Emergency - Cerebrovascular accident (CVA)

From CambridgeNotes

  • "Stroke" is the sudden onset of a neurological symptom – weakness, loss of speech, diplopia, impaired consciousness, etc.
    • Transient ischaemic attack (TIA): focal deficit lasting 24h
    • Cerebrovascular accident (CVA): permanent deficit
  • Aetiology: ischaemic (80%) – thrombus, embolus, or hypotensive; haemorrhagic (20%) – hypertension and subarachnoid haemorrhage (SAH)

ABC

History and Examination

  • Presentation depends on lesion site: cortex or brainstem?
  • SAH: headache, reduced level of consciousness, meningism, focal signs (neuro exam)
  • Other causes? Risk factors, carotid bruit, atrial fibrillation, hypertension (CV exam)
  • Assess risk of aspiration and pressure sores

Differential Diagnosis

Empirical Treatment

  • Maintain sats, hydration (nil by mouth with iv fluids until swallowing assessed), glucose, temperature
  • BP should not be lowered acutely unless it is greater than 220/120 and only then with senior advice

Investigations

  • Bloods: FBC, U&E, glucose
  • ECG; Chest X-ray
  • CT <24h (<12h if ?haemorrhage e.g. on anticoagulation, SAH Sx); LP >12h if ?SAH after negative CT; consider MRI if >10 days after symptoms

Definitive treatment (multi-disciplinary approach is best)

  • Ischaemic (including TIA): consider altepase thrombolysis <3h after haemorrhage excluded; also give aspirin 300mg STAT after haemorrhage excluded, rectally/enterally if necessary (delay 24h following thrombolysis)
  • Haemorrhagic: if SAH continue support (HHHT i.e. lots of fluids) and start nimodipine 60mg PO q4h, surgical assessment; otherwise consider surgery if supratentorial bleed with mass effect, or any posterior fossa bleed
  • Admit to stroke unit (better outcomes)
  • Secondary prevention (<1w after CVA): lifestyle advice (stop smoking, exercise, diet, reduce salt, reduce alcohol); hypertension >2 weeks treated e.g. ACE inhibitor and/or thiazide diuretic; cholesterol >3.5mM treated e.g. statin; do not routinely anti-coagulate up to 14 days following an event (use stockings for DVT/PE prophylaxis instead) unless e.g. atrial fibrillation; aspirin 75mg PO daily if not anti-coagulated (or alternative e.g. clopidogrel); carotid stenosis consider surgery (CEA) if >70%/50% using ECST or NASCET methods
  • Rehabilitation (as soon as possible): physiotherapy, speech and language therapy (SALT); occupational therapy (OT); is the patient depressed?

References

  1. Intercollegiate guidelines 2004

Stroke types

Oxfordshire Stroke Subtype Classification of ischaemic strokes

Subtype Features Notes
Lacunar infarcts (LACI)= 25% Pure motor or sensory stroke, sensorimotor stroke, or ataxic hemiparesis
Total anterior circulation infarcts (TACI) = 17% A combination of new higher cerebral dysfunction (e.g., dysphasia), homonymous visual field defect, and ipsilateral motor or sensory deficit of at least 2 areas of face, arm, and leg High mortality and poor chance of good functional outcome
Partial anterior circulation infarcts (PACI)= 27% Only 2 of 3 components of TACI; higher cerebral dysfunction alone or with motor/sensory deficit more restricted than for LACI More likely to have an early recurrent stroke
Posterior circulation infarcts (POCI) = 19% Brain stem or cerebellar dysfunction More likely to have late recurrence but good overall outcome

(Page updated with reference to Addenbrooke’s Guide to Neurological Emergencies, for Hospitals in Cambridgeshire, Suffolk and Norfolk. March 2006 – March 2007)

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