14 - Stroke 2 Flashcards
In terms of sensory information, what is the role of the thalamus?
It relays information from the DCML and spinothalamic fibres to the post-central gyrus of the parietal lobe.
How might a thalamic infarct present?
PURE SENSORY STROKE
Contralateral loss of all sensory modalities
What are the 4 Oxfordshire community stroke project classifications of lacunar syndromes?
1) TACS - total anterior
2) PACS - partial anterior
3) POCS - posterior
4) LACS - lacunar
What is a TACS, and what are the clinical features?
Total Anterior Circulation Syndrome:
- Hemiparesis +
- Higher cortical dysfunction ie neglect/dysphasia +
- Homonymous hemianopia
What blood vessels are usually affected to cause a TACS?
- Internal carotid artery OR
- Proximal MCA
What is the most common cause of a TACS?
Cardiac emboli due to AF
What is a PACS, and what are the clinical features?
Partial Anterior Circulation Syndrome:
Isolated higher cortical dysfunction OR 2 of: - Hemiparesis - Higher cortical dysfunction - Hemianopia
Which blood vessel is usually affected to cause a PACS?
Branch of MCA
What is the most common cause of a PACS?
Large vessel disease
What is a POCS, and what are the clinical features?
Posterior Circulation Syndrome
- Isolated hemianopia OR - Brainstem signs OR - Cerebellar signs
Occlusion of which blood vessels can result in a POCS?
- Vertebral artery
- Basilar artery
- Cerebellar arteries
- PCA
What is a LACS, and what are the clinical features?
Lacunar Syndrome
- Pure motor stroke OR
- Pure sensory stroke OR
- Sensorimotor stroke OR
- Ataxic hemiparesis OR
- Clumsy-hand dysarthria
If you suspect a stroke, what is the first imaging that should be done, and why?
Non-contrast CT head
- Exclude haemorrhage to allow thrombolytic therapy if ischaemic stroke
- Exclude stroke mimics ie tumour
- Fast, inexpensive, readily available
What may be seen on an immediate CT head following an ischaemic stoke?
Hyperdense segment of vessel due to thrombus/embolus
What imaging modality is most specific and sensitive for the diagnosis of ischaemic stroke?
MRI head
What is the goal of CT perfusion imaging following ischaemic stroke?
- Identifies patients for reperfusion therapy
- Accurate diagnosis of ischaemic stroke
What is the goal of CT angiography imaging following a stroke?
- Identifies thrombus and may guide intra-arterial thrombolysis or clot retrieval
- Evaluate carotid and vertebral arteries to investigate stoke aetiology
What are some stroke differentials?
- Hypoglycaemia
- Epilepsy
- Migraine
- Intracranial tumour
- Intracranial infection
- Sepsis
- Syncope
- Dementia
- Bell’s palsy
What bloods would you order when managing ischaemic stroke?
- FBC
- U&Es
- INR
- Glucose
- LFTs
- TFTs
If no contraindications, thrombolysis should be administered within what time frame following ischaemic stroke?
< 4.5 hrs, ensuring haemorhagic stroke has been excluded
What are the 6 major contraindications of thrombolysis?
- Major recent haemorrhage
- Active peptic ulcer
- Recent trauma/surgery
- Hx of cerebral haemorrhage
- Coagulation defects
- Uncontrolled hypertension
If patient is receiving thrombolysis post-ischaemic stroke, when should aspirin be commenced, at what dose for how long?
24hrs after symptoms started, 300mg PO OD for 14 days
What investigations might you do after an ischaemic stroke to investigate the cause?
- ECG
- ECHO or 24hr tape
- HbA1c
- Cholesterol
- Autoimmune screen
- Doppler
- CT angiography
What medications are commonly given as long term prophylaxis after an ischaemic stroke?
- Clopidogrel 75mg PO OD
- Atorvastatin
What are the common causes of haemorrhage stroke?
- Hypertensive + anticoagulation
- Hypertensive + vascular abnormality ie aneurysm
- Hypertensive + tumour
- Cerebral amyloid angiopathy (Alzheimer’s)
- Drugs (cocaine/amphetamines)
- Thrombocytopenia
If a patient on Warfarin has had a haemorrhage stroke, what can you do to minimise the bleed?
Reverse warfarin:
- IV vit K 10mg + Prothrombin complex concentrate 50units/kg
Which DOAC can be reversed and what is the name of the reversal agent?
Dabigatran
Reversal agent = Idarucizumab IV 5mg bolus
