Good Hope, Heartlands, and Solihull Eye Clinics

Strokes in the eye clinic

David Kinshuck

TIA

Transient ischaemic attacks recover in minutes. Transient motor symptoms or visual loss, with a differential diagnosis of migraine. TIAs don't cause syncope/fainting.

Stroke (CVA = cerebrovascular accident)

A sudden neurological problem lasting longer than a few minutes may be a stroke.

 

'FAST'

Symptoms include reduced movement of feeling in the face, arms (or legs), or speech, happening quickly (time)..'FAST'.

Beware other problems

But often such symptoms are due to other problems such as being unwell, seizures, migraine, alcohol, dementia, or tumours. There are 3 false positives per CVA

Urgent

The new treatment for strokes include thrombolysis and thrombectomy for thrombotic strokes, and these have to be started as soon as possible, certainly less then 6 hours. They may be considered if the neurological problem lasts more than 30 minutes.

Examination

  • refer to stroke unit
  • need immediate CT scanning
  • Look for atrial fibrillation
  • Vascular imaging for younger patients 
  • Carotid dissection common in younger patients 
  • Patent foramen ovale in younger patients 

Treatment includes

  • Clopidrogel exclusively life long 
  • Aggressive blood pressure control even if intravenous... especially in a menorrhagic CVA
  • Intermittent pneumatic stockings
  • Lots of statins
  • Thrombolysis..alteplase for an ischaemic CVA, moderate severity CVA up to 4.5 hours
  • But often patients wake up in the morning with the CVA. For treatment, we have to know when the CVA began and it must be less than 4.5 hours
  • Within. 1 hour is best
  • 2/3 have minimal benefit
  • no aspirin until CT scan..may be a heamorrhagic stroke.

Thrombectomy 

  • pull clot out, usually embolic clot in relatively normal vessel 
  • Dramatic response 50%,
  • to be eligible for  a thrombectomy, the CVA
    • must be within 6 hours,
    • patients must be able to lie flat 1 hour,
    • can use if using anticoagulants,
    • can use in recent surgery or if pregnant 
  • Can get eye problems from injection, swollen eyes, CRAO

AF = Atrial fibrillation

  • this is an irregular heart beat
  • Causes 2O% of CVAs
  • the fibrillation is often due to fibrosis in heart
  • investigations include and echocardiograph and TSH (thyroid hormone test)
  • Annual risk CVA 'chadsvasc' risk
  • Very low risk no anticoagulation, all others
  • All men and nearly all women if in AF need anticoagulation
  • Related to age : Over 65, hypertension, heart failure, TIAs, CVAs, diabetes
  • Aspirin no role in AF
  • 1/3 of people have no symptoms from the AF
  • older patients benefit the most from anticoagulation

Warfarin

  • hair can fall out
  • needs blood tests regularly
  • some patients have a stable INR, but in other patients the INR fluctuates
  • Broccoli and some greens, alcohol interact with the warfarin
  • Home monitoring, can help some people
  • Warfarin only works if INR  2-3#
  • Not ideal in some countries, worse if INR not controlled, bleed brain.
  • Serious bleeds occur
  • Minor bleeds common, 5%
  • Older people more risk of bleeding
  • Aspirin not safer then warfarin >75y
  • warfarin best for metallic valve, mitral stenosis, and if needs ablation as it can be reversed quickly
  • warfarin OK if INR stable


NOACs = Novel oral anticoagulants  

  • These are new drug
  • they cannot be reversed with vitamin K
  • No blood tests are needed
  • There are fewer drug interactions than warfarin
  • There is less intracrainial bleeding (a Sixth!)
  • here may be may be more intestinal bleeding 
  • They wear off in 24h, but are difficult to reverse
  • No anticoag..gi bleeds, can put device in atrial appendix 
  • No difference to prognosis getting pt in normal rhythm, resting rate 70, control rate only for symptoms,
  • But higher rates still reasonably well tolerated
  • Treat heart failure
  • Can start AF treatment in emergency setting .

Pulmonary artery ablation

  • Ablate for symptoms only
  • No aspirin 
  • Cardioverted repeatedly no good
  • Takes 90 mins
  • risky
  • 1/20 serious risk, and does not make you live longer, but it does help symptoms

Other treatments

  • Amioderone..lung liver skin thyroid liver, risks outweigh use for most

 

Anticoagulation and surgery

  • Cataract surgery continue controlled anticoagulation 
  • accept risk
  • High risk ask haematologist
  • Defer surgery 
  • AFG : Nearly all af can stop and operate
  • But mechanical valves, eg lmw heparin  1 week before
  • Noacs: Low risk stop 1 day before, and restart 1 day after , but some surgeons (eg lid surgery) need to stop for longer
  • platelets generally need >50
  • History of bleeding, no reason, refer to haematology 
  • bleeding problems
    • may be due to liver, kidney disease, inherited 
    • Previous surgery, heavy period, epistaxis, detailed medication history
    • Bleeding assessment tool..18 pages...!
    • Fbc, lft, renal, aptt, pt, fibrinogen