Stroke Summary

Definition

  • Sudden focal neurological deficit
  • Lasts >24 hours or leads to death
  • Medical emergency

Types

  • Ischaemic (85%) - vascular occlusion
  • Haemorrhagic (15%) - bleeding in brain
  • Subarachnoid haemorrhage

Risk Factors

  • Hypertension, AF, diabetes
  • Smoking, alcohol, inactivity
  • Age, gender, family history

Clinical Features

  • FAST: Face, Arm, Speech, Time
  • Weakness, sensory loss, speech problems
  • Visual disturbances, headache

Acute Management

  • Thrombolysis (<4.5 hours)
  • Thrombectomy (<6-24 hours)
  • Aspirin 300mg (after ICH excluded)

Complications

  • Cerebral edema, seizures
  • Pneumonia, DVT, pressure sores
  • Long-term disability

Stroke

Clinical syndrome of sudden neurological deficit

Overview

Stroke is a clinical syndrome characterised by sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death.

Medical Emergency

Stroke is a medical emergency requiring immediate assessment and treatment. Time is brain!

Causes

Ischaemic Stroke (85%)

  • Neurological dysfunction due to ischemia
  • Vascular occlusion or stenosis
  • Causes:
    • Thrombus (atherosclerosis complication)
    • Embolus (from heart or arteries)
  • Affects large arteries or small penetrating arteries

Haemorrhagic Stroke (15%)

  • Intracerebral haemorrhage:
    • Bleeding within brain parenchyma
    • Main cause: high blood pressure
  • Subarachnoid haemorrhage:
    • Bleeding into subarachnoid space
    • 85% from intracranial aneurysm
    • 10% non-aneurysmal peri-mesencephalic
    • 5% vascular abnormalities

Rarer Causes

  • Cerebral venous thrombosis
  • Carotid artery dissection
  • Vasculitis
  • Arteriovenous malformations

Risk Factors

Lifestyle Factors

  • Smoking
  • Alcohol misuse
  • Drug abuse (cocaine, methamphetamine)
  • Physical inactivity
  • Poor diet

Cardiovascular Disease

  • Hypertension
  • Atrial fibrillation (permanent and paroxysmal)
  • Infective endocarditis
  • Valvular disease
  • Carotid artery disease
  • Congestive heart failure
  • Congenital heart disease

Other Factors

  • Age (risk doubles every decade after 55)
  • Gender (men > women at younger age)
  • Hyperlipidemia
  • Diabetes mellitus
  • Sickle cell disease
  • Hypercoagulable disorders
  • Chronic kidney disease
  • Obstructive sleep apnoea

Clinical Features

Suspect stroke if the person presents with sudden onset, focal neurological deficit which is ongoing or has persisted for longer than 24 hours.

Common Symptoms

General Symptoms

  • Confusion, altered consciousness
  • Headache (sudden, severe, unusual)
  • Nausea and/or vomiting
  • Neck or facial pain

Focal Neurological Deficits

  • Weakness (face or limbs)
  • Sensory loss (paraesthesia or numbness)
  • Speech problems (dysarthria, aphasia)
  • Visual problems (loss, diplopia)

Other Features

  • Dizziness, vertigo, loss of balance
  • Cranial nerve deficits
  • Difficulty with coordination and gait
  • Horner's syndrome (miosis, ptosis, anhidrosis)

Posterior Circulation Strokes

Suspect if the person presents with acute vestibular syndrome: acute, persistent vertigo/dizziness with nystagmus, nausea/vomiting, head motion intolerance, and new gait unsteadiness.

FAST Assessment

Differential Diagnosis

Many conditions (stroke mimics) can present with similar clinical features to stroke and TIA.

Toxic/Metabolic

  • Hypoglycemia
  • Drug and alcohol toxicity
  • Electrolyte imbalances

Neurological

  • Seizure (Todd's paresis)
  • Migraine with aura
  • Demyelination (MS)
  • Peripheral neuropathies
  • Spinal epidural haematoma

Other Conditions

  • Syncope
  • Vestibular disorders
  • Infections (CNS abscess, meningitis)
  • Space occupying lesions (tumor, subdural hematoma)
  • Encephalopathies
  • Vasculitis
  • Conversion disorder

Assessment

First Step

Exclude hypoglycemia in people with sudden onset of neurological symptoms.

ROSIER Score

For people admitted to emergency department with suspected stroke, establish diagnosis rapidly using ROSIER (Recognition of Stroke in the Emergency Room) score:

ROSIER Scoring (≥1 = stroke possible)

  • Loss of consciousness or syncope? (-1 point)
  • Seizure activity? (-1 point)
  • Asymmetric facial weakness? (+1 point)
  • Asymmetric arm weakness? (+1 point)
  • Asymmetric leg weakness? (+1 point)
  • Speech disturbance? (+1 point)
  • Visual field defect? (+1 point)

Brain Imaging

Management

Thrombolysis

Thrombectomy

Antiplatelet/Anticoagulant Therapy

Ischaemic Stroke

  • Aspirin 300mg ASAP (within 24 hours)
  • Continue 300mg daily for 2 weeks
  • PPI if previous aspirin-related dyspepsia
  • Alternative antiplatelet if aspirin allergy

Other Stroke Types

  • Cerebral venous thrombosis: full anticoagulation
  • Arterial dissection: anticoagulants or antiplatelets
  • Haemorrhagic stroke: reverse anticoagulation if needed

Surgery

General Principles

Supportive Care

  • Oxygen only if saturation < 95%
  • Blood glucose: maintain 4-11 mmol/L
  • Swallowing screen before oral intake
  • Nutritional screening and support
  • Hydration assessment and maintenance

Blood Pressure Management

  • ICH: Rapid BP lowering if SBP 150-220mmHg within 6 hours
  • Target SBP 130-140mmHg for ≥7 days
  • Ischaemic stroke: Only treat if hypertensive emergency
  • Reduce to ≤185/110mmHg if thrombolysis candidate

Complications

Short-term Complications

Neurological

  • Haemorrhagic transformation
  • Cerebral edema
  • Seizures
  • Increased intracranial pressure

Medical

  • Venous thromboembolism (DVT, PE)
  • Cardiac complications
  • Infections:
    • Aspiration pneumonia
    • Urinary tract infection
    • Cellulitis from pressure sores

Long-term Complications

Physical

  • Mobility problems
  • Sensory deficits
  • Continence problems
  • Pain
  • Fatigue
  • Swallowing difficulties
  • Visual problems
  • Skin problems

Psychosocial

  • Cognitive impairment
  • Communication difficulties
  • Emotional/psychological problems
  • Depression and anxiety
  • Sexual dysfunction
  • Financial problems
  • Difficulties with activities of daily living

Rehabilitation and Recovery

Multidisciplinary Team

  • Physiotherapists (mobility, balance)
  • Occupational therapists (ADLs, adaptations)
  • Speech and language therapists
  • Neuropsychologists
  • Dietitians
  • Social workers

Rehabilitation Approaches

  • Early mobilization
  • Constraint-induced movement therapy
  • Task-specific training
  • Cognitive rehabilitation
  • Communication therapy
  • Swallowing therapy

Secondary Prevention

  • Blood pressure control
  • Cholesterol management
  • Antiplatelet/anticoagulant therapy
  • Diabetes management
  • Lifestyle modifications
  • Smoking cessation