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Nervous System > Cerebral Infarction > Flashcards

Cerebral Infarction Flashcards

1
Q

How does stroke risk change with age?

A

Increases with age?

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2
Q

What is an example of public awareness being used to help treat stroke?

A
  • Remember FAST
    • Facial weakness
    • Arm weakness
    • Speech problems
    • Time to call 999
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3
Q

What is a stroke?

A

Sudden onset of focal or global neurological symptoms caused by ischaemia or haemorrhage and lasting more than 24 hours

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4
Q

What are the 2 different broad categories of strokes?

A

Ischaemic stroke (85%)

Haemorrhagic stroke (15%)

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5
Q

Are most strokes ischaemic strokes or haemorrhagic strokes?

A

Ischaemic (85%)

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6
Q

What does TIA stand for?

A

Transient ischaemic attack

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7
Q

What is a transient ischaemic attack (TIA)?

A

Term used if symptoms resolve within 24 hours

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8
Q

How long do most TIAs take to resolve?

A

Most TIAs resolve within 1 to 60 minutes

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9
Q

What are the different causes of haemorrhagic stroke?

A

1) Primary intracerebral haemorrage
2) Secondary haemorrhage (subarachnoid haemorrhage or arteriovenous malformation)

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10
Q

What are the different causes of ischaemic stroke?

A

1) Large artery atherosclerosis (such as carotid)
2) Cardioembolic (such as atrial fibrillation)
3) Small artery occlusion
4) Undetermined/cryptogenic
5) Rare causes (arterial dissection, venous sinus thrombosis)

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11
Q

What are some modifiable risk factors for stroke?

A
  • Smoking
    • 2x increases risk of cerebral infarction
    • 3x increased risk of subarachnoid haemorrhage
    • Some of the increased risk relates to cardiac problems
  • Obesity
    • Independent risk factor for vascular disease including stroke
  • AF
    • 5x increased risk of embolic stroke
    • Antiplatelets (such as aspirin) have no benefit in reducing ischaemic stroke
    • Anticoagulants (warfarin and COACs) reduce risk by 2/3rds
    • DOACs have less risk of causing bleeding than warfarin
  • Cocaine
  • Diabetes
    • Diabetes increases incidence 3x
  • Hyperlipidaemia
    • Hypertension, smoke and diabetes contribute to LDL-C deposition in arterial walls
    • Risk related to development of atheroma in blood vessel walls
  • Hypertension
    • Most important modifiable risk factor
    • Chronic hypertension exacerbates atheroma and increases involvement of smaller distal arteries
  • No exercise
  • Diet
  • Alcohol
    • Small amounts may decrease stroke risk, heavy drinking increases risk 2.5x
  • Oral contraceptives
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12
Q

What are some non-modifiable risk factors for stroke?

A
  • Previous stroke
  • Age
  • Male
  • Family history
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13
Q

What can reduce the risk of AF leading to a stroke?

A
  • Anticoagulants (warfarin and DOACs) reduce risk by 2/3rds
  • DOACs have less risk of causing bleeding than warfarin
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14
Q

How do small end arteries coming directly off large arteries have a higher risk of causing stroke?

A

Small end arteries coming directly off large arteries experience higher pressure and are at risk of lipohyalinosis (small vessel wall thickening, decreasing luminar diameter) causing:

  • Lacunar ischaemic stroke
  • Small vessel haemorrhages
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15
Q

What parts of the brain are at particular risk of lipohyalinosis?

A
  • Brainstem
  • Basal ganglia
  • Subcortical areas
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16
Q

What is lipohyalinosis?

A

Small vessel wall thickening, decreasing luminar diameter

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17
Q

What can the circulation of the brain be seperated into?

A

Anterior circulation

Posterior circulation

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18
Q

What is the anterior circulation of the brain composed of?

A
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19
Q

What is the posterior circulation of the brain composed of?

A
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20
Q

What does the carotid system supply?

A

Most of the hesmispheres of the brain and cortical deep white matter

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21
Q

What does the vertebro-basilar system supply?

A

The brainstem, cerebellum and occipital lobes

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22
Q

Signs and symptoms of stroke should correlate to what?

A

Fit in with an artery territory and an area of the brain

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23
Q

Diagnosis of a stroke should give an answer to what questions?

A
  • What is the neurological deficit
  • Where is the lesion
  • What is the lesion
  • Why has the lesion occurred
  • What are the potential complications and prognosis
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24
Q

What are some frontal lobe functions?

A
  • High level cognitive functions
    • Such as abstraction, concentration, reasoning
  • Memory
  • Control of voluntary eye movements
  • Motor control of speech (dominant hemisphere)
  • Motor cortex
  • Urinary continence
  • Emotion and personality
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25
Q

What are examples of high level cognitive functions?

A
  • Such as abstraction, concentration, reasoning
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26
Q

What are some parietal lobe functions?

A
  • Sensory cortex
  • Sensation (identify modalities of touch, pressure, position)
  • Awareness of parts of the body
  • Spatial orientation and visuospatial information (non dominant hemisphere)
  • Ability to perform learning motor tasks (dominant)
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27
Q

What cortex is found in the parietal lobe?

A

Sensory cortex

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28
Q

What are some temporal lobe functions?

A
  • Primary auditory receptive area
  • Comprehension of speech (dominant)
  • Visual, auditory and olfactory perception
  • Important role in learning, memory and emotional affect
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29
Q

What lobe is the primary auditory receptive area found?

A

Temporal lobe

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30
Q

In what lobe is the visual cortex found?

A

Occipital lobe

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31
Q

What are some occipital lobe functions?

A
  • Primary visual cortex
  • Visual perception
  • Involuntary smooth eye movement
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32
Q

Does does ACA stroke stand for?

A

Anterior cerebral artery stroke

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33
Q

What does MCA stroke stand for?

A

Middle cerebral artery stroke

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34
Q

Where does most weakness occur in a stroke due to the anterior cerebral artery?

A

Leg more than arm weakness

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35
Q

Where does most weakness occur in a stroke due to middle cerebral artery?

A

Face and arm more than leg weakness

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36
Q

Why does a small stroke of deep white matter cause major defects?

A

Affects major tracts where fibres are pact closely together, such as spinothalamic tract

37
Q

What is the function of the cerebellum?

A

Balance and coordination

38
Q

What is the brainstem composed of?

A

Composed of midbrain, pons and medulla

39
Q

How many of the cranial nerves arise from the brainstem?

A

10 of the 12

40
Q

Why doo strokes lead to contralateral hemiparesis?

A

Due to crossing of cortical tracts in lower medulla

41
Q

What is hemiparesis?

A

Weakness of one entire side of the body

42
Q

What are some major functions of the brainstem?

A
  • Eye movements
  • Breathing
  • Swallowing
  • Heart beat
  • Consciousness
43
Q

What is the clinical presentation of stroke?

A
  • Motor (clumsy or weak limb)
  • Sensory (loss of feeling)
  • Speech (dysarthria/dysphasia)
  • Neglect/visuospatial problems
  • Vision, loss in one eye (amaurosis fugax) or hemianopia
  • Gazy palsy (inability to move both eyes in a single direction)
  • Ataxia, vertigo, incoordination, nystagmus
44
Q

What is gaze palsy?

A

Inability to move both eyes in a single direction

45
Q

What are strokes classified by?

A

Oxford community stroke project classification (OSCP)

46
Q

What are the different classes of stroke?

A
  • Total anterior circulation stroke (TACS)
  • Partial anterior circulation stroke (PACS)
  • Lacunar stroke (LACS)
  • Posterior circulation stroke (POCS)
47
Q

What does TACS stand for?

A

Total anterior circulation stroke

48
Q

What does PACS stand for?

A

Partial anterior circulation stroke

49
Q

What does LACS stand for?

A

Lacunar stroke

50
Q

What does POCS stand for?

A

Posterior circulation stroke

51
Q

What are the requirements for a stroke to be considered LACS?

A

A lacunar stroke (LACS) is a subcortical stroke that occurs secondary to small vessel disease. There is no loss of higher cerebral functions (e.g. dysphasia).

One of the following needs to be present for a diagnosis of a LACS:

Pure sensory stroke

Pure motor stroke

Sensori-motor stroke

Ataxic hemiparesis

52
Q

What are the requirments for a stroke to be considered PACS?

A

A partial anterior circulation stroke (PACS) is a less severe form of TACS, in which only part of the anterior circulation has been compromised.

Two of the following need to be present for a diagnosis of a PACS:

Unilateral weakness (and/or sensory deficit) of the face, arm and leg

Homonymous hemianopia

Higher cerebral dysfunction (dysphasia, visuospatial disorder)

53
Q

What are the requirements for a stroke to be considered TACS?

A

A total anterior circulation stroke (TACS) is a large cortical stroke affecting the areas of the brain supplied by both the middle and anterior cerebral arteries.

All three of the following need to be present for a diagnosis of a TACS:

Unilateral weakness (and/or sensory deficit) of the face, arm and leg

Homonymous hemianopia

Higher cerebral dysfunction (dysphasia, visuospatial disorder)

54
Q

What are the requirments for a stroke to be considered POCS?

A

A posterior circulation syndrome (POCS) involves damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem).

One of the following need to be present for a diagnosis of a POCS:

Cranial nerve palsy and a contralateral motor/sensory deficit

Bilateral motor/sensory deficit

Conjugate eye movement disorder (e.g. horizontal gaze palsy)

Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)

Isolated homonymous hemianopia

55
Q

What does a stroke in the right hemisphere cause?

A
  • Left hemiplegia, homonymous hemianopia, neglect syndromes (agnosias)
    • Visual agnosia
    • Sensory agnosia
    • Anosagnosia (denial of hemiplegia)
    • Prospagnosia (failure to recognise faces)
56
Q

In general, blockage of a what causes TACS?

A

Main artery to one hemisphere

57
Q

What is TACS often due to?

A
58
Q

In general, blockage of a what causes PACS?

A

Branch of main artery

59
Q

In general, blockage of a what causes LACS?

A

Small perforating artery

60
Q

What is the clinical presentation of LACS?

A

Weakness/numbness of:

  • Face and arm and leg
  • Or face and arm
  • Or arm and leg

May have dysarthria

Ataxic hemiparesis

No affect on higher function, will not have dysphasia, inattention or hemianopia

61
Q

What is nonoparesis?

A

Weakness to one limb

62
Q

Blockage to what causes POCS?

A

Any posterior artery

63
Q

What is the clinical presentation of POCS?

A
  • Loss of balance/coordination
  • Vertigo
  • Double vision
  • Dysarthria
  • Visual loss (hemianopia)
64
Q

What is the medical term for vision loss?

A

Hemianopia

65
Q

Where does basilar artery occlusion cause ischaemia?

A

Ischaemia in pons

66
Q

Describe the clinical presentation of basilar artery occlusion?

A

Predominantly motor/oculomotor signs/symptoms

Bilateral but asymmetrical

Alteration in level of consciousness common:

  • May progress over 12 to 24 months

May present as reduced responsiveness

67
Q

What kind of stroke has the worst mortality?

A

1) TACS
2) POCS
3) PACS
4) LACS

68
Q

What are some conditions that stroke mimics?

A
69
Q

What are the symptoms of stroke?

A
70
Q

What is migraine with aura?

A

Recurring headache that strikes after or at the same time as sensory disturbances called aura

71
Q

Why does migraine aura occur with stroke?

A
  • Due to cortical spreading depression
72
Q

What occurs in migraine aura?

A
  • Visual disturbances
    • Scintillating scotomata
    • Geometric patterns
    • Positive symptoms
  • Can include sensory, motor or speech disturbance
  • Headache onset can be >1 hour after the end of the aura or no headache
73
Q

What is functional anxiety disorder?

A

Are able to accomplish tasks and appear to function well in social situations but internally they are feeling the same symptoms as anxiety disorder

74
Q

What anxiety disorder do some people get after stroke?

A

Functional anxiety disorder

75
Q

What is Hoover’s sign?

A
  • When pressure is felt in the paretic leg when the non-paretic leg is raised and no pressure is felt in the non-paretic leg when the paretic leg is being raised
76
Q

What is the clinical presentation of acute vestibular syndrome?

A
  • Can be very disabling
  • Vertigo
  • Nystagmus
    • Unidirectional, increase in intensity when patient looks in direction of fast phase
  • Vomiting
  • MRI can be helpful
77
Q

What are the aims of therpies for stroke?

A
  • Restored blood supply
  • Prevent extension of ischaemic damage
  • Protect vulnerable brain tissue
78
Q

What are some potential therapies for stroke?

A
  • Aspirin
  • Heparin
  • Neuroprotectant
  • Tissue plasminogen activator (TPA)

Intra-arterial therapy/thrombectomy

79
Q

What does TPA stand for?

A

Tissue plasminogen activator

80
Q

What does NNT mean?

A

Number needed to treat to prevent 1 death or dependent

81
Q

What is the best treatment for stroke?

A

Thrombectomy

82
Q

What professionals are found in stroke clinics?

A
  • Clinical staff
  • Stroke nurses
  • Physiotherapists
  • Speech and language therapists
  • Occupational therapists
  • Dietician
  • Psychologist
  • Orthoptist
83
Q

What is the criteria for TPA use?

A
  • <4.5 hours from symptom onset
  • Disabling neurological deficit
  • Symptoms present more than 60 minutes
  • Consent obtained
84
Q

What is the exclusion criteria for IV TPA?

A
  • Anything that increases probability of haemorrhage
    • Blood on CT scan
    • Recent surgery
    • Recent episodes of bleeding
    • Coagulation problems
  • BP > 185 systolic or >110 diastolic
  • Glucose <2.8 or >22mmol/L
85
Q

How do the benefits of TPA change with time?

A

Decreases with time, whilst harm increases

86
Q

What should be used with medical treatment for strokes?

A

Endovascular treatment

87
Q

What can the risk of stroke recurrence be reduced by?

A
  • Antiplatelet
  • Antihypertensive
  • Statins and endarterectomy
88
Q

What is an example of a endarterectomy?

A

Example of endarterectomy is carotid endarterectomy (used for internal carotid artery stenosis)

89
Q

What investigations are done for stroke?

A
  • All/most patients:
  • Routine blood tests
    • FBC, glucose, lipids, ESR…
  • CT or MRI head scan
    • Infarct vs haemorrhage
  • ECG and holter
    • Look for AF, LVH
  • Carotid Doppler ultrasound
    • Look for stenosis
  • Some patients:
  • Echocardiogram
    • Valves, ASD, VSD, PFO
  • Cerebral angiogram/venogram
    • Vasculitis
  • Hyper-coagulable blood screen

Nervous System (48 decks)

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