CVA
Definition
A sudden neurological disturbance, due to blockage (ischaemic stroke) or bursting (haemorrhagic) of a brain blood vessel. This is either a:
- TIA - symptoms subside after 24 hours
- Stroke - symptoms do not subside
Epidemiology
110,000 people have their first and 30,000 people a recurrent stroke per year in the UK. After cancer and heart disease, stroke is the third biggest killer in the UK. The majority of stroke sufferers are over 65 with 1 in 100 over 75's having a stroke.
Pathophysiology
Risk Factors
Stroke is a vascular disease and as such has the same risk factors as any other vascular condition:
PMHx
Family History
- Family history of stroke or other vascular event
Social History
- Smoking
- Alcohol
- High cholesterol
- Poor diet
- Being overweight
- Little exercise
Clinical Features
The presentation of a stroke depends on which artery/ies and so which area of the brain is affected. There are a few types of stroke that you should know about. Broadly speaking these are:
- Total Anterior Circulation Infarction (TACI pronounced "tacky")
- Partial Anterior Circulation Infarction (PACI pronounced...it rhymes with "tacky")
- Lacunar Infarction
- Posterior Infarction (these last two don't have clever acronyms for some reason)
There are also some other non-cerebral strokes that are worth knowing about:
- Brainstem stroke
- Lacunar stroke
TACI/PACI
The symptoms of a TACI are about the same as a PACI, but obviously more severe and more widespread. The prognosis is better in PACIs.
Anterior Cerebral Artery
- contralateral leg paralysis
- gegenhalten rigidity - rigidity against passive movement
- perserveration - uncontrollable repetition of the same word
- "alien limb" syndrome - limb takes a "mind of its own" aka Dr Strangelove syndrome (I'm not sure they're not taking the piss. Speaking of which...)
- Urinary incontinence
- Grasp reflex
Middle Cerebral Artery
- Contralateral hemiparesis & sensory loss in upper body
- Aphasia (if on dominant side)
- Contralateral neglect syndrome
- Homonymous hemianopia
Posterior Infarction
Posterior Cerebral Artery
- Contralateral homonymous hemianopia
- Contralateral loss of pain and temperature sensations (spinothalamic tract)
- Ipsilateral deficits of Cranial Nerves V, VIII, IX, X, & XI
- Horner's Syndrome
Lacunar Infarction
With lacunar strokes you basically get: pure motor, pure sensory, pure sensorimotor or ataxic hemiparesis.
Brainstem Stroke
Essentially these come down to: headache, vertigo, nausea and vomiting; weakness, either bilateral or unilateral; visual disturbance, nystagmus, ptosis or Horner's syndrome; hearing loss; dysarthria; dysphagia; ataxia; impaired level of consciousness; and altered pattern of respiration.
Cerebellar stroke
Basically, you can get: headache, nausea and vomiting; dizziness/vertigo; visual disturbance, nystagmus or gaze palsy; gait/limb ataxia; speech disturbance; hypertension; and loss of consciousness.
Investigations
The investigations of stroke have three purposes: confirmation of diagnosis; identification of site of primary pathology; and finding factors affecting management.
Confirmation of diagnosis
CT or MRI. This will confirm the diagnosis and also help in determining the nature of the stroke i.e. haemorrhagic or ischaemic. It may also with help with:
Idenfication Of Primary Pathology
Non-invasive
- CT
- MRI
- Ultrasound of carotids (if normal, no further investigation needed)
- Echocardiography
Invasive
- Angiography
Factors Affecting Management
Imaging
- Chest X-Ray - cardiac enlargement in hypertension or arrhythymias
- ECG - cardiological abnormalities e.g. arrhythmias, enlargement, MI
Bloods
- Glucose - diabetes
- Cholesterol and lipids - risk factor for further ischaemia and for hyperlipidaemia in under 65s
- FBC - polycythaemia, thrombocytopenia
- ESR - vasculitis
- Urine analysis - polyarteritis, thrombocytopenia
Management
Acute
- thrombolysis - within three hours, no sign of haemorrhage on CT, initiated by a specialist
- antithrombotic and antiplatelet drugs i.e. aspirin (controversial due to adverse effect on haemorrhagic strokes)
There is actually little you can do to directly affect the progress of a currently-evolving stroke, especially if you don't see them within three hours to initiate thrombolysis.
Long-term
Prevention Of Further Problems
This consists of secondary prevention of strokes and prevention of complications. Secondary prevention consists of controlling modifiable risk factors. Complications include:
- Thrombi (DVT, PE)
- Pneumonia (particularly via aspiration)
- Pressure sores
- Frozen shoulder and contractures
Support and Rehabillitation
This is both medical staff and the multidisciplinary team. The main members of MDT who are important are:
- Physiotherapist
- Occupational therapist
- Social worker (to sort care)
- Speech therapist
- Psychologist
Medically, airway, swallowing and blood pressure need to be assessed and management catered appropriately.