Stroke

Physical Examination

• General Examination

  • The patient might use walking aids indicating mobility issues due to stroke. Presence of a nasogastric tube or percutaneous endoscopic gastrostomy (PEG) tube might suggest swallowing difficulties. The posture could be characterized by flexed upper limbs and extended lower limbs. Affected side might appear wasted or oedematous.

  • The patient's gait should be assessed if they can walk. They may demonstrate a flexed posture in the upper limbs and 'tip toeing' in the lower limbs.

• Motor Examination

  • During the assessment of muscle tone, there could be spastic rigidity, and a 'clasp-knife' phenomenon may be observed, which is initial resistance to passive movement followed by a sudden release. Clonus might be present at the ankles, characterized by rhythmic oscillations (>4 beats).

  • Power in the affected limbs may be reduced, graded according to the Medical Research Council (MRC) scale. It's notable that in stroke, extensor muscles are typically weaker than flexor muscles in the upper limbs, and the opposite is true for the lower limbs.

  • Reflexes might be brisk with an extensor plantar response (Babinski's sign - lower limbs), indicating an upper motor neuron lesion.

• Cerebellar

  • Coordination could be impaired, which could be due to weakness but might also indicate cerebellar involvement, especially in a posterior circulation stroke.

• Sensory

  • May be normal

• Additional Examination

  • Additional signs may include unilateral upper motor neuron facial weakness, which often spares the forehead due to its bilateral innervation.

  • Assess the gag reflex and swallowing to reduce the risk of aspiration.

  • Examination of visual fields and higher cortical functions, such as for neglect.

  • In terms of finding the potential cause of the stroke, the pulse should be checked for irregularities indicative of atrial fibrillation. Blood pressure should be measured, and auscultation should be performed to listen for cardiac murmurs or carotid bruits, which could point towards an anterior circulation stroke.

Investigations

• Immediate CT head: This is used to differentiate between an ischemic infarct and a hemorrhagic stroke. It can also rule out other intracranial causes like a tumour or subdural hematoma and assess for complications such as hydrocephalus.

• Carotid Dopplers: Ultrasound of the carotid arteries can detect significant stenosis or plaque, which could be a source of emboli causing the stroke.

• ECG: An electrocardiogram is performed to look for atrial fibrillation (AF), a common cause of embolic stroke.

• Echo: An echocardiogram, either transthoracic or transesophageal, can identify underlying valvular heart disease, clots, or vegetations that could be sources of emboli.

• Investigations for cardiovascular disease: Lipid profile and fasting glucose/HbA1c can help identify risk factors such as dyslipidemia and diabetes mellitus, respectively, which are associated with vascular disease.

• Baseline Investigations: These include full blood count (FBC), urea and electrolytes (U+E), liver function tests (LFT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and urine dipstick for blood and protein. These tests can help identify other potential contributors to the patient's clinical condition and are part of routine care for hospitalised stroke patients.

Management

• Multidisciplinary Approach: Involvement of a comprehensive team including a neurologist, neurosurgeon, specialist nurse, physiotherapist, and speech and language therapist, among others.

• Initial Assessment: Use the ABCDE approach, excluding hypoglycemia. Initiate appropriate investigations, including blood tests, ECG, and CT head. Involve the stroke or 'brain attack' team.

• Definitive Management for Infarct:

  • Administer thrombolysis with alteplase if, within 4.5 hours of symptom onset, no contraindications such as intracranial haemorrhage (ICH) on CT

  • Admit the patient to a hyperacute stroke unit for multidisciplinary care.

  • Regular neurological observations.

  • Initiate aspirin 300mg orally (or rectally/via enteral tube if dysphagic) along with a proton pump inhibitor (PPI) for 2 weeks, then switch to clopidogrel 75mg orally for life. Note: delay aspirin initiation until 24 hours after thrombolysis.

  • Begin high-dose statin therapy

• General Management:

  • Address immediate needs: airway, breathing, and circulation.

  • Manage hyperthermia, hypertension, hypoglycemia, and hyperglycemia.

  • Ensure fluid and electrolyte balance.

  • Prevent and treat complications.

  • Provide dedicated nursing care.

  • Implement rehabilitation measures.

• Secondary Prevention:

  • Refer for carotid endarterectomy within 1 week if the patient has stable neurological symptoms from an acute non-disabling stroke and has symptomatic carotid stenosis of 50-99%.

  • Initiate anticoagulation after 2 weeks if atrial fibrillation is present.

  • Provide lifestyle advice (e.g. smoking cessation), and control of diabetes, hypertension, and cholesterol.