Stroke/cerebrovascular accident

Stroke, a significant medical emergency, occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients. Here’s an overview of stroke:

Causes

  • Ischemic Stroke:
    • Caused by blockages or clots in arteries leading to the brain.
    • Common causes include thrombosis, embolism, systemic hypoperfusion.
  • Hemorrhagic Stroke:
    • Occurs due to bleeding into or around the brain.
    • Causes include hypertension, aneurysms, arteriovenous malformations, and blood disorders.
  • Transient Ischemic Attack (TIA):
    • A temporary blockage of blood flow to the brain, often called a ‘mini-stroke’.

Diagnosis

  • History:
    • Sudden onset of neurological deficits.
    • Ask about the FAST symptoms:
      • Face drooping,
      • Arm weakness,
      • Speech difficulties,
      • Time to call emergency services.
    • Risk factors: Hypertension, diabetes, smoking, hyperlipidemia, atrial fibrillation.
  • Examination:
    • Neurological assessment: Glasgow Coma Scale, assessment of cranial nerves, motor and sensory examination, coordination, and speech.
    • Check for signs of increased intracranial pressure.
  • Investigations:
    • CT Scan/MRI of the Head: First-line to differentiate between ischemic and hemorrhagic stroke.
    • Carotid Ultrasound: Assess carotid artery disease.
    • Echocardiography: Identify cardiac sources of emboli.
    • Blood Tests: CBC, coagulation profile, lipid profile, blood glucose level.

Differential Diagnosis

  • Hypoglycemia: Can mimic stroke symptoms.
  • Migraine with Aura: Temporary neurological symptoms, often with a history of similar episodes.
  • Seizures: Postictal paralysis (Todd’s paralysis) can mimic stroke.
  • Brain Tumors or Abscesses: Can present with focal neurological deficits.
  • Drug Intoxication: Certain drugs can cause stroke-like symptoms.

Management

  • Acute Management:
    • Immediate medical evaluation and stabilization.
    • For ischemic stroke: Thrombolytic therapy (tPA) if within the window period (usually 4.5 hours from onset).
    • For hemorrhagic stroke: Control of blood pressure, surgical interventions (clipping or coiling of aneurysms, decompressive surgery).
  • Secondary Prevention:
    • Antiplatelets (aspirin, clopidogrel) for ischemic stroke.
    • Anticoagulants for strokes due to atrial fibrillation.
    • Control of risk factors: Hypertension, diabetes, dyslipidemia.
    • Lifestyle modifications: Smoking cessation, diet, exercise.
  • Rehabilitation:
    • Multidisciplinary approach: Physiotherapy, occupational therapy, speech therapy.
    • Psychological support and cognitive therapy.
  • Follow-Up:
    • Regular medical follow-ups to monitor and manage risk factors.
    • Neurological assessments to track recovery.
  • Patient and Family Education:
    • Education on recognizing stroke symptoms.
    • Guidance on adherence to medications and lifestyle changes.
  • Special Considerations:
    • Tailoring antithrombotic therapy considering individual risk factors.
      • CHA2DS2-VASc vs HAS-BLED
    • Monitoring for complications like aspiration pneumonia, deep vein thrombosis.
  • Referral
    • Referral to a neurologist or stroke specialist.
    • Consideration for referral to specialized stroke rehabilitation services.

Prompt recognition and treatment of stroke are crucial to reduce the risk of permanent disability or death. Managing risk factors and rehabilitation are key components of long-term care post-stroke.

Transient Ischaemic Attack

Transient Ischemic Attack (TIA), often referred to as a “mini-stroke,” is a temporary disruption of blood flow to part of the brain, spinal cord, or retina, causing stroke-like symptoms that typically resolve within 24 hours. Understanding TIA is crucial as it often precedes a full-blown stroke.

Causes

  • Blood Clots (Thromboemboli): Most common cause, originating in the heart or arteries.
  • Atherosclerosis: Narrowing of arteries due to plaque buildup.
  • Heart Conditions: Atrial fibrillation and other heart diseases increasing clot risk.
  • Blood Disorders: Conditions increasing blood clotting potential.
  • Other Risk Factors: Hypertension, diabetes, smoking, high cholesterol, family history of stroke or TIA, and advanced age.

Diagnosis

  • History:
    • Sudden onset of neurological deficits like speech disturbance, weakness, numbness, or loss of vision.
    • Duration of symptoms, typically lasting less than one hour.
    • Assessment of cardiovascular risk factors.
  • Examination:
    • Neurological exam to assess strength, sensation, coordination, reflexes, speech, and vision.
    • Cardiac examination for murmurs, irregular rhythms, or signs of heart failure.
    • Examination of the carotid arteries in the neck for bruits (abnormal sounds indicating turbulence in blood flow).
  • Investigations:
    • Brain Imaging (CT/MRI): To rule out stroke and other pathologies.
    • Carotid Ultrasound: To check for carotid artery disease.
    • Echocardiogram: To identify potential cardiac sources of emboli.
    • ECG and Cardiac Monitoring: To detect atrial fibrillation or other rhythm abnormalities.
    • Blood Tests: Including complete blood count, lipid profile, diabetes screening.

Differential Diagnosis

  • Migraine with Aura: Can present with similar temporary neurological symptoms.
  • Seizure: Particularly postictal paralysis.
  • Hypoglycemia: Can mimic TIA symptoms.
  • Brain Tumor or Abscess: Could present with episodic symptoms.
  • Multiple Sclerosis: In some cases, can present with transient neurological deficits.

Management

  • Immediate Management:
    • Hospitalization if symptoms are recent or if the diagnosis is uncertain.
    • Thrombolytic therapy is not used due to the transient nature of symptoms.
  • Secondary Prevention:
    • Antiplatelet agents (aspirin, clopidogrel).
    • Statins for cholesterol management.
    • Antihypertensive medications for blood pressure control.
    • Anticoagulants if atrial fibrillation or other indications are present.
    • Endarterectomy for severe carotid stenosis
  • Lifestyle Modifications:
    • Smoking cessation, diet and exercise, weight control.
    • Diabetes management.
  • Follow-Up:
    • Regular monitoring and adjustments in medications as needed.
    • Continuous evaluation for the emergence of new symptoms or stroke.
  • Patient Education:
    • Recognize and act promptly on recurrent symptoms.
    • Understand the importance of medication adherence and lifestyle changes.
  • Referrals:
    • Neurology, cardiology, or stroke prevention clinics.

Conclusion

TIA is a warning sign of potential future stroke and should be treated with urgency. A thorough assessment, appropriate management of risk factors, and vigilant follow-up are essential to prevent subsequent strokes.