Stroke

Stroke
Definition and classification
Stroke burden
  • Incidence of first ever stroke is about 200 per 100 000 per year
  • Prevalence is around 5-12 per 1000 population, depending on the age of the sample
  • It is a disease of older people (over 2/3rds of cases occur in the over 65s, less than 15% occur in under 45s)
  • Globally it is the third most common cause of death (after coronary heart disease and all cancers)
  • In England and Wales it accounts for 12% of all deaths and is the commonest cause of severe disability among community dwellers
Classification
Various methods including;
  • Infarct or haemorrhage (also haemorrhagic infarcts)
  • Pathogenesis—large vessel, small vessel, cardioembolic (AF or LV mural thrombus), valve disease, infective endocarditis, non-atheromatous arterial disease (vasculitis, dissection), blood disorders
  • Vessel affected—anterior circulation (mainly middle cerebral artery), lacunar (deep small subcortical vessels), posterior circulation (vertebral and basilar arteries)
  • Bamford’s classification—clinical features to define likely stroke territory. Used in major trials and gives prognostic information about each group (see Table 8.1).
Table 8.1 Bamford’s classification

Total anterior circulation stroke (TACS)

Features

Hemiparesis and hemisensory loss

Homonymous hemianopia

Cortical dysfunction (dysphasia, visio-spatial or perceptual problems)

Infarction (TACI)

85%

Haemorrhage

15%

Causes

Occlusion of the internal carotid artery or proximal middle cerebral artery

Emboli from heart, aortic arch or carotids, in situ thrombosis

Prognosis at 1 year

Dead

60%

Dependent

35%

Independent

5%

Partial anterior circulation stroke (PACS)

Features

Two of the three listed in this table above OR cortical dysfunction alone

Infarction (PACI)

85%

Haemorrhage

15%

Causes

Occlusion of the anterior or middle cerebral artery

Prognosis at 1 year

Dead

15%

Dependent

30%

Independent

55%

Lacunar stroke (LACS)

Features

Hemiparesis

OR

Hemi-sensory loss

OR

Hemi-sensorimotor loss

OR

Ataxic hemiparesis (with NO cortical dysfunction)

Infarction (LACI)

95%

Haemorrhage

5%

Causes

Small perforating arteries microatheroma

Hypertensive small vessel disease

Prognosis at 1 year

Dead

10%

Dependent

30%

Independent

60%

Posterior circulation stroke (POCS)

Features

Brainstem symptoms and signs (diplopia, vertigo, ataxia, bilateral limb problems, hemianopia, cortical blindness, etc.)

Infarction (POCI)

85%

Haemorrhage

15%

Causes

Occlusion of vertebral, basilar or posterior cerebral artery

Emboli from heart, aortic arch or vertebrobasilar artery

Prognosis at 1 year

Dead

20%

Dependent

20%

Independent

60%

Predisposing factors
Fixed
  • Age: stroke risk increases with age (this is the strongest risk factor)
  • Sex: males > females
  • Ethnicity: higher risk in Blacks and Asians than Whites living in the West. Probably due to increased obesity, hypertension, and diabetes
  • Family history: positive family history increases risk. Not simple inheritance—complex genetic/environmental interaction
  • Previous stroke/TIA: risk of recurrence is about 10-16% in the first year, highest in the acute phase
  • Other vascular disease: presence of any atheromatous disease (coronary, peripheral arterial etc) increases risk of stroke
Modifiable by lifestyle change
  • Smoking: causal and dose related. Risk diminishes 5 years after quitting
  • Alcohol: Conflicting evidence with some studies suggesting any alcohol consumption increases risk, while others suggest heavy drinking is a risk factor, but moderate intake is protective
  • Obesity: Increased risk of all vascular events in obesity—confounded by increase in other risk factors (hypertension, diabetes) but probably weak independent factor, especially central obesity
  • Physical inactivity: Increased stroke in less active—again confounded by presence of other risk factors in the inactive; to date limited evidence that increased activity lowers risk
  • Diet: Healthy eaters have lower risk, but may have healthier lifestyles in general. Low salt, high fruit and vegetable, high fish and antioxidant diets are likely to be protective, but trials have failed to show an effect from dietary interventions
  • Oestrogens: the oral contraceptive confers a slightly increased risk of stroke and should be avoided in the presence of other risk factors. Postmenopausal hormone replacement therapy has been shown to increase risk of ischaemic stroke, but not TIA or haemorrhagic stroke
Medically modifiable
  • Hypertension: clear association between increasing BP and increased stroke risk across all population groups. Risk doubles with each 5-7 mmHg increase in diastolic blood pressure. Also increases with systolic rises and even isolated systolic hypertension
  • AF: Risk of stroke significantly increased in AF (see image ‘Atrial fibrillation’, p.276)
  • Diabetes: risk factor independent of hypertension
  • High cholesterol: weaker risk factor than in heart disease—likely due to diversity of stroke aetiologies
  • Carotid stenosis: risk increases with increasing stenosis and with the occurrence of symptoms attributable to the stenosis
  • Other comorbidity: Increased risk in some conditions, such as sickle-cell anaemia, blood diseases causing hyperviscosity and vasculitides
Acute assessment
Due to the development of new acute treatments (eg thrombolysis and carotid endarterectomy) the focus for modern stroke management in hospital has shifted towards rapid and accurate diagnosis during the first few hours/days.
Investigations (Table 8.2)
Table 8.2 The rationale for investigations in acute stroke

Test

Rationale

FBC

Anaemic or polycythaemic

Elevated white count suggestive of sepsis

High or low platelet count

Urea and electrolytes

Look for evidence of dehydration, and assess fluid replacement

LFTs

Baseline assessment

Evidence of comorbidity

CK

Evidence of muscle breakdown (if prolonged lie on floor)

Glucose

Diabetic—old or new diagnosis (elevated sugars initially may represent hyperglycaemic stress response)

Hypoglycaemia ▶ may mimic stroke

Cholesterol

Vascular risk factor

ESR

Elevation in vasculitis or sepsis (including endocarditis)

CRP

Any evidence of sepsis (eg aspiration pneumonia)

Blood cultures

Consider if sepsis or new heart murmur heard (endocarditis)

Urinalysis

Diabetic, vasculitis, urinary infection

ECG

Assess rhythm (look for AF)

Evidence of IHD/MI or previous hypertension

CXR

Often useful screening test—look for any sign of aspiration, what is the heart size, etc.

CT brain

Guidelines advise scan within 24hr for all strokes, or sooner (<1hr) if:

Thrombolysis candidate

<GCS 13 or fluctuating neurology

Severe headache at onset

  • On warfarin

  • Papilloedema, neck stiffness or fever

CT will distinguish stroke from non-stroke, eg tumour, identify whether bleed or an infarct, the likely cause of the event — carotid territory infarcts from stenosis, multiple infarcts from cardiac emboli

Blood appears white in early CT; infarcts may not show acutely (first few hours), develop into low-density areas after a few days

Small infarcts may never be seen, and the diagnosis is made clinically or on MR scan

▶A normal CT does not exclude a stroke

Carotid Doppler

Request in carotid territory events with good recovery where the patient is a candidate for endarterectomy

Echocardiogram

Consider where multiple (? cardio embolic) infarcts, in AF, after recent MI (looking for thrombus) or where there is a murmur

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Jul 22, 2016 | Posted by in GERIATRICS | Comments Off on Stroke

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