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MD4001 - Physiology > Blood Supply and Stroke > Flashcards

Blood Supply and Stroke Flashcards

1
Q

What is the main anterior circulation of the brain?

A
  • Internal carotid arteries
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2
Q

What do the internal carotid arteries supply?

A
  • Anterior 3/5 of the cerebrum
  • Diencephalon
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3
Q

What are the main branches of the internal carotid arteries?

A
  • Middle cerebral artery (MCA)
  • Anterior cerebral artery (ACA)
  • Perforating branches (striate, lenticulochoridal arteries)
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4
Q

What are the main arteries of the posterior circulation of the brain?

A

vestobasilar arteries

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5
Q

What do the vestibasilar arteries supply?

A
  • Brainstem
  • Cerebellum
  • Posterior 2/5 of cerebrum
  • Diencephalon
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6
Q

What are the main branches of the vestibasilar arteries?

A
  • Cerebellar (PICA, AICA, SCA)
  • Pontine
  • Posterior cerebral arteries
  • Striate & thalamic
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7
Q

What is autoregulation of the arteries of the brain?

A
  • Brain is well-adapted to keep cerebral blood flow in an optimal range
  • Blood vessels respond to changes in blood pressure top maintain and steady and safe flow rate
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8
Q

What are the 3 main questions when someone presents with stroke like symptoms?

A
  • What is the problem?
  • Where is the problem?
  • What are you going to do?
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9
Q

What are the main signs of a stroke?

A
  • Sudden onset
  • Facial asymmetry
  • Speech disturbance (dysphasia)
  • Asymmetrical weakness in muscles
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10
Q

What is the definition of a stroke?

A
  • Interruption of the blood supply to a focal part of the brain causing loss of neurological function
  • Symptoms last >24 hours or lead to death with no apparent cause other than that of vascular origin
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11
Q

What is the definintion of a transient ischaemic attack?

A
  • Same cause as stroke
  • Symptoms lasting <24 hours
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12
Q

What are the 5 main causes of a haemorrhagic stroke?

A
  • Hypertension
  • Amyloid angiopathy
  • Tumour
  • Vascular malform (AVM)
  • Bleeding disorders
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13
Q

What are the three different types of stroke and what is the prevalence?

A
  • Ischaemic – 80-85%
  • Haemorrhagic – 15%
  • Subarachnoid haemorrhage – 5%
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14
Q

What is primary brain damage?

A
  • Mechanical damage associated with the mass effect
  • Within minutes to hours from the onset of bleeding
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15
Q

What is secondary brain damage?

A
  • Surrounding oedema
  • Oxidative stress and inflammation
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16
Q

What are the main causes of ischaemic stroke?

A
  • large vessel atheroma
  • small vessel disease
  • hypoperfusion
  • cardio-embolism
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17
Q

What is a lacunar stroke?

A
  • type of ischaemic stroke that occurs in deep areas of the brain when the small perforating branches are obstructed by microatheroma
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18
Q

Describe the progression of an ischameic stroke

A
  • Core = where permanent damage occurs in ischaemic stroke **Nothing can be done to save these neurons
  • Penumbra = surrounds the core **these are neurons that can be saved with fast and appropraite management
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19
Q

What is the “watershed” area?

A

most vulnerable to hypoperfusion because they are furthest away from the source of blood

**Can occur if BP is reduced too rapidly in patients who present with hypertension

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20
Q

What is the prevelance of stroke in each artery of the brain in ischamic stroke?

A
  • 51% MCA
  • 13% small vessels
  • 7% ACA
  • 5% PCA
21
Q

What are the main areas of assessment when a patient presents with a stroke?

A
  • Airway
  • Breathing
  • Circulation
  • Clarify the history!
  • Clarify the history!!
  • Past medical history: Conditions, Medications
  • Check the signs
  • Level 1 investigations
22
Q

Outline the main aspects and signs to look for in an examinatio of vascular neurology

A
  • BP and pulse measurements in 2 arms
  • Level of consciousness (Glasgow Coma Score; document progress)
  • Cardiac and carotid bruits
  • Blood glucose level
  • Neck stiffness/meningism (Kernig’s/Brudzinski signs)
  • Abnormal or involuntary movements
  • Any seizure-like activity
  • Skin rash/infarcts e.g. vasculitis, popular rash
  • Specific neurological
    • Eye movements (gaze preference, fixed deviation)
    • Speech, visual fields, inattention, motor & sensory
    • Gait assessment
23
Q

What are the main classification systems for stroke?

A
  • Oxford Community Stroke Project (OCSP)
    • Clinical
  • TOAST classification
    • Mechanism (e.g. large vessel, small vessel, cardioembolic)
  • Carotid or vertebrobasilar territory
24
Q

What should you check in the OCSP classification of stroke

A
  • motor/sensory pathways (muscle power, sensation)
  • Visual pathways (field of vision)
  • Higher cortical functions (speech, spatial awareness)
  • Brainstem functions (swallowing, eye movements)
25
Q

Features of lacunar syndrome (LACS)

A
  • Pure motor, pure sensory, sensorimotor, ataxic hemisphere
26
Q

What are the 4 classifications in the OCSP?

A
  • TACS - Total anterior circulation syndrome
  • PACS - Partial anterior circulation syndrome
  • LACS - lacunar syndrome
  • POCS - posterior circulation syndrome
27
Q

What are the features of posterior circulation syndrome (POCS)?

A
  • Brainstem, cerebellar and/or isolated homonymous hemianopia
28
Q

What are the features of total anterior circulation syndrome (TACS)?

A
  • Triad of hemiparesis (or hemisensory loss), dysphasia (or other higher cortical function) and homonymous hemianopia
29
Q

What are the features of partial anterior circulation syndrome (PACS)?

A
  • 2 of the features of TACS or isolated dysphasia or parietal lobe signs (e.g. inattention, agnosia, apraxia, agraphesthesia, alexia
30
Q

What are the 5 S’s that mimic stroke?

A
  • Seizures
  • Sepsis
  • Syncope
  • SOL (tumour, subdural)
  • Somatisation
31
Q

what things are regularly overlooked when diagnosing stroke?

A
  • Evolution of symptoms
  • Maximum deficit
  • Drugs
    • Newly prescribed
    • OCP
    • Recreational
  • Visuo-spatial or perceptual disorder
  • Truncal ataxia
  • Apraxia
32
Q

What are the main investigations that should be carried out when stroke is suspected?

A
  • Good history and examination
  • ECG/Holter (24hr ECG), ECHO
  • Cholesterol/autoimmune & thrombophilia screen
  • Carotid doppler
  • CT brain/MRI brain
  • Cerebral angiography
33
Q

What are the common risk factors of stroke?

A
  • Hypertension
  • Ischaemic heart disease
  • smoker
  • peripheral vascular disease
  • TIA
  • diabetes mellitus
34
Q

What are the main indications for urgent head imaging?

A
  • Depressed level of consciousness
  • Unexplained progressive or fluctuating symptoms
  • Papilledema, neck stiffness or fever
  • Severe headache at onset
  • History of trauma prior to onset
  • Indication of thrombolysis or anticoagulation
  • History of anticoagulant treatment or known bleeding tendency
35
Q

Reasons for a head CT (1st option)?

A
  • Fast image acquisition
  • Widely available
  • Good at showing blood and bone
36
Q

What can a head CT show?

A
  • Cerebellar haemorrhage
  • Another cause (tumour; SDH)
  • Early ischaemia
37
Q

What are the main types of MRI

A
  • T1-weighted MRI
  • T2-weighted MRI
  • Perfusion MRI
  • Diffusion Weighted Imaging
  • Apparent Diffusion Coef. Imaging
  • Flair
38
Q

What are the contraindications for MRI?

A
  • metal implants
  • children/agitated patients
  • body weight limitations
  • claustrophobia
39
Q

Give the treatment option in the following stage of stroke identification:

BEfore or ideally after scanning

A

Aspirin (300mg/day)

40
Q

Give the treatment option in the following stage of stroke identification:

  • Haemorrhage excluded
  • Considered suitable treatment
  • Onset < 4.5 hours
A

Thrombolytic treatment with IV r-tPA administed in specialist centre

41
Q

Give the treatment option in the following stage of stroke identification:

  • Patients with AF
  • Haemorrhage excluded
  • Usually after 10-14 days of stroke
A

Anticoagulation

42
Q

Give the treatment option in the following stage of stroke identification:

  • patients with IHS
A

Aggressive early BP treatment

43
Q

Give the treatment option in the following stage of stroke identification:

Patients with cerebellar stroke

A

Consulation with neurosurgery for secondary hydrocephalus

44
Q

What is the management of a subarchnoid haemorrhage?

A
  • CT brain/lumbar puncture if CT normal looked for bilirubin and xanthochromia. Cerebral angiogram
  • Management:
    • Airway: intubate if severe hypoxaemia
    • Fluid: 3L of 0.9% NaCl per 24hours
    • BP: keep MAP < 130mmHg. If higher; IV labetalol or esmolol or enalapril
    • Nimodipine 60mg 6X/day (for three weeks)
    • Codeine or tramadol for pain (avoid NSAID)
    • Phenytoin if seizures have occurred
45
Q

What is the secondary drug treatment - anti-thrombotic

A
  • Clopidogrel or Aspirin + Dipyridamole. In atrial fibrillation: Warfarin or NOAC (dabigatran, rivaroxaban, apixaban)
46
Q

what is the secondary drug treatment - blood pressure

A
  • Target BP < 130/80 with calcium channel blocker, thiazide diuretic (Bendroflumethiazide or indapamide), ACE inhibitor (perindopril)
47
Q

What is the secondary drug treatment - anti-lipids

A
  • If total cholesterol > 4.0mmol/L (or LDL-C > 2.5 mmol/L [100mg/dl]) treat with statin (simvastatin – but caution in ICH or history of cerebral haemorrhage)
48
Q
A

MD4001 - Physiology (11 decks)

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