Neurology
Question 13 of 300
A 75 year old lady is brought to the Emergency Department with acute onset weakness of her left side which began about 2 hours previously. She is alert but with marked weakness affecting the left face and arm associated with slurred speech. What is her ROSIER score?
Answer:
- For people who are admitted to the emergency department with a suspected stroke or TIA, establish the diagnosis rapidly using a validated tool, such as ROSIER (Recognition of Stroke in the Emergency Room).
- ROSIER score (≥ 1 = stroke possible):
- Loss of consciousness or syncope? (- 1 point)
- Seizure activity? (- 1 point)
- Asymmetric facial weakness? (+ 1 point)
- Asymmetric arm weakness? (+ 1 point)
- Asymmetric leg weakness? (+ 1 point)
- Speech disturbance? (+ 1 point)
- Visual field defect? (+ 1 point)
Stroke
Neurology
Last Updated: 27th April 2023
Stroke is a clinical syndrome characterised by sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death.
Causes
- Ischaemic stroke (85% of strokes):
- Neurological dysfunction due to ischaemia and death of brain, spinal cord, or retinal tissue following vascular occlusion or stenosis.
- Ischaemic strokes occur when large arteries (such as the extracranial carotid or vertebral arteries), intracranial arteries or small penetrating arteries (lacunar) are occluded by:
- Thrombus, often as a complication of atherosclerosis or
- Embolus of fatty material from an atherosclerotic plaque or a clot in a larger artery or the heart, often as a complication of atrial fibrillation or atherosclerosis of the carotid arteries)
- Haemorrhagic stroke (15% of strokes):
- Neurological dysfunction caused by a focal collection of blood from rupture of a blood vessel within the brain (intracerebral haemorrhagic stroke) or between the surface of the brain and the arachnoid tissues covering the brain (subarachnoid haemorrhagic stroke).
- Intracerebral haemorrhage is bleeding within the brain parenchyma or ventricular system. The main cause of intracerebral haemorrhage is high blood pressure.
- Subarachnoid haemorrhage is bleeding into the subarachnoid space from a cerebral blood vessel, aneurysm or vascular malformation. The source of bleeding is an intracranial aneurysm in approximately 85% of people, a non-aneurysmal peri-mesencephalic haemorrhage in 10% of people and other vascular abnormalities (including arteriovenous malformation) in 5% of people.
- Rarer causes of stroke:
- Cerebral venous thrombosis — more likely in patients with a prothrombotic tendency, for example, related to pregnancy, infection, dehydration or malignancy.
- Carotid artery dissection — tends to occur in younger people and may be preceded by neck trauma.
Risk factors
Risk factors for stroke and TIA include:
- Lifestyle factors associated with cardiovascular disease such as:
- Smoking
- Alcohol misuse and drug abuse (for example cocaine, methamphetamine)
- Physical inactivity
- Poor diet
- Established cardiovascular disease such as:
- Hypertension
- Permanent and paroxysmal atrial fibrillation (AF)
- Infective endocarditis
- Valvular disease
- Carotid artery disease
- Congestive heart failure
- Congenital or structural heart disease including patent foramen ovale
- Other factors such as:
- Age — the risk of having a stroke doubles every decade after the age of 55.
- Gender — Men are more likely than women to have a stroke at younger age. In women, an increased risk of stroke has been associated with current use of oral contraceptives, migraine with aura, the immediate postpartum period, and pre-eclampsia.
- Hyperlipidemia
- Diabetes mellitus
- Sickle cell disease
- Antiphospholipid syndrome and other hypercoagulable disorders
- Chronic kidney disease
- Obstructive sleep apnoea (OSA)
Clinical features
Suspect stroke if:
- The person presents with sudden onset, focal neurological deficit which is ongoing or has persisted for longer than 24 hours and cannot be explained by another condition such as hypoglycaemia. The clinical features of stroke vary depending on causative mechanism and the area of the brain affected and may include:
- Confusion, altered level of consciousness and coma.
- Headache – sudden, severe and unusual headache which may be associated with neck stiffness. Sentinel headache(s) may occur in the preceding weeks.
- Weakness − sudden loss of strength in the face or limbs.
- Sensory loss – paraesthesia or numbness.
- Speech problems such as dysarthria.
- Visual problems – visual loss or diplopia.
- Dizziness, vertigo or loss of balance.
- Nausea and/or vomiting.
- Specific cranial nerve deficits such as unilateral tongue weakness or Horner’s syndrome (miosis, ptosis, and facial anhidrosis).
- Difficulty with fine motor coordination and gait.
- Neck or facial pain (associated with arterial dissection).
Posterior circulation strokes may be difficult to diagnose and should be suspected if the person presents with:
- Symptoms of acute vestibular syndrome — acute, persistent, continuous vertigo or dizziness with nystagmus, nausea or vomiting, head motion intolerance, and new gait unsteadiness.
Differential diagnosis
Many conditions (sometimes known as stroke mimics) can present with similar clinical features to stroke and TIA. These include:
- Toxic/metabolic disturbance such as:
- Hypoglycaemia
- Drug and alcohol toxicity
- Conditions which can cause dizziness or disturbed balance such as:
- Syncope
- Peripheral vestibular disturbance — vertigo or dizziness
- Neurological conditions such as:
- Seizure
- Migraine with aura
- Demyelination
- Peripheral neuropathies such as Bell’s palsy
- Spinal epidural haematoma
- Trauma
- Systemic or local infection including:
- Central nervous system abscess, meningitis and encephalitis
- Encephalopathies such as hypertensive encephalopathy or Wernicke’s encephalopathy.
- Space occupying lesions including:
- Tumour, subdural haematoma
- Other conditions such as:
- Acute confusional state
- Dementia
- Vasculitis
- Somatoform or conversion disorder
Assessment
- Exclude hypoglycaemia in people with sudden onset of neurological symptoms as the cause of these symptoms.
- For people who are admitted to the emergency department with a suspected stroke or TIA, establish the diagnosis rapidly using a validated tool, such as ROSIER (Recognition of Stroke in the Emergency Room).
- ROSIER score (≥ 1 = stroke possible):
- Loss of consciousness or syncope? (- 1 point)
- Seizure activity? (- 1 point)
- Asymmetric facial weakness? (+ 1 point)
- Asymmetric arm weakness? (+ 1 point)
- Asymmetric leg weakness? (+ 1 point)
- Speech disturbance? (+ 1 point)
- Visual field defect? (+ 1 point)
- Perform brain imaging immediately with a non-enhanced CT for people with suspected acute stroke if any of the following apply:
- indications for thrombolysis or thrombectomy
- on anticoagulant treatment
- a known bleeding tendency
- a depressed level of consciousness (Glasgow Coma Score below 13)
- unexplained progressive or fluctuating symptoms
- papilloedema, neck stiffness or fever
- severe headache at onset of stroke symptoms.
- Perform scanning as soon as possible and within 24 hours of symptom onset in everyone with suspected acute stroke without indications for immediate brain imaging.
Management
- Thrombolysis with alteplase for people with acute ischaemic stroke
- Alteplase is recommended within its marketing authorisation for treating acute ischaemic stroke in adults if:
- treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms and
- intracranial haemorrhage has been excluded by appropriate imaging techniques
- Staff in emergency departments, if appropriately trained and supported, can administer alteplase for the treatment of ischaemic stroke provided that patients can be managed within an acute stroke service with appropriate neuroradiological and stroke physician support.
- Ensure that protocols are in place for delivering and managing intravenous thrombolysis, including post-thrombolysis complications.
- Alteplase is recommended within its marketing authorisation for treating acute ischaemic stroke in adults if:
- Thrombectomy for people with acute ischaemic stroke
- Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if not contraindicated and within the licensed time window), to people who have:
- acute ischaemic stroke and
- confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
- Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
- who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
- if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
- Consider thrombectomy together with intravenous thrombolysis (where not contraindicated and within the licensed time window) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes):
- who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and
- if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
- Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if not contraindicated and within the licensed time window), to people who have:
- Aspirin and anticoagulant treatment
- Acute ischaemic stroke
- Offer aspirin 300 mg as soon as possible, but certainly within 24 hours, to everyone presenting with acute stroke who has had a diagnosis of intracerebral haemorrhage excluded by brain imaging.
- Continue aspirin daily 300 mg until 2 weeks after the onset of stroke symptoms, at which time start definitive long-term antithrombotic treatment. Start people on long-term treatment earlier if they are being discharged before 2 weeks.
- Offer a proton pump inhibitor, in addition to aspirin, to anyone with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is reported.
- Offer an alternative antiplatelet agent to anyone with acute ischaemic stroke who is allergic to or genuinely intolerant of aspirin.
- Acute venous stroke
- Offer people diagnosed with cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage) full-dose anticoagulation treatment (initially full-dose heparin and then warfarin [international normalised ratio 2 to 3]) unless there are comorbidities that preclude its use.
- Stroke associated with arterial dissection
- Offer either anticoagulants or antiplatelet agents to people who have stroke secondary to acute arterial dissection.
- Haemorrhagic stroke
- Return clotting levels to normal as soon as possible in people with a primary intracerebral haemorrhage who were receiving warfarin before their stroke (and have elevated international normalised ratio). Do this by reversing the effects of the warfarin using a combination of prothrombin complex concentrate and intravenous vitamin K.
- Acute ischaemic stroke
- Surgery
- Acute intracerebral haemorrhage
- People with intracerebral haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary.
- Previously fit people should be considered for surgical intervention following primary intracerebral haemorrhage if they have hydrocephalus.
- People with any of the following rarely require surgical intervention and should receive medical treatment initially:
- small deep haemorrhages
- lobar haemorrhage without either hydrocephalus or rapid neurological deterioration
- a large haemorrhage and significant comorbidities before the stroke
- a score on the Glasgow Coma Scale of below 8 unless this is because of hydrocephalus
- posterior fossa haemorrhage
- Acute intracerebral haemorrhage
- General principles
- Supplemental oxygen
- Give supplemental oxygen to people who have had a stroke only if their oxygen saturation drops below 95%. The routine use of supplemental oxygen is not recommended in people with acute stroke who are not hypoxic.
- Blood sugar control
- Maintain a blood glucose concentration between 4 and 11 mmol/litre in people with acute stroke.
- Blood pressure control for people with acute intracerebral haemorrhage
- Offer rapid blood pressure lowering to people with acute intracerebral haemorrhage who do not have any of the exclusions listed below and who present within 6 hours of symptom onset and have a systolic blood pressure between 150 and 220 mmHg. Aim for a systolic blood pressure target of 130 to 140 mmHg within 1 hour of starting treatment and maintain this blood pressure for at least 7 days.
- Consider rapid blood pressure lowering for people with acute intracerebral haemorrhage who do not have any of the exclusions listed below and who present beyond 6 hours of symptom onset or have a systolic blood pressure greater than 220 mmHg. Aim for a systolic blood pressure target of 130 to 140 mmHg within 1 hour of starting treatment and maintain this blood pressure for at least 7 days.
- Do not offer rapid blood pressure lowering to people who:
- have an underlying structural cause (for example, tumour, arteriovenous malformation or aneurysm)
- have a score on the Glasgow Coma Scale of below 6
- are going to have early neurosurgery to evacuate the haematoma
- have a massive haematoma with a poor expected prognosis.
- Blood pressure control for people with acute ischaemic stroke
- Anti-hypertensive treatment in people with acute ischaemic stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues:
- hypertensive encephalopathy
- hypertensive nephropathy
- hypertensive cardiac failure/myocardial infarction
- aortic dissection
- pre-eclampsia/eclampsia
- Blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for intravenous thrombolysis.
- Anti-hypertensive treatment in people with acute ischaemic stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues:
- Assessment of swallowing function
- On admission, ensure that people with acute stroke have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication.
- Oral nutritional supplementation
- Screen all hospital inpatients on admission for malnutrition and the risk of malnutrition. Repeat screening weekly for inpatients.
- Hydration
- Assess, on admission, the hydration of everyone with acute stroke. Review hydration regularly and manage it so that normal hydration is maintained.
- Supplemental oxygen
Complications
- Short-term complications
- Haemorrhagic transformation of ischaemic stroke
- Cerebral oedema
- Seizures
- Venous thromboembolism
- Cardiac complications
- Infection — people with stroke are at increased risk of infection including aspiration pneumonia, urinary tract infection, and cellulitis from infected pressure sores
- Long-term complications
- Mobility problems
- Sensory problems
- Continence problems
- Pain
- Fatigue
- Problems with swallowing, hydration and nutrition
- Sexual dysfunction
- Skin problems
- Visual problems
- Cognitive problems
- Difficulties with activities of daily living (ADL)
- Emotional and psychological problems
- Communication problems
- Financial problems
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
