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ANKI Neuro > [6] Acute Stroke > Flashcards

[6] Acute Stroke Flashcards

1
Q

What is stroke also known as?

A

Cerebrovascular event

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2
Q

What is a stroke?

A

A clinical syndrome caused by disruption to the blood supply of the brain

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3
Q

What is a stroke characterised by?

A

Rapidly developing signs of focal or global disturbance of cerebral functions, lasting for more than 24 hours or leading to death

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4
Q

What is a transient ischaemic attack?

A

A similar presentation that resolves within 24 hours

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5
Q

What are the 2 types of stroke?

A
  • Ischaemic

- Haemorrhagic

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6
Q

Can ischaemic and haemorrhagic strokes be distinguished clinically?

A

Not reliably, but there are pointers

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7
Q

What clinical signs point towards a haemorrhagic stroke?

A
  • Meningism
  • Severe headache
  • Coma within hours
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8
Q

What clinical signs point towards an ischaemic stroke?

A
  • Carotid bruit
  • Atrial fibrillation
  • Past TIA
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9
Q

What happens in ischaemic stroke?

A

There is loss of blood supply to part of the brain

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10
Q

After how long does brain tissue cease to function when deprived of oxygen?

A

60-90 seconds

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11
Q

After how long does brain tissue suffer irreversible injury when deprived of oxygen?

A

After approx 3 hours

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12
Q

How might atherosclerosis be involved in stroke?

A

It can disrupt blood supply by narrowing the lumen of blood vessels, leading to a reduction in blood flow

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13
Q

By what methods can atherosclerosis cause the formation of blood clots?

A
  • Due to the reduction in blood flow

- May release showers of small emboli through the disintegration of atherosclerotic plaques

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14
Q

What is an embolic infarction?

A

When the emboli formed elsewhere in the circulatory system

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15
Q

Where do the emboli typically form in embolic infarction?

A
  • Heart

- Carotid arteries

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16
Q

What can cause embolic infarction originating from the heart?

A

AF

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17
Q

What happens in an embolic infarction?

A

The clots enter the cerebral circulation, then lodge in and block brain blood vessels

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18
Q

What are haemorrhagic stroke classified on the basis of?

A

Their underlying pathologies

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19
Q

Give 5 causes of haemorrhagic strokes

A
  • Hypertensive haemorrhage
  • Ruptured aneurysm
  • Ruptured AV fistula
  • Transformation of prior ischaemic infarction
  • Drug-induced bleeding
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20
Q

How do haemorrhagic strokes result in tissue injury?

A
  • Causing compression of tissue from an expanding haematoma(s)
  • Blood released by brain haemorrhage appears to have direct toxic effects on brain tissue and vasculature
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21
Q

What might result from compression of brain tissue from a haematoma in haemorrhagic stroke?

A

It may lead to loss of blood supply to affected tissue, with resulting infarction

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22
Q

What are the causes of stroke in a younger patient?

A
  • Vasculitis
  • Thrombophilia
  • Subarachnoid haemorrhage
  • Venous sinus thrombosis
  • Carotid artery dissection
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23
Q

What are the causes of stroke in older patients?

A
  • Thrombosis in situ
  • Atherothromboembolism
  • Heart emboli
  • CNS bleed
  • Sudden BP drop
  • Vasculitis
  • Venous sinus thrombosis
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24
Q

What might cause heart emboli leading to stroke?

A
  • Atrial fibrillation
  • Infective endocarditis
  • Myocardial infarction
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25
Q

What might cause a CNS bleed leading to stroke?

A
  • Hypertension
  • Head injury
  • Aneurysm rupture
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26
Q

What sudden BP drop may lead to stroke?

A

More than 40mmHg

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27
Q

Give an example of a type of vasculitis that can lead to stroke

A

Giant cell arteritis

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28
Q

What are the risk factors for stroke?

A
  • Hypertension
  • Smoking
  • Diabetes mellitus
  • Heart disease
  • Peripheral arterial disease
  • Post-TIA
  • Polycythaemia vera
  • Carotid artery occlusion or carotid bruit
  • COCP
  • Hyperlipidaemia
  • Excess alcohol
  • Clotting disorders
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29
Q

What kinds of heart disease increase the risk of stroke?

A
  • Valvular
  • Ischaemic
  • Atrial fibrillation
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30
Q

What can cause a CNS bleed leading to a stroke?

A
  • Hypertension
  • Head injury
  • Aneurysm rupture
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31
Q

What sort of vasculitis can lead to a stroke?

A

Giant cell arteritis

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32
Q

What two ways do strokes typically present?

A
  • Sudden onset

- Step-wise progression of symptoms over hours

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33
Q

What tool can be used to assess sudden onset symptoms that resemble stroke?

A

FAST

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34
Q

What are the steps of FAST tool for stroke symptom assessment?

A
  • Face (weakness or asymmetry)
  • Arm (weakness)
  • Speech (difficulty)
  • Time to call 999
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35
Q

What do the symptoms of stroke depend on?

A

The area of the brain that is affected

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36
Q

What affects the severity and quantity of symptoms of stroke?

A

How extensive the affected area of brain is

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37
Q

What are some possible symptoms of cerebral hemisphere infarct?

A
  • Contralateral hemiplegia
  • Contralateral sensory loss
  • Homonymous hemianopia
  • Dysphasia
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38
Q

How does the contralateral hemiplegia in a cerebral hemisphere stroke progress?

A

Flaccid initially then becomes spastic

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39
Q

What are some possible symptoms of a stroke involving posterior circulation ischaemia?

A
  • Motor deficits in any combination of arms and legs up to quadriplegia
  • ‘Crossed’ syndromes
  • Sensory deficits
  • Homonymous hemianopia
  • Ataxia, imbalance, unsteadiness or disequilibrium
  • Vertigo
  • Diplopia
  • Dysphagia
  • Dysarthria
  • Locked in syndrome
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40
Q

What motor deficits can occur in a posterior circulation ischaemia?

A
  • Weakness
  • Clumsiness
  • Paralysis
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41
Q

What is meant by ‘crossed’ syndromes?

A

Ipsilateral cranial nerve dysfunction and contralateral long motor or sensory tract dysfunction

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42
Q

What sensory deficits can occur as a result of posterior circulation ischaemia?

A

Numbness including loss of sensation or parasthesia in any combination of the extremities

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43
Q

What causes a locked in syndrome?

A

Complete infarction of the pons

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44
Q

What are the features of a locked in syndrome?

A
  • Quadriparesis
  • Loss of speech
  • Preserved awareness and cognition
  • Sometimes preserved eye movements
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45
Q

What are lacunar infarcts?

A

Small infarcts around the basal ganglia, internal capsule, thalamus and pons

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46
Q

What can lacunar infarcts cause?

A
  • Pure motor
  • Pure sensory
  • Mixed signs
  • Ataxia
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47
Q

What is left intact by a lacunar infarct?

A

Cognition/consciousness

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48
Q

What is an important symptom that affects a large proportion of stroke patients?

A

Dysphagia

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49
Q

How is a diagnosis of stroke made?

A

Clinically with imaging to assist

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50
Q

What modes of imaging can be helpful in assessing a patient who has had a stroke?

A
  • CT scan

- MRI scan

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51
Q

What group of stroke patients is a CT scan recommended in?

A

Those in the acute phase of the stroke

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52
Q

Which type of stroke is a CT scan very sensitive in diagnosing?

A

Haemorrhagic stroke in acute stage

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53
Q

How does the appearance of a CT scan progress in a patient with an ischaemic stroke?

A

Often normal at first but improved accuracy after 6 hours

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54
Q

What is an MRI better than a CT scan at assessing in stroke patients?

A

The site and extent of ischaemic damage

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55
Q

What proportion of stroke patients is an MRI contra-indicated in?

A

1/3

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56
Q

What can contra-indicate an MRI scan in a stroke patient?

A
  • Too ill
  • Confusion
  • Pacemaker
  • Other metal
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57
Q

Why may additional studies be needed once a stroke has been diagnosed?

A

To assess the underlying cause of the acute event

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58
Q

What helps to indicate which test may be useful in identifying underlying cause of a stroke?

A
  • Age
  • Comorbidities
  • Presentation
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59
Q

What are some common additional tests used to assess for underlying causes of stroke?

A
  • USS/doppler of carotid arteries
  • ECG and echo
  • Angiogram of cerebral vasculature
  • Blood tests
60
Q

What underlying cause of stroke can be detected by USS of carotid arteries?

A

Carotid artery stenosis

61
Q

What underlying cause of stroke can be detected by ECG and echo?

A

Arrhythmias and resultant clots

62
Q

What underlying cause of stroke can be detected by angiogram of cerebral vasculature?

A

Aneurysms and AV malformation

63
Q

What underlying cause of stroke can be detected by blood tests?

A
  • Hypercholesterolaemia
  • Clotting disorders
  • Other rare conditions
64
Q

What are the differentials for acute stroke?

A
  • Hypoglycaemia
  • TIA
  • CNS tumour
  • Subdural bleed
  • Todd’s palsy
  • Drug overdose
65
Q

When can a TIA be a differential for a stroke?

A

In the first 24 hours of symptoms only

66
Q

What aspects of homeostasis should be restored and/or maintained in all patients with stroke?

A
  • Keeps sats over 95% with O2

- Blood sugar levels

67
Q

What does the specific management of an acute stroke depend on?

A

The kind of stroke

68
Q

What is the aim of definitive therapy for an ischaemic stroke in the first few hours?

A

Removing the blockage

69
Q

How can the vessel blockage be removed in an ischaemic stroke?

A
  • Thrombolysis (breaking it down)

- Thrombectomy (mechanical removal)

70
Q

What drug can be used in thrombolysis?

A

Alteplase

71
Q

What is the main benefit of thrombolysis?

A

It can improve prognosis after the acute stroke

72
Q

What improves the benefits of thrombolysis?

A

The earlier it is given

73
Q

What are the criteria that must be met for thrombolysis to be givne?

A
  • Within 4.5 hours of onset

- Haemorrhage has been excluded

74
Q

What can happen if haemorrhage has not been excluded or thrombolysis is given after 4.5 hours?

A

It can worsen the outcomes

75
Q

What sort of ischaemic stroke is mechanical thrombectomy viable for?

A

Occlusion of large arteries e.g. middle cerebral artery

76
Q

How is mechanical thrombectomy performed?

A

Endovascularly

77
Q

Besides thrombectomy or thrombolysis, what other treatments can help improve outcomes of ischaemic strokes?

A
  • Decompressive hemicraniotomy

- Anti-platelets

78
Q

When is a decompressive hemicraniotomy useful in treating an ischaemic stroke?

A

To reduce pressure due to brain swelling

79
Q

What causes significant brain swelling in ischaemic stroke?

A

Strokes affecting large portions of the brain - mainly those in the middle cerebral artery

80
Q

What criteria should patients meet to be considered for a decompressive hemicraniotomy?

A
  • Aged 60+
  • Deficit suggestive of infarction of middle cerebral artery
  • Decreased consciousness
  • Signs on CT of at least 50% of territory of MCA affected
81
Q

Within what timeframe should a decompressive hemicraniotomy be performed fro acute stroke?

A

Within 48 hours

82
Q

What anti-platelet should all patients with an ischaemic stroke be gien?

A

Aspirin

83
Q

How can aspirin be given to post-stroke patients?

A
  • Orally (if not dysphagic)

- Rectally

84
Q

How long should 300 mg aspirin be continued post-stroke?

A

2 weeks

85
Q

What should be initiated after the 2 weeks 300mg aspirin post stroke?

A

Definitive ant-thrombotic therapy

86
Q

How can haemorrhagic strokes be managed?

A
  • Supportive therapy
  • Active monitoring
  • Reversal of any anticoagulation
  • Surgical intervention
87
Q

What parameters should be monitored in patinets that have had a haemorrhagic stroke?

A
  • Consciousness
  • Blood sugar
  • Oxygenation
  • BP
88
Q

If a previously fit haemorrhagic stroke patient has hydrocephalus what therapy should they be considered for?

A

Surgical intervention

89
Q

How can anticoagulated patients who have had a haemorrhagic stroke be reversed?

A

Combination of prothrombin complex and IV vitamin K

90
Q

What is the main burden of stroke?

A

40% of survivors have some degree of functional impairment

91
Q

What problems should be screened for in stroke patients upon admission to hospital and management be commenced as soon as possible?

A
  • Orientation
  • Positioning, moving and handling
  • Swallowing
  • Transfers
  • Pressure area risk
  • Continence
  • Communication
  • Ability to understand
  • Nutrition and hydration
92
Q

How should mobility be managed early after a stroke?

A

Sit patient on edge of bed and consider standing within the first 3 days

93
Q

What support should people with a post-stroke disability receive?

A
  • Rehab as an inpatient

- Rehab in the community

94
Q

What areas of disability can stroke rehabilitation help to address?

A
  • Cognition
  • Communication
  • Emotional function
  • Movment
  • Self-care
  • Swallowing
  • Vision
95
Q

What cognitive functions should be looked at as part of stroke rehabilitation?

A
  • Memory
  • Attention
  • Visual neglect
96
Q

What interventions can be used to improve memory post-stroke?

A
  • Increase awareness of memory deficit
  • Enhance learning
  • External aids like calendars and diaries
  • Environmental prompts
97
Q

How can attention be improved post-stroke?

A

Manage the patient’s environment and provide prompts relevant to the functional task

98
Q

What techniques can be used to help reduce visual neglect post-stroke?

A
  • Brightly coloured lines on the edge of a page

- Auditory cues

99
Q

Which team of specialists can be helpful in managing communication problems in a person who has had a stroke?

A

Speech and language therapists (SALT)

100
Q

How can SALT help to improve communication in a person who has had a stroke?

A
  • Direct impairment based therapy
  • Enhance remaining language capabilities
  • Teach other methods of communicating
101
Q

What alternative communication methods can be useful to patients who have had a stroke?

A
  • Gestures
  • Writing
  • Prompts
  • Assistive technology
102
Q

Who should receive emotional support and education after a stroke?

A

Patient and their relatives

103
Q

When should a stroke patient with persisting emotional difficulties be referred to more specialised services?

A

At 6-month or annual reviews

104
Q

What types of therapies can be used to improve a patients movement after a stroke?

A
  • Physiotherapy
  • Fitness training
  • Strength straining
  • Repetitive task training
105
Q

Who is physiotherapy useful for after a stroke?

A

Those with weakness in their trunk or limbs, sensory disturbances, and balance difficulties

106
Q

How can people who have had a stroke improve their fitness?

A
  • Encourage physical activity

- Cardio and resistance training started with a physio

107
Q

Who can be considered for strength training after a stroke?

A

People with muscle weakness

108
Q

What sorts of strength training is useful after a stroke?

A
  • Repetition of body weight activities e.g. sit -to-stand
  • Weights
  • Resistance machines and exercise bikes
109
Q

What repetitive tasks can be trained in the upper limb?

A
  • Reaching
  • Grasping
  • Pointing
  • Manipulating objects
110
Q

What repetitive tasks can be trained in the lower limb?

A
  • Sit-to-stand
  • Transfers
  • Walking
  • Using stairs
111
Q

What type of activities must be looked at when assessing a patients ability to self-care?

A

Activities of daily living

112
Q

How can better self care be implemented in a patient post-stroke?

A
  • Encourage attending to neglected side
  • Establish dressing routine
  • Use equipment
113
Q

What equipment can help to improve a patient’s ability to self-care after a stroke?

A
  • Chair raiser
  • Hoists
  • Small aids e.g. long handled sponge
114
Q

What should be offered to patients with dysphagia after a stroke?

A
  • 3-times a week swallowing therapy

- Ensure adequate mouth care to reduce the risk of aspiration pneumonia

115
Q

What can swallowing therapy involve for stroke patients?

A
  • Compensatory strategies
  • Exercises
  • Postural advice
116
Q

What should be offered to stroke patients with persisting hemianopia?

A

Eye movement therapy

117
Q

How can the prevention of stroke be classified?

A
  • Primary prevention
  • Secondary prevention
  • (Tertiary prevention)
118
Q

What is primary stroke prevention?

A

Preventing stroke in someone who has no history of stroke or TIA

119
Q

What is secondary prevention of stroke?

A

Preventing another stroke occurring in someone who has a history of stroke or TIA

120
Q

What are some well-documented modifiable risk factors for stroke?

A
  • Hypertension
  • Exposure to cigarette smoke
  • Diabetes
  • AF
  • Dyslipidaemia
  • Carotid artery stenosis
  • Sickle cell disease
  • Post-menopausal hormone therapy
  • Poor diet
  • Physical inactivity
  • Obesity
121
Q

How can hypertension be modified as a risk factor for stroke?

A

Should be screened for and treated appropriately

122
Q

How can smoking be modified as a risk factor for stroke?

A

Offer support, advice and medication to help cessation

123
Q

How should AF be modified as a risk factor for stroke?

A

Assess need for thromboprophylaxis against risk of bleeding

124
Q

Which patients with AF should be offered oral anticoagulation?

A
  • Those with sinus rhythm not restored within 48 hours of onset
  • High risk of recurrence
125
Q

What suggests a high risk of AF recurrence?

A
  • Structural heart defect

- Prolonged AF ( longer than 12 months)

126
Q

What mediations can be considered for oral anticoagulation?

A

Warfarin or DOAC

127
Q

Who should receive statin therapy for primary prevention of CVD?

A

Adults who have a 20% or greater 10 year risk of CVD

128
Q

What dietary advise can help reduce risk of stroke?

A
  • At least 5 fruit and veg per day
  • Total fat intake less than 30% of total calories
  • Saturated fat less than 10% total calories
  • Dietary cholesterol less than 300mg/day
129
Q

What is the recommended advice to give regarding exercise to reduce stroke risk?

A

At least 30 mins of moderate intensity exercise at least 5 days a week

130
Q

How can recommended amount of exercise be achieved more easily?

A

Incorporate into daily life e.g. brisk walking, cycling etc.

131
Q

What advice should be given to obese people to reduce risk of stroke?

A

Advice about achieving and maintaining a healthy weight

132
Q

What things can put people at increased risk of thromboembolism?

A
  • Large anterior MI
  • Left ventricular aneurysm or thrombus
  • Paroxysmal tachycardias
  • Chronic heart failure
  • History of thromboembolic events
  • Prosthetic heart valves
  • Rheumatic heart disease
  • AF
133
Q

What can be given to patients at increased risk of thromboembolism to reduce the risk of stroke?

A

Anti-thrombotic treamtent

134
Q

What measures can be used for the secondary prevention of stroke?

A

The same as used for primary prevention

135
Q

What is the standard preventive therapy for atherosclerotic stroke?

A

Carotid endarterectomy

136
Q

What is a less invasive alternative for carotid endarterectomy?

A

Carotid stenting

137
Q

What is recommended for people with neurological symptoms of acute non-disabling stroke or TIA with carotid stenosis of 50-99%?

A
  • Refer for carotid endarterectomy within one week
  • Surgery within maximum of 2 weeks
  • Control modifiable risk factors
138
Q

What are the potential complications of stroke?

A
  • Neurological problems
  • Pain
  • Psychological disorders
  • Cognitive impairment
  • Speech and communication difficulties
  • Visual impairments and hemianopia
  • Bladder and bowel problems
  • Swallowing problems
  • Malnutrition and dehydration
  • Sexual dysfunction
  • Difficulties with ADL
  • Thromboembolism
  • Pneumonia
  • Bedsores
139
Q

What neurological problems can occur following a stroke?

A
  • Balance
  • Movement
  • Tone
  • Sensation
140
Q

What sorts of pain can result from stroke?

A
  • Neuropathic

- Musculoskeletal

141
Q

What psychological problems can occur following a stroke?

A
  • Depression
  • Anxiety
  • Emotionalism
  • Disturbed social interaction
  • Disinhibition
  • Agression
142
Q

How can stroke affect cognition?

A
  • Attention and concentration problems
  • Memory
  • Disturbance of spatial awareness
  • Disturbance of perception
  • Apraxia
  • Disturbances of executive functioning
143
Q

What problems can disturbance of executive functioning post-stroke cause?

A

Difficulty in planning, organising, initiating and monitoring behaviour

144
Q

What sorts of speech and communication difficulties can arise due to stroke?

A
  • Dysphasia
  • Dysarthria
  • Apraxia of speech
145
Q

What bladder and bowel problems can occur due to stroke?

A
  • Urinary incontinence
  • Faecal incontinence
  • Constipation

ANKI Neuro (30 decks)

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