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Assessment Tools in Stroke

F.A.S.T.

(Or Cincinnati stroke score)

Glasgow Coma Scale


Most widely used neurological assessment tool. Originally designed for traumatic brain injury patients. Limited to: eye opening/motor response/verbal response Scores 3-15 with <7 signifying significant level of consciousness dysfunction

Oxfordshire Stroke Classification


Useful at bedside to predict: outcomes function mortality risk of recurrence. Classify patient from clinical pattern at time of maximal deficit following event.

TACI: Total Anterior Circulation Infarct. (dysphasia/dyscalculia/visuospatial disorder), homonymous visual field/ipsilateral motor and/or sensory deficit of at least two areas- face arm or leg. PACI: two of the three components of TACI. LACI: pure motor/pure sensory/sensory-motor, or ataxic hemiparesis. POCI: cerebellar/brainstem a wide range of components

Oxfordshire (Bamford)

The Bamford Classification of Stroke: (Bamford et al; Lancet 1991; 337:1521-6)


For first stroke. Assess at point of maximum impairment. Why classify? Stroke heterogeneous. Natural history very different. dependency death recurrence Stroke treatment and trials of treatment direct therapies at subgroups Why this classification? simple easy (relatively) widely applicable esp for narrow therapeutic time window/community based studies Alternative classification: by size and site of infarct (commonly used).

Bamford acronyms S =stroke TACS TACH TACI

H haemorrhage PACS PACH PACI

I infarct LACS LACH LACI POCS POCH POCI

Total Anterior Circulation Infarct (TACI) 20% of strokes/would benefit from thrombolysis/thrombotic Partial Anterior Circulation Infarct (PACI) 35% of strokes/occluded branches of the MCA/mostly embolic. Lacunar Infarct (LACI) 20% of stroke/often silent and under diagnosed/need MRI/HTN bleeds/embolic. Posterior Circulation Infarcts (POCI) 25% of stroke/brainstem, cerebellar or occipital lobes/complex presentations/thrombosis embolism.
TACI 40% 55 5 60 35 5 PACI 5 40 55 15 30 55 LACI 5 30 65 10 30 60 POCI 5 30 65 20 20 60

30 days

1 year

Dead Dependent Independent Dead Dependent Independent

ABCD A = Age > or = 60yrs B = BP 1 point

> or = 140/90 1 point

C = Clinical findings: unilateral weakness = 2 pts Speech impairment = 1 pt (with no weakness) D = Duration > 60 mins = 2 points 10-59 mins = 1 point D = Diabetes = 1 point Tool Interpretation: > 4 High risk < or = 4 Low risk

Maximum score 7

FIM
Functional Independence Measure Only used by us as a baseline for rehabilitation. Becoming more popular

We dont use:
NIHSS too lengthy/training reqd Intracerebral Haemorrhage score mainly around mortality scores in intraparenchymal ICBs. Barthel very broad disability measure of 10 items. Rankin 8 items

My own personal:
Coma/LOC Pupillary disturbances Cheyne-Stokes respirations Paralysis of conjugate gaze Continence Dysphagia

= poor outcome

The End

Assessment tools in the rehab & community setting


Anna Reed CNS- Older Persons Health & Rehabilitation Wairarapa DHB

Functional Independence Measure (FIM)


Consistent data collection Measures rehabilitation outcomes Used across a continuum of care Tracks changes in functional & cognitive status Assesses degree of disability & burden of care

Depression, apathy & mood disorders in stroke


Strong relationship between post-stroke depression & functional or cognitive impairment Structured interviews Geriatric depression scale Hamilton rating scale for depression 0-6months MinD 6months + MDD

Impact of stroke on family/carers


Assessment of caregiver needs is often neglected by health professionals Caregiver Needs & Concerns Checklist MDT approach to support the transition
Formal Informal Semi formal

References
Bakas, T., Austin, J., Okonkwo, K., Lewis, R. & Chadwick, L. (2002) Needs concerns, strategies and advice of stroke caregivers in the first 6 months after stroke. Journal of Neuroscience Nursing, 34(5) 245. Chumney, D.,Nollinger, K., Sheska, K.et al. The Ability of the Functional Independence Measure to accurately predict functional outcome of a stroke specific population: a systematic review. Journal of Rehabilitation Research and Development. 47, (1). 17-30 NollingerWwww.rehab.research.va.gov/jour/10/471/pdf/chumney.pdf Stroke Recovery and Rehabilitation (2009). Joel Stein et al (eds). New York; DemosMedical Publishing Stroke Foundation of New Zealand. Clinical Guidelines for Stroke Management. (2010) (Consultation Draft) Wellington. New Zealand