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S Louw Rapid, comprehensive neurological assessment to exclude stroke

By Sara Woods,2014-04-14 16:31
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S Louw Rapid, comprehensive neurological assessment to exclude stroke

    Rapid, comprehensive neurological assessment to exclude stroke

Do Observe Write

    Confront: test both upper and Level of cooperation and “Visual fields N all 4 Qs, no then lower visual fields concentration neglect”

    simultaneously Absence of visual field defect

    or visual neglect rdththFollow my finger: move Absence of 3, 4 or 6 “FROEM; no diploplia; no through all 4 quadrants; do cranial nerve paresis; nystagmus”

    you see double anywhere Absence of nystagmus.

    If diploplia, check if it is

    monocular (which is refractive,

    not neurological) thTouch face in all 3 divisions of If abnormal sensation, check if “N 5th5 Nerve: ask: “does it feel the there is a strict midline same on both sides” demarcation or other non-

    anatomical distribution. ththAsk pt to UMN or LMN 7 palsy “N 7

    Horner’s? “PEARL” ; raise eyebrows

    Pupil size and response to ; close eyes tightly

    light (screw them up)

    ; show me your teeth

    ; blow up your cheeks

    Say “West Register Street” Listen for dysarthria “No dysarthria” Say golf and guinea

    Speech: notice if there is any Observe word finding difficulty; “No dysphasia” word finding difficulty in difficulty in following

    conversation; commands.

    Specific test: can you name If concerns about

    some spotted animals; can comprehension: 3-stage paper

    you name as many mammals test: Take this in your right as you can think of (time for 1 hand, fold it in two and put it minute: Normal is >12) on the floor”.

    Hold your arms out in front of Any drift “Normal posture; no drift” you please, palms up; now

    close your eyes

    Grip my fingers with both Any weakness “No weakness of grip, triceps

    hands; now push me away; and biceps”

    now pull me towards you. Do

    both arms simultaneously.

    “I am going to touch your left Touch both. N sensation; no neglect. or right or both hands please

    tell me which I touch.”

    Keep your leg bent, but lift it Any asymmetrical weakness “No weakness of hip flexors or

    off the floor; now keep your not explained by arthritis. quads”

    leg straight, don’t let me bend

    it.” [Do legs separately.]

    Please tap your wrist in a Dysdiadochokinesis “No DDDK”

    rhythmical way [demonstrate -

    do both hands separately].

    Please put your finger on my Intention tremor, dysmetria. “No dysmetria or i/t.” finger, then on your nose. Do

    both sides separately.

    Please can you walk in a Any stumbling, ataxia; smooth “Normal gait” straight line; now try a heel-toe turning; using synkinetic arm walk. swing. Note elderly usually

    cannot walk heel-toe.

    NB: Do not give aspirin if any of the above is abnormal, i.e. if it is not a TIA.

    Transient Ischaemic Attack

WHAT IS IT?

    TIA is medical emergency characterised by a sudden onset of focal neurological symptoms and signs resolving rapidly (average of 15 minutes, most < 1 hour), including : -

    o Unilateral weakness or sensory loss in face or limb(s).

    o Speech disturbance.

    o Unilateral visual loss.-

    N. B. : Even if the patient is improving, symptoms and signs have to be completely resolved to

    diagnose TIA. If not resolved patient should be admitted, regardless of mildness of persisting deficit, as the diagnosis may be stroke. Anyone with a focal neurological deficit of abrupt onset presenting to the Accident and Emergency department should be considered to have had a stroke unless complete resolution occurs within 1 hour.

    Loss of consciousness, pre-syncope and isolated dizziness are rarely due to TIA and should have a senior medical review before referral to the stroke service. All diabetics should have BM done.

WHAT DO I DO?

    High risk patients (who have a stroke risk of > 5% in 48 hours) should be referred urgently, and are defined by:

    o Symptoms within the last week AND

    o ABCD2 score of ? 4

    Age? 60 years 1 point

    Blood pressure ? 140/90 1 point

    Clinical features

     Focal weakness 2 points

     Speech disturbance (and no motor weakness) 1 point

     Sensory or visual features only 0 points

    Duration

     ?60 minutes 2 points

     10-59 minutes 1 point

     <10 minutes 0 points

    Diabetes 1 point

    o OR more than one episode in last week

    o All other patients with likely TIA should be referred on the same day for outpatient review in

    the TIA clinic and investigation within a week. Fax referral form overleaf to nearest TIA

    clinic. Please include a clear description of the neurological deficit, vascular risk factors, and

    ECG if possible. Please include the patient’s contact (telephone) details.

WHAT TESTS ARE NEEDED ?

    o ECG at the time is very helpful to detect AF and signs of recent ischaemia. o FBC, ESR, U & Es, LFTs, blood glucose, cholesterol and HDL,. Clotting is not required

    (unless on Warfarin).

WHAT TREATMENT IS NEEDED ?

    o Give 300 mg loading dose of aspirin. Start or continue antiplatelet treatment with aspirin

    75mg. If there has been previous GI bleeding on aspirin, then aspirin plus a PPI is less likely

    to cause a rebleed than Clopidogrel alone. Only if there is genuine allergy to aspirin should

    Clopidogrel 75 mg be used. Do not combine Clopidogrel with aspirin.

    o Patients with classic TIA on warfarin should simply continue Warfarin if their INR was not

    outside their therapeutic range. Patients in AF without warfarin do not require admission for

    anticoagulation unless they meet the admission criteria given above.

    o We will counsel re lifestyle changes and address the issue of statins and Dipyridamole at the

    TIA clinic.

WHAT DO I TELL THE PATIENT ?

    o Patients with high immediate risk of stroke should receive appointment for outpatient

    assessment within 24 hours (Newcastle) or attend A and E immediately for admission (North

    Tyneside).

    o Patients at lower risk will get an outpatient appointment soon (average clinic delay is < 1

    week) and may be contacted by phone to arrange this.

    o They should re-attend A&E if in the meantime they have a further event. o Notify patients that DVLA rules state no one may drive within a month of TIA or stroke, but

    the patient does not need to inform the DVLA at this stage.

    TIA REFERRAL FORM NORTH OF TYNE

    Your name: Date:

Patient details: Address:

    Name:

    DOB:

Patient Contact Telephone numbers:

    (home):

    (mobile):

    TIMING

    When did event (first) occur? Date:

    How many times since? Number:

    When did the last event occur? Date:

    Date of first contact with health services re these TIAs Date: ABCD 2 RISK SCORE and clinical details

    Score Further description of features

    Age ? 60 years 1

    BP ? 140/90 1 / mmHg

    Weakness 2 (face/arm/leg? which side?)

    Speech 1

    disturbance

    Other features 0 (sensory and if so face/arm/leg, which side? visual? ataxia?)

     Clinical Features during episode (score only once) Duration ? 60 mins 2 (best estimate of duration)

    10-59 mins 1

    <10 mins 0

    History of 1

    diabetes

    TOTAL SCORE

    FURTHER RELEVENT INFORMATION (on history of episodes, comorbidities, past medical history etc)

    IF REFERRAL IS TO NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST Refer to Emergency Care with this form for immediate admission if event in last week AND score ? 4 OR >1 event in last week.

    If score <4, please fax the completed form to (0191) 293 2793 (Dr Curless secretary, NTGH) or (01670) 529 183 (Dr Huntley secretary, WGH) or (01434) 655 680 (Dr Wright secretary, HGH) IF REFERRAL IS TO NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST For high risk cases score ?4 please phone Neurology Day Unit (0191 2825011) to arrange urgent

    outpatient appointment whilst the patient is still with you and fax form to (0191) 282 4370. For low risk cases please fax form to 0191 282 4370

Post the original copy plus a cover note if you wish to add further information and ECG if possible

At weekends, please contact on call stroke team with high risk referrals.

Form to be filed in patient’s hospital medical records 1

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