NEUROLOGY AND STROKE

ACUTE ISCHAEMIC STROKE

Introduction

5 min

Introduce yourself and the group

Provide rationale for the session and relevance to clinical practice

Outline learning objectives:

Demonstrate focused history taking from (+/- examination) of patient presenting with symptoms suggestive of an ischaemic stroke or TIA
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 role of MDT approach to ongoing stroke management

Explain structure of session

Total time:

60 min

Number of students:

1-5

Grade of students:

3rd to 5th year medical students

Created by:

Dr Daniel O'Neill

Uploaded:

20th September 2019

Last updated:

20th September 2019

Resources needed for this session:

Students can scan the QR code opposite to view all investigation results on their phone as you work through the session.

Resources linked to this session:

Activity 1: History Taking

10 min

Ask student(s) to take a focused history from a patient presenting with stroke or TIA symptoms, to include past medical history, drug history, family history and social history with a key focus on occupation, previous level of functioning and activities of daily living.

Activity 2: Examination

5 min

If appropriate, ask students to perform an NIHSS score (focused neurological examination) on the patient. Record their score on a local proforma or online calculator using the QR code opposite. Note to perform this assessment, they could consider doing the online training course.

Activity 3: Diagnostic Reasoning

10 min

Ask students to present they key features of the case and suggest a few differential diagnoses. Feedback on presentation style (max 1 minute).

Discuss with students:

What are some causes of these symptoms that are not caused by stroke? Discuss stroke mimics.
What investigations would you request for this patient to confirm the diagnosis of stroke?
What investigations would be useful to rule out alternative diagnoses and assess for risk factors of stroke?

Activity 4: Initial Imaging

15 min

Ask students to review the CT head from the patient they have seen. If there is no CT head available for the patient, use the example opposite. Students can scan the QR code to view the images on their phone if required.

Discuss with students:

What are the key abnormalities seen on this CT scan? Describe in basic terms and suggest cerebrovascular territories.
What is the appearance of haemorrhagic stroke on CT?
What is the appearance of ischaemic stroke on CT?
If the CT would normal would this change your diagnosis and plan?
When might other imaging modalities indicated?

Activity 5: Basic Management

5 min

Ask students to find local/hospital acute stroke guidelines. Considering the patient they have just seen, ask them to suggest:

What are the key acute management steps?
Would thrombolysis have been an option for this patient?
Discuss thrombolysis.
- When is thrombolysis indicated?
- What other considerations are important when assessing possible thrombolysis candidates?
- What are the contraindications to thrombolysis?
Briefly discuss thrombectomy.

Activity 6: Stroke Classification

5 min

Ask students to research the Bamford/Oxford stroke classification. Using this method, ask them to classify the stroke syndrome this patient had, if appropriate.

Discuss with students the implications for prognosis, based on stroke syndrome.

Activity 7: Further Management

5 min

Discuss the following:

Where should the ongoing management of stroke patients take place?
What are the complications of stroke? Consider short and long term?
Who makes up the stroke multidisciplinary team?
Which team members might be most important in your patient’s rehabilitation?
Considering the risk factors and aetiology of stroke what further investigations would be useful e.g. ambulatory cardiac monitoring, carotid dopplers
Discuss secondary prevention strategies e.g. anticoagulation for AF, blood pressure, cholesterol