Conversion disorder
- Completed stroke-focal deficit not progressing
- RIND (Reversible ischemic neurological disorder)                             General Examination
                                                                               - Skin - xanthelasma
Diff. between TIA and stroke is the time limit. TIA = <24 hours. Stroke =      - Rashes – arteritis
>24 hours.                                                                     - Limbs – ischemia, venous thrombosis
-   Eye – diabetic changes, retinal emboli, hypertensive changes, arcus          b. Hereditary / familial factors
    senilis (lipid disposition in the cornea)                                    c. High fibrinogen
-   CVS                                                                          d. Previous vascular event
        o BP = hyper/hypotension
        o Heart rhythm – af                                               Classification of stroke
        o JVP – cf                                                        - Infarction (85%)
        o Peripheral pulses and bruit                                              o Artherosclerosis (60%)
-   RS - RTI, Pulmonary oedema                                                     o Non-atherosclerosis (40%)
-   Abdomen – Urinary retention                                                              Embolic (50%)
-   Locomotor system                                                                         Others (50%)
        o Injury sustained during collapse                                - Haemorrahge (15%)
        o Comorbidity which influence management                                   o ICH - intracerebral haemorrhage (85%)
                                                                                             HTN (70%)
Risk factors                                                                                 AVM + others (30%)
A. Modifiable                                                                      o SAH – subarachnoid haemorrhage (15%)
- Hypertension                                                                               Rupture aneurysm (85%)
- Smoking                                                                                    Idiopathic (15%)
- Cardiac factors
         o Artiral fibrillation                                           HTN – hypertension
         o IE                                                             AVM – arteriovenous malfunction
         o Recent MI
- Oral pill                                                               Causes
- Carotid stenosis                                                        Common                               Uncommon
- Obesity                                                                 Thrombosis                           Hypercoagulable disorders
- TIA                                                                     Cardioembolic                        Venous sinous thrombosis
- Sickle Cell Disease                                                                                          Fibromuscular dysplasia
B. Potentially modifiable                                                                                      Vasculitis
- DM                                                                                                           Cardiogenic
- Hyperhomoecystinuria                                                                                         SAH vasospasm
C. Non modifiable                                                                                              Drugs: cocaine, amphetamine
- Age
- Sex
         a. Race/ethnicity
Causes of ICH                                                                        g. Alert receiving ED
- Vascular anomaly                                                                   h. Rapid transport to close appropriate facility
- Small vessel disease - HTN                                                  2. Not recommended
- Impaired clotting                                                                  a. Dextrose containing fluids in nonhypoglycemic patients
- Amyloid angiopathy                                                                 b. Hypotension/excessive BP reduction
                                                                                     c. Excessive intravenous fluids
Acute Stroke Management
- Five mainstays                                                           Multimodal MRI
        o Treatment of general condition that need to be stabilized        -   Diffusion-weighted imaging
        o Specific therapy directed against particular aspects of stroke   - Perfusion-weighted imaging
           pathogenesis
        o Prophylaxis & treatment of complications which may be
           either neurological or medical
        o Early secondary prevention
        o Early rehabilitation

Investigation
- Is it vascular –CT/MRI
- Ischemic / Haemorrhagic (RE) – CT/ MRI
- Is it SAH – CT
- Cardiac – ECG, echo
- Vascular Disease – Duplex US, MRA, CTA
- Risk factors – CBC, Sugar, Lipids
- Unusual cause – ESR, Clotting screen

EMS Management of Patients with Suspected Stroke
   1. Recommended
         a. ABCs
         b. Cardiac monitoring
         c. IV access
         d. O2 saturation <92%
         e. Assess for hypoglycaemia
         f. Nil per os (NPO)

				
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posted:11/15/2011
language:English
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