Stroke

Advanced Diploma in Nursing

School of Health Sciences
Nanyang Polytechnic

Dr Peng Li Lee
Senior Consultant
Emergency Medicine Department, NUH
Course Objectives

1. Describe the 2 major types of stroke

2. Identify the causes of stroke
3. Identify the clinical manifestations of stroke
4. Discuss the investigations and management of stroke in
ED
5. Understand the significance of a transient ischemic attack
(TIA)
introduction
• Stroke is ranked no. _______ as the leading cause of death in Spore
• Stroke is ranked no. _______ as the leading condition for
hospitalizations.
Types & causes of stroke
2 types of strokes
Causes of ischaemic stroke –
#1 thrombotic
CAUSES OF ISCHAEMIC STROKE – #2 EMBOLIC
Difference between thrombotic & embolic:
Clot formed in the brain (thrombotic) vs
from a distant site e.g heart / major neck vessels that float to the brain (embolic)
CAUSES OF HAEMORRHAGIC STROKE

Main causes:

1. Hypertension

2. Arteriovenous
Malformation
(AVM)

3. Aneurysm
A cerebral arteriovenous malformation (AVM) is a disorder of the brain's blood vessels.
It is characterized by an abnormal connection between the arteries and the veins in the
brain.
It is a condition that is present at birth, in less than 1% of people.
There are often no symptoms until complications occur, which often lead to a
hemorrhagic stroke.
Depending on the
location of AVM,
the bleed can be
intracerebral or
subarachnoid or
both.
 • A cerebral (brain) ANERYSM is a bulging or
ballooning out of a part of a blood vessel
wall due to a weak point in the latter’s wall.

• As the aneurysm grows, the vessel wall

becomes thinner and weaker.

• It can become so thin that it spontaneously

leaks or ruptures, releasing blood into the
space around the brain called the
The most common location for
subarachnoid space. This results in a
brain aneurysms is in the network
subarachnoid haemorrhage (SAH).
of blood vessels at the base of
the brain called the Circle of
• Blood can also leak into the cerebrospinal
Willis.
fluid (brain fluid) or into the brain substance
itself, resulting in an intracerebral
haematoma.
AVM = 1%
Revision: Classifications of stroke

Ischaemic Haemorrhagic
Stroke Stroke

T
haemorrhage

E
haemorrhage
Clinical manifestations of stroke
The clinical symptoms and signs depends on the
side, location & size of the lesion and
the amount of collateral blood flow.
Public education: F.A.S.T
NIH Stroke Scale
Clinical assessment tool to evaluate stroke severity (deficit)
Higher the score, the worse the deficit (highest 42) – minor = 4, 16-20 = severe.
Guides treatment
Nurses can do it with training.

https://www.saebo.com/nih-stroke-scale-nihss/
Clinical manifestations of stroke
Can haemorrhagic stroke be differentiated from
ischaemic stroke clinically?
Mr A

• 65 yr old male
• Background hx: DM, Hypt, Hypercholesterolaemia
• Was working in the market as a hawker when he was noted to have
slurred speech and difficulty walking with Rt sided weakness at 9am.
• Brought by ambulance to ED at 9:30am.
• BP 136/96, PR 68, SpO2 99%.
• He was alert and was able to respond appropriately to questions but
speech slurred: denies headache, double vision, nausea or vomiting.
• Neuro exam: Power Rt 2/5, Lt 5/5.
Mr b

• 65 yr old male
• Background hx: DM, Hypt, Hypercholesterolaemia
• Worked as a storekeeper, found by colleagues to be unconscious at
9:15am. He was last seen normal at 9:00am.
• Brought by ambulance to ED at 9:30am.
• BP 200/106, PR 90, SpO2 95%.
• Drowsy E1V3M3 = 7, pupils 4mm equal.
• Neuro exam: Power Rt slide decreased tone & decreased movement.
Ms c

• 45 yr old female
• No past medical history
• C/O of severe headache at work a/w nausea & vomiting.
• Subsequently fainted.
• BP 220/116, PR 90, SpO2 95%.
• Drowsy E1V3M3 = 7, pupils 5mm equal on Rt, 3mm on Lt
• Neuro exam: Decreased tone in both limbs
Clinical manifestations of stroke
Can haemorrhagic stroke be differentiated from
ischaemic stroke clinically?

NO
Stroke mimics

• Hypoglycaemia
• Todd’s paralysis
• Complex Migraine
• Brain tumour
• Cerebral Venous Thrombosis
• Vertebral Artery Dissection
• Conversion Disorder
 Transient ischaemic attack
- tia
A transient ischaemic attack (TIA) or "mini stroke" is caused by a
temporary disruption in the blood supply to part of the brain.
The disruption in blood supply results in a lack of oxygen to the brain.
This can cause sudden symptoms similar to a stroke, such as speech and
visual disturbance, and numbness or weakness in the face, arms and legs.

However, a TIA doesn't last as long as a stroke. The effects often only last
for a few minutes or hours and fully resolve within 24 hours.
Ed investigations &
ED management
of stroke

Approach & Rationale

 #1 separate the ischaemic (infarct) from
haemorrhagic (bleed) stroke

Imaging Ischaemic vs Haemorrhagic



Management Prevent secondary

Reperfusion to
brain damage
is different establish flow
from raised ICP

Neurologist Neurosurgery
#2 infarct – re-establish flow

STEMI (AMI) ISCHAEMIC INFARCT

Thrombolysis Thrombolysis (rTPA)

Percutaneous Coronary Endovascular therapy =

Intervention (PCI) = Mechanical
Coronary angioplasty thrombectomy
(Clot retrieval)

Standard of Care: Standard of Care:

Primary PCI Thrombolysis
 #2 infarct – tHROMBOLYSIS
THROMBOLYSIS FOR ISCHAEMIC STROKE

Cannot be given too late Within 3 hrs (up to 4.5 hrs) of onset
“Time is Brain”
The earlier it is given, the greater the benefit Based on results from studies

Pro: Reduced death & dependency Non-disabled outcome

Cons: Risk of intracranial bleed & early death Overall the death from ICH after thrombolytic is offset
2.4% vs 0.4% control by prevention of death in those with big infarcts & dev
ICH complication / early death
Overall beneficial for disabling deficits Not given if deficits are mild

Not for everyone Any factors that increase risk of bleed:

~ 70% are not eligible On warfarin
Too late (no benefit) Low platelet (<100 k)
Too mild (not worth the risk) Recent surgery (2 weeks)
Too severe infarct seen on CT (too high risk) High BP (185/110)
List of contraindications Seizure with stroke
Evidence of trauma or active bleeding
Too old (70-80 yrs)
Limitations of thrombolysis

Large vessel occlusion: ICA, Basilar artery

High clot burden (>8mm unlikely to
dissolve)
Thrombectomy (Endovascular clot removal)
For patients with acute stroke due to a large vessel occlusion within 6 hrs of onset
#3 Haemorrhagic – Strategies

Aims
Determine the cause of bleed Anerysm – clip / coil
Control the Blood Pressure (BP) Aim < 140 / 90
Prevent haematoma
extension
If on anticoagulant, consider
transfusion of clotting factors
Control pressure within brain Medication: Mannitol
Hyperventilation
Nurse 30 deg head up
Prophylactic anticonvulsant therapy Keppra / Phenytoin
Protect airway (low GCS)
Evacuation of haematoma
#4 BP management in acute stroke

The relationship between hypertension and stroke is dynamic and

multifaceted.

Be it in the context of managing ischemic or hemorrhagic stroke,

selecting an appropriate blood pressure (BP) agent & target values
involves integration of several issues
that must be recognized in order to
formulate an effective strategy for BP control.
#4 BP management in acute stroke
INFARCT
Allow up to BP 220/120 unless pt is
for thrombolysis
Loss of autoregulation in acute
stroke
High BP is a protective mechanism
to drive the flow to the pernumbra
(area next to infarct)
Acute lowering of BP causes the
pernumbra to have lesser blood
flow -> extension of the ischaemia /
infarct
For thrombolytic candidate, high BP
can affect eligibility & delay IV rTPA
target BP < 185/110
BLEED
Generally target BP 140/90
High BP worsens the bleed.
Blood flow to brain is affected by BP
& ICP.
CPP = MAP* – ICP
In raised ICP, you may need a higher
BP to maintain cerebral perfusion
pressure.
Balancing act btw maintaining
cerebral perfusion and adverse
effects due to high BP.
Time benchmarks for potential thrombolytic
candidates – ninds / acls

Door to Needle Time = 60 mins

Hypoglycaemia
Todd’s paralysis
Migraine
Vertebral artery
dissection

STROKE THROMBOLYSIS PROTOCOL

Aim:
Reduce the thrombolytic time for patients with acute ischaemic
stroke who presents within 4 hours of onset.

Door-to-needle time 60 mins.

Hyperacute stroke management in ed

• Make sure it is a stroke, rule out stroke mimics

• Get the CT scans done stat: plain CT & CT-angio (check Cr
level)
• Screen for indications & contraindications for thrombolysis
• Work with Neurologist to decide on thrombolysis
• IV thrombolysis : door to needle time = 60 mins
• Work with Neurosurgeon in haemorrhagic stroke
• Control the blood pressure
• Correct any hypoglycaemia / hyperglycaemia
• Neuro HD / ICU transfer
Discussions & Questions