STROKE
STROKE
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ACUTE ISCHAEMIC STROKE
ACUTE ISCHAEMIC STROKE
ABOUT THIS SESSION
ABOUT THIS SESSION
This is a self-directed learning resource designed to be worked through in the clinical environment.
Learning objectives:
Learning objectives:
Demonstrate focused history taking from of patient presenting with symptoms suggestive of an ischaemic stroke or TIA
Understand the role of the NIHSS score for examination of patients presenting with acute stroke
Recognise key presenting symptoms and signs of acute stroke and suggest key differential diagnoses
Suggest and interpret key investigations in the diagnosis of stroke
Understand the immediate management of stroke, including thrombolysis (including an awareness of thrombectomy)
Understand the longer-term management of stroke patients and role of the MDT in ongoing stroke management
Total time:
60 minsNumber of students:
1-2Grade of students:
3rd to 5th year medical studentsCreated by:
Dr Grace Swann and Dr Charlotte HaydenUploaded:
28th August 2020Last updated:
28th August 2020Resources needed for this session:
Resources needed for this session:
Patient, pen, paper, neurological examination kit
Resources linked to this session:
Resources linked to this session:
none
Activity 1: History Taking and Examination
20 minActivity 1: History Taking and Examination
Take a focused history from a patient presenting with a stroke or TIA to include past medical history, drug history, family history and social history.
You may want to have a read over the Geeky Medics guide to stroke history taking beforehand.
Perform a focused neurological examination on the patient. Try to get a doctor to observe you and give feedback if possible. If you are unsure how best to focus the examination use the NIHSS tool as a framework.
Activity 2: Documentation and Diagnostic Reasoning
10 minActivity 2: Documentation and Diagnostic Reasoning
Document your findings in a systematic manner. You may want to use a local clerking proforma or have a look at this useful summary from Geeky Medics.
Write down 3-5 key differential diagnoses, with the most likely at the top. From this list, suggest one or two key features from the history and/or examination that makes each more and less likely.
Consider:
What conditions may mimic an acute stroke?
How should these conditions be ruled out?
What initial investigations are indicated in acute stroke?
What are you expecting them to show?
Review the patient's notes.
Which of the tests you suggested has the patient had since admission?
What did they show?
You can calculate the patient's NIHSS score here.
Has the patient's NIHSS score changed since admission?
What is the role of the NIHSS score in stroke assessment and ongoing management?
Activity 3: Radiology
10 minActivity 3: Radiology
Review the patient's CT head from admission. If there is no CT head available for the patient, use the examples opposite.
Consider:
What are the key abnormalities seen on these CT scans? Describe the abnormal area in terms of the area of the brain affected and the blood vessels that supply the area.
How might a haemorrhagic stroke appear on CT?
How might an ischaemic stroke appear on CT?
If the CT would normal would this change your diagnosis and plan?
What other imaging modalities might be considered?
When might these be indicated?
Activity 4: Initial Management
5 minActivity 4: Initial Management
Find your hospital's local acute stroke guidelines. Considering the patient you have seen:
How should this patient be managed acutely?
Would thrombolysis be (or have been) an option for this patient?
Considering thrombolysis:
When is thrombolysis indicated?
What other considerations are important when assessing possible thrombolysis candidates?
What are the contraindications to thrombolysis?
Consider thrombectomy:
What is thrombectomy?
When is thrombectomy considered?
Is thrombectomy offered in your hospital? If not, why not? Where is the nearest local service?
Activity 5: Classification of Stroke
5 minActivity 5: Classification of Stroke
What classification system(s) for acute ischaemic stroke have you come across?
Look up the Bamford/Oxford stroke classification.
Using this method, what classification of stroke has the patient you have seen presented with?
What classification of stroke has the patient above had?
What symptoms would you expect to see in this patient?
What implications does the stroke classification have for prognosis - morbidity and mortality?
Activity 6: Management
10 minActivity 6: Management
Consider:
Where should the ongoing management of stroke patients take place?
What are the complications of stroke? Try and categorise these into short and long term complications.
Who makes up the stroke multidisciplinary team? Which team members might be most important in your patient’s rehabilitation? How would the multidisciplinary team manage an unsafe swallow following a stroke?
Considering the risk factors and aetiology of stroke what further investigations would be useful?
What management would need to be considered to ensure secondary prevention? Consider cardiovascular risk factors - how should each of these be addressed?
What is used as venous thromboembolism prophylaxis in patients following ischaemic stroke?
Summary and Feedback
5 minSummary and Feedback
Highlight three key things you have learned today. Summarise them on a post-it note and keep it somewhere you will find in a week or two.
Found this useful? Please leave some feedback.
References and Further Reading
References and Further Reading
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