Cerebral Infarction & Haemorrhage

Question 1

Define infarction

Answer 1

An area of tissue death due to lack of oxygen

Question 2

What % of strokes are ischaemic?

Answer 2

70-80%

Question 3

What is the most common cause of ischaemic stroke?

Answer 3

Cerebral atherosclerosis

Question 4

State at least 5 risk factors for ischaemic stroke

Answer 4

Smoking, diabetes mellitus, hypertension, FHx strokes, past TIAs, OCP, peripheral vascular disease, alchoholism, hyperviscosity (e.g. sickle cell, polycythaemia vera)

Question 5

Describe the typical clinical features of ischaemic stroke

Answer 5

Sudden onset, precise symptoms depend on territory but can include numbness, loss of vision, dysphagia, facial drooping, speech difficulties, weakness

Question 6

Which artery is most commonly affected in ischaemic stroke?

Answer 6

Middle cerebral artery

Question 7

Name the investigations required for stroke

Answer 7

CT (infarct vs haemorrhage), MRI, blood pressure, FBC, ESR, U&Es, glucose, lipid profile, chest x-ray, ECG, carotid doppler

Question 8

Describe the management of ischaemic stroke

Answer 8

Aspirin and/or dipyridamole. If symptom onset <4h ago, thrombolytics
Long-term: management of hypertension and hyperlipidaemia, anticoagulation (e.g. DOAC)

Question 9

Describe the clinical features of anterior cerebral artery strokes

Answer 9

Contralateral leg paresis, sensory loss, cognitive deficits (e.g. apathy, confusion, poor judgement)

Question 10

Describe the clinical features of middle cerebral artery strokes

Answer 10

Contralateral weakness and sensory loss (mainly face and arm), cortical sensory loss, contralateral homonymous hemianopia or quadrantanopia, if dominant (usually left) hemisphere aphasia, if non-dominant (usually right) hemisphere neglect. Eye deviation towards side of lesion

Question 11

Describe the clinical features of posterior cerebral artery strokes

Answer 11

Contralateral hemianopia or quadrantanopia, rarely hemiballismus
Midbrain involvement: CN III and IV palsy with pupillary changes, hemiparesis
Thalamic involvement: sensory loss, amnesia, decreased level of consciousness

Question 12

Describe the clinical features of proximal basilar artery stroke

Answer 12

Impaired extra-ocular muscle function, vertical nystagmus, reactive mioisis, hemi or quadriplegia, dysarthria, locked-in syndrome, coma

Question 13

Describe the clinical features of distal basilar artery stroke

Answer 13

Somnolence, memory and behavioural abnormalities, oculomotor deficits

Question 14

Describe the clinical features of postero-inferior cerebellar artery stroke (Wallenberg syndrome)

Answer 14

Ipsilateral ataxia, ipsilateral Horner’s syndrome, ipsilateral facial sensory loss, contralateral loss of pain and temperature sensation, nystagmus, vertigo, nausea, vomiting, dysphagia, dysarthria, hiccoughs

Question 15

Describe the clinical features of anterior spinal artery stroke (medial medullary infarct)

Answer 15

Contralateral hemiparesis with facial sparing, contralateral loss of proprioception and vibration sensation, ipsilateral tongue weakness

Question 16

Describe the clinical features of lacunar infarcts involving the posterior limb of the internal capsule

Answer 16

Pure motor contralateral hemiparesis

Question 17

Describe the clinical features of lacunar infarcts involving the ventral thalamus

Answer 17

Pure hemisensory loss

Question 18

Describe the clinical features of lacunar infarcts involving the ventral pons or internal capsule

Answer 18

Ipsilateral ataxia and leg paresis, dysarthria, facial weakness, dysphagia, mild hand weakness and clumsiness

Question 19

What % of intraparenchymal haemorrhage is caused by hypertension?

Answer 19

50%

Question 20

State the most common site of intraparenchymal haemorrhage

Answer 20

Basal ganglia

Question 21

What is the most common cause of subarachnoid haemorrhage?

Answer 21

Rupture of a berry aneurysm (85%)

Question 22

What is the most common site of subarachnoid haemorrhage?

Answer 22

Internal carotid bifurcation

Question 23

Describe the clinical features of subarachnoid haemorrhage

Answer 23

Thunderclap headache, vomiting, impaired consciousness

Question 24

State at least three risk factors for subarachnoid haemorrhage

Answer 24

Polycystic kidney disease, Ehlers Danlos syndrome, aortic coarctation, arteriovenous malformation, capillary telangiectasia, cavernous angioma

Question 25

Describe the pathophysiology of extradural haemorrhage

Answer 25

Skull fracture leads to rupture of the middle meningeal artery, causing a rapid arterial bleed. The patient has a lucid interval then loses consciousness

Question 26

Describe the pathophysiology of subdural haemorrhage

Answer 26

A minor trauma damages bridging veins causing a slow venous bleed. The patient is fine then develops fluctuating consciousness

Question 27

State the two main risk factors for subdural haemorrhage

Answer 27

Old age, alcoholism - both cause brain atrophy

Question 28

Name the six types of brain herniation

Answer 28

Uncal, transtentorial, cingulate (subfalcine), transcalvarial, upward, tonsillar