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CDHB

Stroke Classification/Causes

Infarction (85%):

• Oxfordshire clinical classification of stroke type:
  • TACI: Total anterior circulation infarction syndrome (hemiplegia+ hemianopia+ dysphasia/ neglect).
  • PACI: Partial anterior circulation infarction syndrome.
  • LACI: Lacunar infarction syndrome.
  • POCI: Posterior circulation infarction syndrome.

  All patients admitted to the ASU should have an Oxfordshire classification documented.

• TOAST* classification of stroke aetiology:
  • "Large artery" thrombosis or embolism: e.g., ICA stenosis or aortic arch atheroma (common), MCA stenosis (uncommon).
  • Cardioembolic: atrial fibrillation is the most common cause.
  • Small vessel (lacunar): common in hypertension and diabetes.
  • Other, e.g.:
    • Carotid or vertebral artery dissection - consider in younger patients, especially if retro-orbital or neck pain.
    • Cerebral venous sinus thrombosis - see below.
  • Unknown

  *TOAST = Trial of Org 10172 in Acute Stroke Treatment. Adams et al. Stroke. 1993; 24:35-41.

Intracerebral Haemorrhage (ICH) (15%):

• Deep ICH: Usually caused by hypertension. Can be associated with vascular abnormalities in young (<45y) patients, or those with no history or evidence of hypertension.
• Lobar ICH: Hypertension, amyloid angiopathy (elderly), AVM, aneurysm, cerebral venous sinus thrombosis.
• Also consider:
  • Coagulation disorders (including warfarin, dabigatran, and LMWH use).
  • Haemorrhagic infarction (e.g., cerebral venous sinus thrombosis).
  • Contusion (trauma).

Subarachnoid Haemorrhage (SAH)

• These patients should be admitted to the Neurosurgical ward, not ASU. Refer to Subarachnoid Haemorrhage.

Cerebral Venous Sinus Thrombosis (CVT)

• Uncommon but important to recognize and treat. Diagnosis is often delayed and usually requires MRI with magnetic resonance venography (MRV) to detect.
• Clinical presentation is broad:
  • Headache and haemorrhagic infarction are usually present.
  • Onset may be abrupt, progressive, or step-wise.
  • Papilloedema may be present.
  • Seizures can occur.
• Consider CVT in the differential diagnosis of ICH, especially temporal lobe ICH (lateral sinus thrombosis) or "atypical" ICH.
• Treatment is anticoagulation with heparin, even when haemorrhage is present. Neurological consultation is essential.

Topic Code: 1504