Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

4.5. Neurology and SS > 11. Stroke medicine > Flashcards

11. Stroke medicine Flashcards

1
Q

What is a TIA?

A

Transient ischaemic attack are focal neurological deficits lasting <24hrs

ABCD2 score predicts short term risk of a stroke after a TIA (>=4 - higher risk)
- age, BP, clinical features, DM, duration of symptoms

RF = AF, HTN, anti-coag, obesity, FH, smoking/alcohol, DM

Suspected TIA

  • Aspirin 300mg daily
  • Carotid doppler
  • CT/MRI head - only if abnormal findings on exam

Mx

  • lifestyle = smoking cessation, alcohol <14U/w
  • optimise comorbidities = DM, OSA, HF
  • control HTN = aim <130, bendroflumethiazide, amlodipine (CCB), ACEi
  • NO AF = clopidogrel 75mg OD
  • AF = warfarin (dose adjusted)
  • atorvastatin 20-80mg
  • surgical intervention for carotid artery disease

Do not offer COCP, consider progesterone only or non-hormonal

Do not drive for a month - licence invalid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Define stroke

A

Syndrome, focal disturbance of cerebral function, rapidly developing, lasting >24h, no apparent cause other than vascular origin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the aetiology of a stroke?

A

Ischemic (80%)

  • Thrombotic (vessel wall, flow, clot)
  • Embolic
    • large vessel disease
    • cardioembolic
    • small vessel disease

Haemorrhage (15%) - intracerebral, subarachnoid

  • HTN - basal ganglia bleed
  • Cerebral amyloid angiopathy - corticomedullary bleed
  • Tumour
  • AVM
  • Anticoag-associated (warfarin, heparin aspirin, alcohol, chemo)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Outline the OCSP classification for stroke

A

Total anterior circulation stroke (TACS) = hemiparesis, hemisensory loss, hemianopia, higher cortical dysfunction

  • worse prognosis
  • usually cardiac emboli

Partial anterior circulation stoke (PACS) = 2 of the above or higher cortical dysfunction only
- usually large vessel disease (carotids)

Lacunar stroke (LAC) = pure motor, pure sensory 
- usually small vessel disease (atheroma)

Posterior circulation stroke (POCS) = posterior circulation event
- can be anything

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What tools can be used to assess a stroke?

A

FAST = face, arms, speech, time

ROSIER = to distinguish between stroke and stroke mimic

NIHSS (NIH stroke scale) = evaluates neurological status, scores on levels of consciousness, language, neglect, visual field loss, extra ocular movement, motor strength, ataxia, dysarthria, sensory loss

  • > 8: large vessel
  • > 10 malignant oedema MCA (CTa)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Outline a stroke from the anterior cerebral artery

A

Supplies = Medial brain, paracentral lobules (micturition), corpus callosum

Motor/sensory = lower limb

Present = contralateral, flaccid paralysis followed by spasticity (UMN signs), loss of all sensory, loss of voluntary control of micturition, split brain syndrome, alien hand syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Outline a stroke from the middle cerebral artery

A

Supplies = superior temporal, lateral aspect of frontal/parietal

Motor/sensory = face, upper limb

Present = contralateral, flaccid paralysis followed by spasticity (UMN signs), loss of all sensory in upper limb and face

Proximal occlusion = face/arm motor, internal capsule carrying motor fibres of face/arms/legs

Distal occlusion = face arms motor

Visual = proximal: contralateral homonymous hemianopia, distal: contralateral homonymous superior or inferior quadrantanopia

Dominant side (L) = Speech: global aphagia, brocas aphasia

Non dominant (R) = hemispatial neglect, tactile extinction, visual extinction, anosognosia, wernickes aphasia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Outline a stoke from the posterior cerebral artery

A

Supplies = occipital, inferior temporal, midbrain, thalamus

Present = contralateral homonymous hemianopia with macular sparing (supply by PCA + MCA), visual agnosia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Outline a stoke from the cerebellar artery

A

Supplies = cerebellum, brainstem

Present = distal: DANISH (Dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia), proximal: brainstem as well, ipsilateral cranial N signs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Outline a stroke from the basilar artery

A

Supplies = occipital lobe, midbrain, thalamus

Present = distal : bilateral, proximal: locked in syndrome
loss of blood supply to pons

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Outline a stroke from the lenticulostriate artery

A

Supplies = internal capsule (posterior: limbs, genu: face), basal ganglia

Present = contralateral paralysis of face and limbs, parkinsonian features

PURE MOTOR

(Lacuna infarcts)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Outline a stroke from the thalamoperforator artery

A

Supplies = thalamus (relay station for sensory before primary sensory cortex)

Present = contralateral sensory loss of face and limbs

PURE SENSORY

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How should stroke be Ix?

A

CT head - if acute ASAP

  • early ischaemic signs: hypoattenuation, sulcal effacement, obscuration and loss of gray matter, hyperattenuating vessel
  • haemorrhagic: white area, midline shift, twisted ventricle, intracranial herniation

ECG + CXR (as standard)

CT perfusion: CBF (cerebral blood flow), CBV (cerebral blood volume)

MRI - if longer history 2-3h, if suspected stroke in posterior fossa, or brainstem involvement

Bloods = FBC, U+Es, LFTs, ESR, CRP, glucose, cholesterol, clotting

ECG - or 24h tape

ECHO - valvular assessment, vegetation

Entire circulation/carotid doppler

INR

EEG

CSF - presence on blood in subarachnoid haemorrhage

Serum protein electrophoresis

AutoAb screen

Urine analysis - pheochromocytoma (catecholamines)

Cerebral angiography

Haemostatic profile

Toxicology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Outline the Mx of an ischaemic stroke

A

Check if ischemic or haemorrhagic - CT head ASAP

Aspirin 300mg orally or rectally (continue for 14d)

Alteplase within 4.5hrs

  • Contraindications = previous intracranial haemorrhage, seizure at onset of stroke, intracranial neoplasm, active bleeding, pregnancy, INR >1.7
  • CHADS-VASC 2 - determine if anticoag is suitable for pt with AF and are at risk of stroke

Avoid correct of HTN - unless related comp

Carotid endarterectomy

Mechanical thrombectomy (can perform up to 24h, LVO, NIHSS >5)

Sec prevention = clopidogrel, aspirin, statin, anti-HTN (aim <130), anticoag (HAS-BLED score before starting warfarin/DOAC, INR target 2.5), smoking cessation, diet/exercise with rehab, GP follow up, screen for sleep apnoea, Mx co-morbidities, carotid endarterectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Outline the Mx of a haemorrhagic stroke

A

Stop antcoag

Consult neurosurgeon

Decompressive craniotomy - RICP

Coil embolisation/aneurysm clipping

Neurosurgery for clot reduction

Shunt insertion (hydrocephalus)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

List the possible complications of a stroke

A

Cerebral = herniation (RICP sec to oedema), haemorrhagic transformation, acute hydrocephalus, seizure, SIADH, depression

Systemic = infection, fever, VTE, pressure sores, muscle wasting, remaining focal neurology, swallowing difficulties - aspiration

17
Q

What are the RF for stroke?

A

Global = age, DM, HTN, hypercholesterolemia
- FH: familial hypercholesterolaemia, thrombophilia

Lifestyle = smoking, cocaine, OCP, HRT

Cardiac = AF, PFO, endocarditis, IHD, MI

Periphery = carotid stenosis, dissection

Cerebral = malformation, berry aneurysms

Bleed = anti-coag, thrombophilia, sickle cell, warfarin, hypercoagulable state

18
Q

What factors can be addressed and how, in stroke rehab?

A

Aphasia/dysarthria (30%) = SALT

Impaired swallow = alternative fluids, swallow assessment, NG tube, dietitian, gastrostomy

Hydration/nutrition (25%) = dietitian for advice and monitoring, NG tube

Balance/walking(80%) = OT, PT, mobility aids, balance training, functional task-specific training, lower limb strengthening exercises

Fatigue = assess for mental/physical factors that may be contributing

Continence = timed toileting, review caffeine intake, med review, bladder re-training, pelvic floor exercises, minimise constipation, oral laxatives

Spasticity/contractures (25%) = positioning, passive movement, pain control, IM botulinum, baclofen

Sensation (80%) = trained how to avoid injury

Mouth care = mouth care at least TDS

Cognitive impairment = devel compensatory behaviours, learning adaptive skills, neuropsychologist assessment

Anxiety/depression(25-30%) = in social interaction, in exercise, psychosocial education groups

Neuropathic pain (20%) = neuropathic pain relief

Shoulder pain (20%) = positioning, weight supported, analgesia, localised joint injection

19
Q

Outline secondary prevention measures for stroke

A

1) Lifestyle modification
- smoking cessation
- weight <25 BMI
- avoid heavy alcohol intake
- diet: low fat/salt/sugar, high fibre
- 3-5 x 30m aerobic exercise per week

2) Antithrombotic therapy
- clopidogrel, aspirin-dipyridamole, aspirin
- AF: warfarin (heart valve), DOAC (heart valve: apixaban, dabigatran, rivaroxaban)

3) RF modification
- lifestyle interventions
- patient involvement

4) Address any specific causes
- HTN: target 130/80, ACD approach
- hyperchol: target <4, LDL <2, atorvastatin
- DM: target HbA1c <6.5%
- carotid atherosclerosis: >50% stenosis, surgery
- AF Mx

20
Q

Give a list of stroke mimics

A
  • SAH
  • SDH
  • Venous infarcts
  • Malignancy: primary/secondary (SOL)
  • MS flare
  • Venous sinus thrombosis
  • Abscesses
  • Hemiplegic migraine
  • Functional hemiparesis
  • BPPV
  • Vestibular neuronitis
  • Transient global amnesia (TGA)
  • Functional neurological syndrome
  • Delirium
  • Seizure
21
Q

List secondary prevention measures for stroke

A

Antithrombotic therapy (antiplatelet vs anticoagulation)

BP control(average BP<130/80)

Lipid control (t. chol<4, LDL chol<2)

Glycaemic control (HbA1c <7)

Carotid endarterectomy (symptomatic ICA >50% lumen reduction NASCET)

Lifestyle changes (smoking cessation, weight loss, optimisation of sleep, exercise)

22
Q

Outline the implications of stroke on a person life

A

BIO = dysphagia, dysarthria, limb weakness, dec mobility, sensory loss, altered vision, incontinence, loss of balance (in falls), joint stiffness, seizures

PSYCHO = depression, emotional lability, guilt, anxiety, poor memory/concentration, loss of identity

SOCIAL = unable to work, role adjustments, financial strain, impact on family/friends, communication difficulties

23
Q

Give a DDx for stroke in a young pt

A

Vasculitis

Cervical dissection (explore Ct disorders)

Drug use = cocaine

Malformations = congenital, AVM

Clotting abnormalities = factor 5 leidon, protein C/S

24
Q

What is capsular warning syndrome

A

Term used to describe recurrent stereotyped lacunar transient ischaemic attacks (TIAs)

Syndrome is associated with a high risk of developing a completed stroke

S+S = repeated sensory and/or motor symptoms affecting at least two of the face, arm and leg, without cortical signs (aphasia, neglect, gaze preference)

25
Q

Outline metabolic syndrome and how it is linked to stroke

A

3/5 = abdominal obesity, high blood pressure, high blood sugar, high serum triglycerides, and low serum high-density lipoprotein (HDL)

Greater risk of getting coronary heart disease, stroke, T2DM, hyperuricemia; fatty liver (especially in concurrent obesity) progressing to nonalcoholic fatty liver disease; PCOS, ED and acanthosis nigricans

26
Q

List some stroke specific outcome measures

A

Barthel = extent Independence with ADLs

Rivermead = mobility performance measure

Nottingham extended = ADL scale

Modified Rankin = degree of disability or dependence

27
Q

List some physical outcome measures used in stroke assessment

A

BERG balance = 14-item scale measuring balance

Timed up and go = measures functional mobility (<10s)

10m walk = assess waking speed M/s

6 min walk = assess distance (>400-700m)

Timed unsupported steady stand = (60s)

5x timed sit to stand = quantify functional lower extremity strength

9 hole peg test = measure finger dexterity

Arm A = measure of passive and active function

Fugl meyer = assess the sensorimotor impairment

28
Q

What tests are used when performing a cognition screen on a stroke pt?

A

MoCA (Montreal cognitive assessment) = >26

OCS (oxford cognitive screen)

Addenbrooke cognitive screen (ACE) = <82 dementia

4.5. Neurology and SS (17 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions