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☆
Fig.55.1DrugtherapyoptionsinParkinson’sdisease.
Surgicalmanagement
DeepbrainstimulationmaybeconsideredinadvancedPDwhereoptimalmedicaltherapy hasfailedtoadequatelycontrolsymptoms.
Psychosocialconsiderations
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Give family members and carers information about the condition and direct them to support services.Includeinformationaboutthe differenttypesofimpulse controldisorders,e.g.reckless behavioursandhypersexuality DriverswithPDmustinformtheDVLAoftheircondition(seeChapter115).Iftheyhavedaytime sleepiness,theymustnotdrive Where appropriate,offer patients andtheir family members/carers oral andwritten information aboutthefollowing,anddocumentthediscussion:
LikelyprogressionofPD
Advancecare planning, includingAdvance Decisionsto Refuse Treatment(ADRT) andDo
NotAttemptCardiopulmonaryResuscitation(DNACPR)orders,andlastingpowerofattorney
forfinanceorhealth.
Complications
Seekspecialistadviceregardingthemanagementofthefollowingcomplications:
Daytimesleepiness:considermodafinilifreversiblecauseshavebeenexcluded Rapideyemovementsleepbehaviourdisorder Nocturnalakinesia:considerlevodopaordopaminergicagonists Orthostatic hypotension: review antihypertensives, dopaminergics, anticholinergics, and antidepressants.Considermidodrine,orfludrocortisoneifmidodrineiscontraindicated Depression(seeChapter38) Psychoticsymptoms(hallucinationsanddelusions):considerreducingthedosagesofcontributing PDdrugs.Considerstartingquetiapineorclozapine PDdementia:consideracholinesteraseinhibitor,ormemantineifcontraindicated Droolingofsaliva:refertospeechandlanguagetherapy.Ifunsuccessful,considerglycopyrronium bromide Impulsecontroldisorders.
Monitoringandfollow-up
Regularreviewsevery6–12months ConsideralternativediagnosesifatypicalfeaturesdevelopsuchasParkinson’splussyndromes Assessforimpulsecontroldisorderdevelopmentateachreview Ensurethepatient/familyhaveaccesstoareliablesourceofinformation,e.g.specialistnurse ConsiderreferringpatientsatanystageofPDtothepalliativecareteam.
1 UK Parkinson’s Disease Society Brain bank diagnostic criteria. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK379754/
2OPTIMALcalculator—veryuseful forconvertingpatients’medicationstoavoidmisseddoses, e.g.if
theyarenilbymouthduringanacuteadmission.Availableat:http://www.parkinsonscalculator.com/
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Chapter56
Strokeandtransientischaemicattack
Guideline:NICENG128(Strokeandtransientischaemicattackinover16s:
diagnosisandinitialmanagement):https://www.nice.org.uk/guidance/ng128
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
A stroke is defined as a rapid-onset, focal neurologicaldeficit due to a vascular lesion lasting>24hours.Ifthedeficitlasts<24hours,thisistermedatransientischaemicattack (TIA). Patients with a stroke present with focal neurological deficit which can be classifiedintodifferentsyndromes(Table56.1).
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Table56.1Bamford/Oxfordclassificationofstroke
Syndrome Definitions
Totalanteriorcirculationstroke(TACS) Allthreeof:
Unilateralweakness±sensorydeficit Homonymoushemianopia Highercorticaldysfunction,i.e.dysphasia,dyspraxia,orneglect
Partialanteriorcirculationstroke(PACS) TwoofthreeofTACScriteria
Lacunarsyndrome(LACS) Purehemimotororsensoryloss,orboth,orataxichemiparesis
Posteriorcirculationsyndrome(POCS) Oneof:
Cranialnervepalsyandacontralateralmotororsensorydeficit Bilateralmotororsensorydeficit Conjugateeyemovementdisorder Cerebellardysfunction(ataxia,nystagmus,vertigo,incoordination) Isolatedhomonymoushemianopiaorcorticalblindness
Diagnosis
History
Takeafocusedhistoryincludingthetimeofonsetandtypeofneurologicaldefect.Check if the patient takes anticoagulation or antiplatelettherapy and consider risk factors, i.e. smoking, diabetes, hypertension, hyperlipidaemia, AF, prosthetic valves, bleeding or thrombotictendencies,andvasculitis.
UseatoolsuchastheRecognitionofStrokeintheEmergencyRoom(ROSIER)scale.
Strokeislikelyifscore>0(Table56.2).
Table56.2ROSIER1scaleforrecognitionofstroke
Lossofconsciousnessorsyncope –1
Seizureactivity –1
New,acuteonset(ornewonwaking)asymmetricfacialweakness +1
New,acuteonset(ornewonwaking)asymmetricarmweakness +1
New,acuteonset(ornewonwaking)asymmetriclegweakness +1
New,acuteonset(ornewonwaking)speechdisturbance +1
New,acuteonset(ornewonwaking)visualfielddefect +1
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Be aware of, and rule out, stroke mimics including hypoglycaemia, head injury, epilepsy (Todd’sparesis),space-occupyinglesion,drugoverdoseandcentralnervoussysteminfection.
Examination
SystemicallyexaminethepatientusinganABCDEassessment(Table56.3).
Table56.3ClinicalsignsintheABCDEassessmentofapatientwithstrokeorTIA
A AirwaymaybecompromisedifGCSscoreissignificantly↓
B ↓airentryduetoaspirationpneumonia
C Hypertension(mayhavecaused,orbecausedbystroke)
AF Prostheticheartvalves Carotidbruit(carotidarterystenosis)
D ReducedGCSscore
Hypoglycaemia(strokemimic)
E Papilloedema(↑intracranialpressure)
Bruisingorbleeding(secondarytoinjury) Systematicneurologicalexaminationtohelplocalizetheareaofinfarct
The National Institutes of Health Stroke Scale (NIHSS) should be used to assess
neurologicaldeficitandstrokeseverity.Fulldetailscanbeaccessedonline.
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ThedeficitsassessedforintheNIHSSare:
Levelofconsciousness Eyegazeabnormality Visualfields Presenceoffacialpalsy Upperlimbmotor Lowerlimbmotor Presenceofataxia Sensorydeficit Language Presenceofdysarthria Presenceofinattention(neglect).
Investigations
Bedside
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Routineobservations:includingbloodpressureandheartrate Electrocardiogram:AForsignsofischaemicheartdisease Point-of-careglucose.
Bloods
FBC U&E LFT Glucose Lipidprofile Coagulationprofile Consideradditionalbloodsin‘youngstroke’patients(Box56.1).
Box56.1‘Youngstroke’bloods
Inyoungstrokepatients,lookforstrokeriskfactorsonbloodssuchaspolycythaemia, thrombocytopenia, ↑ CRP or ESR (vasculitis), HIV, syphilis, deranged coagulation profile(thrombophiliascreen),andderangedrenalfunction(vasculitis).
Imaging
CT head: to identify an intracranial haemorrhage or an established infarct. Should be doneimmediatelyifacuteonset,persistentneurologicalsymptoms,and:
Thrombolysisorthrombectomywouldpotentiallybeindicated(seebelow) Onanticoagulationorknownbleedingtendency GCSscore<13 Unexplainedprogressiveorfluctuatingsymptoms Papilloedema,neckstiffness,orfever Severeheadacheatonset.
Ifthepatientdoesnothaveoneoftheindicationsabove,theyshouldstillhaveaCThead within24hours.
CT contrast angiography ± CT perfusion imaging: if thrombectomy is indicated (NIHSS>5,andthepatienthasagoodpremorbidfunction,i.e.aModifiedRankinScale score<3).
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MRI brain: usually performed to assess the posterior fossa due to posterior stroke symptoms,indiagnosticuncertainty,orinTIAsafterspecialistassessment.
Other
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Carotidimaging(Dopplerultrasound,CTangiography,ormagneticresonanceangiography):
to identify carotid artery stenosis if the patient is considered a candidate for carotid endarterectomy
Holtermonitoring/eventrecorder:toinvestigateforparoxysmalAF Echocardiogram:toruleoutanemboliccauseofstroke.
Management
Acutemanagement
Generalmeasures
UseanABCDEapproachtoensurethatthereisasafeairway,adequateoxygenationand ventilation,effectivecirculation,andreversibledisabilitiesarecorrected.
Stroke
ContactaseniormemberofstaffandtheacutestroketeamandarrangeforanurgentCThead Thrombolysis(Box56.2)foracuteischaemicstrokeisindicatedif:
Within4.5hoursofstrokeonsetAND
Intracranialhaemorrhagehasbeenexcluded Antiplatelet therapy: aspirin 300mg (route: PO/nasogastric/rectal depending on swallow assessment)immediatelyonceintracerebralhaemorrhagehasbeenexcluded,unlessthrombolysis hasbeengiven(withholduntilaCTscanat24hourshasexcludedanyhaemorrhage).Aspirinis continuedfor2weeksafterstrokeonsetandswitchedtolong-termantithrombotictreatmentafter, e.g.clopidogrel75mgOD Prothrombincomplex concentrateandvitamin Kifhaemorrhagicstrokeandthe patienttakes warfarin.DiscusswithhaematologyifbeingtreatedwithaDOAC Admittoaspecialistacutestrokeunit.
Suspectedorconfirmedtransientischaemicattack
Offeraspirin(300mgdaily)immediatelyunlesscontraindicated ReferanysuspectedTIAforspecialistassessmentandinvestigationtobeseenwithin24hoursof symptomonset Offersecondarypreventionassoonaspossibleafterthediagnosisisconfirmed CTheadisnotrequiredunlessthereisaclinicalsuspicionofanalternativediagnosis.
Box56.2Importantconsiderationsinthrombolysis
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Thrombolysis must only be administered by staff trained in delivering thrombolysis and monitoringforanycomplications Theagentusedforthrombolysisistissueplasminogenactivator(tPa),e.g.alteplase Suspectintracranialbleedingfollowingthrombolysisifthereisneurologicaldeterioration,new headache, reduction in GCS score, acute hypertension, seizure, nausea, or vomiting. If haemorrhagictransformationissuspectedduringthrombolysis,stopthetPainfusion,arrangean urgentrepeatCTscan,andcontactaseniorclinicianimmediately Followlocalhospitalprotocols.
Bloodpressurecontrolinstroke
Acuteischaemicstroke
Thrombolysiscandidate:bloodpressurereductionto≤185/110mmHgshouldbeconsidered Otherwise,antihypertensivemedicationsinacutestrokeareonlyrecommendedifthereis:
Hypertensiveencephalopathy,nephropathy,cardiacfailure,ormyocardialinfarction
Aorticdissection
Pre-eclampsiaoreclampsia.
Acuteintracerebralhaemorrhage
Offerrapid blood pressure control tothosewhopresentwithin6 hoursof symptomonsetAND haveasystolicbloodpressureof150–220mmHg. Considerrapidbloodpressurecontrolinthosewhopresentbeyond6hoursofsymptomonsetOR haveasystolicbloodpressure>220mmHg Aimforasystolicbloodpressuretargetof130–140mmHgwithin1hourofstartingtreatmentand maintainthisbloodpressureforatleast7days Donotrapidlylowerthebloodpressureinpeoplewithanunderlyingstructuralcause,GCSscore <6,awaiting early neurosurgicalintervention toevacuatea haematoma, or who have a massive haematomawithpoorexpectedprognosis.
Treatmentafterstabilization
Nutrition
Assessswallowassoonaspossiblebytrainedstaff.Ifswallowisimpaired,refertospeechand languagetherapyandconsiderinsertinganasogastrictubefornutrition,fluids,andmedications Ifanasogastrictubeisnottolerated,considertryinganasalbridletubeorgastrostomy ScreenthepatientformalnutritionusingtheMalnutritionUniversalScreeningTool(MUST).
Remember to review the patient’s medications and change the formulation or route if necessary.
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Multidisciplinaryteamassessment
This includes a specialistteam of nurses, physiotherapists, occupational therapists, speech and languagetherapists,dieticians,andstrokephysicians Patientsshouldbeassistedoutofbedassoonasitissafeforthemtodoso.
Managementofriskfactors
Carotid stenosis: consider carotid endarterectomyinpeople with acute non-disabling strokeor TIA who have symptomatic carotid stenosis of 50–99% according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, or 70–99% according to the EuropeanCarotidSurgeryTrial(ECST)criteria
Cardiovascularriskfactors4:
Dietandlifestyleadvice
Controlofbloodpressure—aimforbloodpressure<130/80mmHg
Antiplatelettherapy,e.g.clopidogrel75mgOD
Cholesterol-loweringdrugs,e.g.atorvastatin40–80mgatnight
AF:considerstartinganticoagulation2weekspoststroke.
Specialconsiderations
Thrombectomy
Thisisofferedinsome centres alongsidethrombolysis.If thrombectomyisindicated, a CTcontrastangiographyshouldfollowtheinitialnon-enhancedCTtoconfirmocclusion oftheproximalanteriorcirculationorbasilarartery.Patientswithstrokesymptomswho were last known to be well up to 24 hours previously can be considered for thrombectomywithappropriatespecialistimaging.
Prostheticheartvalve
If thepatienthas aprostheticheartvalveandanacutedisablingstroke whichis athigh risk of haemorrhagictransformation, they should stop their anticoagulation foraweek, andbemanagedduringthistimewith300mgaspirindaily.
Cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage)
Full-dose anticoagulation treatment (initially with LMWH, then warfarin) should be offered.
https://t.me/med1917
Furtherreading
1.RoyalCollegeofPhysicians(2016).Nationalclinicalguidelineforstroke,fifthedition.Availableat:
https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines
1Nor AM,Davis J, SenB, Shipsey D,LouwSJ,Dyker AG,Davis M,Ford GA.TheRecognitionof
StrokeintheEmergencyRoom(ROSIER)scale:developmentandvalidationofa strokerecognition instrument.LancetNeurology2005,4(11):727–34.
2NIHSS.Availableat:https://www.stroke.nih.gov/resources/scale.htm
3vanSwieten,J.C.,Koudstaal,P.J.,Visser,M.C.,Schouten,H.J.,&vanGijn,J.(1988).Interobserver
agreement for the assessment of handicap in stroke patients. Stroke, 19(5), 604–607.
https://doi.org/10.1161/01.str.19.5.604.
4RoyalCollegeofPhysicians.Nationalclinical guidelinefor stroke,fifth edition.2016. Available at:
https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines
https://t.me/med1917
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