From StudyingMed

< AEB
Jump to: navigation, search

Introduction

  • Stroke – injury to the CNS caused by blockage or haemorrhage of a cerebral artery
    • 3rd most common cause of death in developed countries
      • after coronary artery disease and cancer
    • Leading cause of disability – a lot of care is needed
    • 3-10 minutes can be critical

Strokes

  • Presentations
    • Neurological – rapid onset of focal neurological deficits
      • ‘Anyone can tell they’ve had a stroke’
    • Geriatric – non-specific symptoms

      • Confusion, falls, incontinence: need to do a CT scan to check for it. A lot of old people with dementia have had multiple strokes causing their dementia.
    • Early diagnosis and care is very important
  • Causes
    • Thrombosis (2/3) – acute/subacute
      • Previous TIAs
      • Neurological deficit will progress
    • Embolism (1/4) – sudden onset
      • Clot source
      • Maximum neurological deficit is at the beginning o
    • Haemorrhage
      • 1/20 – Intracerebral – sudden onset

        • associated with increased blood pressure (at the time of the stroke)/physical activity
    • 1/20 – subarachnoid – sudden onset
      • immediate severe headache (like being hit by a plank)
      • elevated BP
      • comatose, bilateral neurological signs, legs extended

Syndromes

  • Cortical
    • Motor/sensory/visual field loss – contralateral side; note that loss of strength in the
      • Dominant side stroke – speech (language) disturbance; motor or sensory signs are on the opposite side of the body to the site of the stroke, and cranial nerve signs are on the same side of the body as the stroke.
      • Non-dominant side stroke – neglect/geographic problems
  • Brainstem
    • Motor/sensory loss – contralateral side
      • Cranial nerves: eyes. Gaze, swallowing, palate, nausea, vertigo, nystagmus – ipsilateral
  • Lacunes – 2mm
    • Pure motor/sensory stroke
      • Cause dysarthria and clumsy hands; involuntary movements
  • Paaralysis at first low-tone, then spasticity develops. Muscle tone increases as time goes on
    • Often in the internal capsule
    • Leg is extended (extensors as stronger than the flexors), arm is flexed and internally rotated (flexors are stronger than the arm)

Risk factors

  • Hypertension, cigarettes, cholesterol, DM, possibly OSA
  • Incidence increases with age
  • Embolic sources
    • Cardiac – AF, MI (mural thrombus)
    • Valve disease: endocarditis, patent foramen ovale (DVT crosses over through foramen ovale)
    • Non-cardiac – mural plaques in the aortic arch or large arteries
  • Best of all – prevent the stroke happening
    • Careful treatment of hypertension, DM, elevated cholesterol, stop smoking
    • Treat/investigage TIA as aggressively as if strokes
    • Full anticoagulant therapy if an embolic source is present, or potentially present:
      • Atrial fibrillation; valvular heart disease or valve prosthesis
      • Dilated cardiomyopathy
      • If reason to start it, needs even better reason to stop it.

Prevalence

  • Control risk factors
  • Treat/investigate TIAs
  • Anticoagulant therapy for embolic risk – warfarin
    • Eg: AF, valve disease, dilated cardiomyopathy


Acute stroke management

  • Early diagnosis
    • Head CT within 3 hours to rule out haemorrhage
      • If not haemorrhage, thrombolytic therapy
    • Investigate embolic sources
      • ECG, carotid Doppler studies
  • Monitor, treat BP, blood glucose, renal electrolytes etc
  • Good nursing to prevent pressure sores and DVT

Rehabilitation

  • As soon as the person has recovered from acute _____, you need to get them on rehabilitation
  • Essentially training people to cope with their new situations
    • With strokes: people are left with permanent lifestyle changes/problems
    • WHO conceptualisation – 3 levels of looking at rehab:
      • Impairment – problems with structure/function
      • Activity and disability – what does stroke prevent you doing; hemiparesis causes you to have a disability that prevents you from doing your normal tasks
      • Participation – in physical, attitudinal and social environment of life
        • Ie: money, jobs, social circumstances, living
    • Unique to every patient

Rehabilitation team – multidisciplinary

  • Medical (doctor)
    • Deal with compliance and education + prevention of secondary problems, watch blood pressure
      • Eg: prevention of another stroke, BP, prevent DVTs, risk factor advice
    • Lead and take responsibility for the team
  • Nurses
    • Bowel and bladder function
      • Avoid retention/constipation
      • Need to avoid urinary catheters as much as possible – risk of HAIs
    • Skincare
      • Patients need 4 hourly turning to prevent pressure sores
    • Provide emotional support, 24/7
    • Physiotherapist
    • At the level of impairment they attack what the patient can’t do

      • Sensorimotor problems are attacked using graded exercises
        • 8 weeks after cortical stroke, if there is no recovery of hand movement, patient is likely to always have a weak hand
      • Attempt to improve daily functions – sitting, standing, gait, training
      • Try to reduce and prevent spasms and contractures by stretching and splinting
      • Try to reduce swelling of limbs by the use of pressure garments and elevation
  • Occupational therapist
    • At the level of disability
      • Assess the level of disability
      • Problems – washing, cleaning, eating, dressing, stepping, balance etc ; particularly bathrooms
        • Formal ways to measure all these things
        • Identify ways to help adaptation
        • Allow patients to trial assist devices
          • Look at home and identify safety issues
          • Evaluation whether patient should drive
        • Patient shouldn’t drive if there is visual neglect, poor judgement, dyspraxia and epilepsy
        • Need to consider hand controls, pedals etc.
        • Also can’t do
  • Diversional therapy
    • Leisure activities
      • Important in older, retired people
  • Speech therapy
    • Impairment

      • Assess level of impairment; note that just checking for a gag reflex is not enough. Cough reflex is what protects the airway. Note that you can have a present gag reflex but an absent cough reflex.
        • Dysphagia (swallowing) and dysarthria (forming words - mechanical) – local muscle power and coordination
          • Put in place strategies for swallowing/eating safely

        • Ie: food texture modification, position of head
          • Language and communication problems
        • Therapy
    • 2 years of speech improvemenet
  • Nutritionist
    • Nasogastric tube if cannot swallow early on; use a PEG tube only beyond 4-6/52
    • Food/diet, risk factors
    • Expert advice and aim to get weight down to ideal, if obesity is an issue – confounding issue with mobility problems. Also, falling if you’re fat is a problem.
  • Psychologist
    • Diagnosis and treatment of depression
    • Train patient to deliberately scan to remove hemianopia
    • Psychological intervention +/- antidepressants (SSRIs) is helpful
    • If the person is not depressed after a stroke, they may have parietal lobe dysfunction (e.g. don’t understand extent of stroke)
  • Social workers
    • Ongoing follow up in day-care groups
    • Evaluate
      • Carers/family support/finance; Roof over head, money in pocket
      • Home situation
    • Counselling for patients/carers 
Increasing independence
    • Setting goals, realistic – re-evaluated each week; measure the goals
    • These review sessions are used to measure progress
    • Involves the family and carers
    • 90% of recovery occurs in the first 3 months, then it’s like an asymptotic curve (never back to normal)

Leaving hospital

  • Need to assess mobility/self-care
  • Should have a family meeting/discussion about issues + future
  • Home visit to check the environment
    • May have a ‘trial leave’ over the weekend
  • Perhaps consider a nursing care facility if necessary
  • 
Community support at home
    • Home nursing
    • Home care
    • Day care
    • Meals on wheels


Notes

  • Acute care is up to 7 days
    • In patient rehab can last for 15-40 days (average 23)
    • Day hospital follow up can go on for 6 months
    • The real work is done in rehabilitation