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Semester 3 > Case 5 - Stroke Summary > Flashcards

Case 5 - Stroke Summary Flashcards

1
Q

what is stroke diagnosis confirmed with

A

imaging

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2
Q

what is a TIA

A

essentially a minor stroke. it may present with stroke Like symptoms but the clinical effects will completely resolve within 24 hours. they are usually the result of micro-emboli. sometimes a mass lesion may mimic a TIA and other tines, they are the result of a temporary reduced blood flow e.g with massive postal hypotension, or decreased blood flow through a stenosed artery.- which is later compensated for by auto regulation mechanisms

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3
Q

what is a completed stroke

A

when the clinical effects have reached their maximum - usually with in six hours of the onset

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4
Q

what is stroke in evolution

A

describes the progress of a stroke in the first 24 hours

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5
Q

what are presentation has a poor prognosis

A

drowsiness

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6
Q

when will damage occur

A

when the blood flow to the brain tissue drops below 50%

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7
Q

why do most strokes occur in the morning

A

the blood pressure is lowered during the night whilst asleep, but on waking, the BP increases an is now more likely to dislodge any embolism

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8
Q

low doses of aspirin effect on stroke

A

has no proven beneficial effect, and in fact, high usage of COX-2 inhibitors increases the risk. it is now also though the at low dose oestrogen does not significantly increase the risk in otherwise healthy women

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9
Q

what is a rare, inherited cause of stroke and vascular dementia

A

CADASIL

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10
Q

what is CADASIL caused by

A

defective NOTCH3 gene. there are many small infarcts in the brain. often presents as migraine and depression in teenage

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11
Q

what are most TIAs due to

A

80% due to thromboembolism

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12
Q

signs based on region of the brain:

A
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13
Q

what is amaurosis fugax

A

this is a sudden loss of vision in one eye, caused by an infarct in the retinal arteries. you can sometimes see the obstruction on ophalmoscopty, which is useful clinically, as the same symptoms are seen in migraines, where the arteries will always appear normal. thus if s defect is visible, it is highly likely to be the result of TIA

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14
Q

what is transient global amnesia

A

this involves an episode of amnesia that usually occurs in those over 65, and completely resolves within 24 hours. unlikely to happen more than once in the same patient

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15
Q

what suggests subclavian artery stenosis

A

difference of more than 20mmHg between arms

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16
Q

what is the prognosis for a TIA

A

5 years after a TIA;
- 30% of patients have a stroke
- 15% have an MI

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17
Q

where is a TIA the most serious

A

in the anterior circulation than a TIA in the posterior circulation

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18
Q

what is the management of a patient with suspected TIA

A

they are often admitted based on their ABCD2 score. this score predicts the likelihood of a further CVA event a patient with a score greater than 4 should be admitted and 3 or less should be investigated as an outpatient

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19
Q

what is the big follow up investigation

A

a carotid doppler scan - to check the levee of carotid artery stenos.

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20
Q

what risk level requires a carotid endarterectomy

A

60%

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21
Q

what is the immediate management

A

300mg of aspirin should be given once diagnosis is confirmed, usually after CT confirms there is no haemorrhage stroke

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22
Q

what dose of aspirin do you continue with after the initial 300 mg

A

100mg daily

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23
Q

what is the biggest cause of cerebral infarct

A

atherosclerosis of the carotid Arteries and the aortic arch - 60%

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24
Q

what is the most common stroke presentation

A

branch of the middle cerebral artery

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25
Q

what does an infract to the MCA affect

A

the internal capsule. a similar set of signs will be caused by internal carotid occlusion

26
Q

in these cases there is what:

A

hemiparesis
Hemiplegia
Limbs usually floppy, and reflexes reduced or absent
Facial weakness
Hemianopia - visual field defect in which vision is lost in half of the visual field in one or both eyes
Aphasia - when the dominant hemisphere is affected
Important to ask about right and left handedness
These symptoms usually develop rapidly, over a period of minutes or less commonly they can develop over a free years

27
Q

are there any headaches with a MCA occlusion

A

not usually - there are no pain receptors within the brain itself

28
Q

what happens to reflex after stroke

A

will return early on, but often become exaggerated with an extensor plantar response

29
Q

if there is a headache, impaired consciousness then the cause is likely to involve what

A

some sort of swellings and thus if the onset it acute, it is likely to be haemorrhage

30
Q

what to look for in eye examination

A

diabetic changes
retinal emboli
hypertensive changes
arcus snellis

31
Q

what is arcus snellis

A

a grey or white arc visible above or below the cornea

32
Q

sudden cessation of blood supply to neurones leads quickly to hypo cells. what does this cause?

A
  • the Na+K+ pump fails and Na begins to accumulate in the cell

this excess Na changes the osmotic balance, and more liquid enters the cell causing oedema

33
Q

what happens due to this oedema

A

the oedema is highly significant. in the direct area around the infarct, the cells will die very quickly, as they swell and burst. but in the area around this there are cells that have oedema but can be saved. this is the penumbra

34
Q

what happens as these cells swell and b burst

A

there is an increase in intracranial pressure which can further affect the bloody supply to the area, resulting in a vicious circle.

35
Q

what is another factor in the accumulation of Na _

A

the continued depolarisation of neurones in the affected area. this is because the re uptake process for glutamate is dependent on ATP an without O2 there is not ATP, so glucose remains present in the synaptic regions, and cells remain depolarised

36
Q

the mechanism of cell damage, as a result of prolonged depolarisation of the cell is known as what

A

excitotoxicity

37
Q

what can excitotoxicity also result in

A

the failure of the AMPA and NMDA receptors, which allows excessive levels of calcium into the cell

38
Q

what does the high level of calcium in a cell allow for:

A
  • the release of free radicals - which also leads to necrosis in the area
  • the production of cytokines which causes inflammation
  • Ca2+ can also directly lead to apoptosis in the penumbra
39
Q

examples of clinical features in a brain stem infarct

A
40
Q

what are the several names that all mean the same thing for brainstem stroke patterns

A

Wallenberg syndrome
lateral medullary syndrome
posterior inferior cerebellar artery thrombosis (PICA)

41
Q

what are the contralateral signs of these syndrome

A
  • spinothalamic sensory loss
  • hemiparesis
42
Q

what are the ipsilateral signs of these syndromes

A
  • facial numbness (V)
  • diplopia (VI)
  • nystagmus
  • ataxia
  • Horner’s syndrome
  • 9th and 10 th nerve lesions
43
Q

what is Horner’s syndrome

A

characterized by a constricted pupil (miosis), drooping of the upper eyelid (ptosis), absence of sweating of the face (anhidrosis), and sinking of the eyeball into the bony cavity that protects the eye (enophthalmos).

44
Q

why would coma be an outcome of a stroke

A

from a stroke affecting the reticular activating system

45
Q

what is locked in syndrome caused by

A

an upper brainstem infarct

46
Q

what is pseudo bulbar palsy and what is it the result of

A

result of a lower brainstem infarct. results in bilateral impairment of 9-12th cranial nerves. there is dysarthria and dysphagia

47
Q

what is a lacunar infarct

A

infarcts in the Deep arteries of the brain. they can be seen on MRI and often are symptomless

48
Q

what is hypertensive encephalopathy

A

literally means damage to the brain. in this case, as a result of malignant hypertension

49
Q

what is papilloedma due to

A

direct infarct affecting the optic nerve
infarct in other part of brain, causing oedema and therefore puts pressure on the optic disc

50
Q

what Is Weber’s syndrome

A

the result of an infarct on one side of the midbrain

51
Q

what does Weber’s syndrome present with

A

ipsilateral III nerve paralysis
contralateral hemiplegia

52
Q

what are diffusion MRI scans

A

these detect abnormalities much earlier than on normal MRI and ct
this type of MRI exploits the fact that damaged cells fill with water and thus contain more water than normal cells in early stages of damage

53
Q

what is an angiography

A

an MR that looks at the blood bezels in the head and neck.

54
Q

how to disinguish between the blood vessels on a MRA

A

vertebral artery is often the smallest
the internal carotid has no branches
external carotid has branches

55
Q

what does an MR angiography show

A

areas of stenosis and thrombus formations. it is also useful when looking for aneurysms

56
Q

what are haemorrhages almost always the result of

A

uncontrolled chronic hypertension

57
Q

what are some contra-indications for thrombolysis

A
  • major surgery, trauma less than two weeks ago
  • active internal bleed
  • prolonged or traumatic CPR
  • pregnancy
  • severe liver disease
  • hypertension >200/120
  • cerebral neoplasm
58
Q

what is the treatment plan for aspirin

A

300mg daily for 2 weeks and then 75mg per day

59
Q

what is given if aspirin hypertensive,

A

give clopidogrel

60
Q

what should also be given is ischaemia is confirmed by CT or MRI

A

dipyridamole

Semester 3 (94 decks)

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