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Medicine Phase 2a Neuro > Cerebrovascular accident > Flashcards

Cerebrovascular accident Flashcards

1
Q

Examples

A

(TIA)

Stroke

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2
Q

Types of stroke

A

Ischaemic

Haemorrhagic

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3
Q

Define cerebrovascular accident

A

Syndrome of rapid onset of neurological deficit caused by focal, cerebral, spinal or retinal INFARCTION
Characterised by rapidly developing signs of focal or global disturbance of cerebral functions, lasting >24 hours or leading to death

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4
Q

Epidemiology

A

3rd most common cause of death in high-income countries (11% of UK deaths)
Leading cause of adult disability worldwide
Incidence increases with age
More common in males

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5
Q

Aetiology

A

Ischaemic/infarction account for 80% of strokes
Haemorrhagic account for 17% of strokes
Others causes 3%

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6
Q

What can cause Ischaemic/infarction that can result in stroke

A
  • Small vessel occlusion/ thrombosis in situ
  • Cardiac emboli from AF, MI or infective endocarditis
  • Large artery stenosis
  • Atherothromboembolism e.g. from carotid
  • Hypoperfusion, Vasculitis, Hyperviscosity (polycythaemia + sickle cell)
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7
Q

Causes of haemorrhages that can result in stroke

A 
Trauma
Aneurysm rupture
Anticoagulation
Thrombolysis
Carotid artery dissection
Subarachnoid haemorrhage
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8
Q

Causes in young people

A
  • Vasculitis
  • Thrombophilia
  • Subarachnoid haemorrhage
  • Carotid artery dissection - spontaneous, or from neck trauma
  • Venous sinus thrombosis
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9
Q

Causes in elderly

A
  • Thrombosis in situ
  • Athero-thromboembolism
  • Heart emboli e.g. AF, infective endocarditis or MI
  • CNS bleed
  • Sudden BP drop by more than 40mmHg
  • Vasculitis
  • Venous sinus thrombosis
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10
Q

Risk factors

A 
Male
Black/Asian
Hypertension
Past TIA
Smoking 
DM
Old age
Heart disease (valvular, ischaemic)
Alcohol
[Imagine patient with all of this]
Polycythaemia, thrombophilia; AF; hypercholestrolaemia; combine oral contraceptive pill; Vasculitis; Infective endocarditis
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11
Q

What % of strokes are ischaemic

A

70%

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12
Q

Aetiology of ischaemic stroke

A

Atherosclerosis is main pathological process.
Thrombosis occurs at site of athermatous plaque in carotid/vertebral/cerebral arteries.
Large artery stenosis acts as a source for embolism rather than occluding the vessel.
An occlusive vasculopathy known as lipohyalinosis that is a consequence of hypertension results in small infarcts known as ‘lacunes’ and/or the gradual accumulation of diffuse ischaemic change in deep white matter.

Ischaemic infarction due to occlusion of a vessel, usually by an embolism of a thrombus.

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13
Q

Pathophysiology of ischaemic stroke

A

Ischaemic -> infarct -> Death of neural tissue -> Loss of functionality

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14
Q

What is the name of the occlusive vasculopathy that results from hypertension and results in the gradual accumulation of diffuse ischaemic change in deep white matter

A

Lipohyalinosis

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15
Q

What is the name for the gradual accumulation of diffuse ischaemic change in deep white matter

A

Lacunes

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16
Q

Describe venous sinus thrombosis

A

Rare
Thrombosis within intracranial venous sinuses, such as the superior sagittal sinus, or in cortical veins
May occur in pregnancy, hypercoaguable states and thrombotic disorders or with dehydration or malignancy

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17
Q

What can result from venous sinus thrombosis

A

Cortical infarction
Seizures
Raised intracranial pressure

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18
Q

What % of strokes are haemorrhagic

A

17%

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19
Q

Risk factors of haemorrhagic stroke

A

Hypertension, excess alcohol, smoking and age

Space occupying lesion e.g. tumour - rare

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20
Q

Pathophysiology of haemorrhagic stroke

A

Primarily intracerebral haemorrhage
Risk factors -> small vessel disease and aneurysms -> rupture and haemorrhage
Hypertension resulting in micro aneurysm rupture

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21
Q

Aetiology of lobar intercerebral haemorrhage

A

Deposition of amyloid-B in the walls of small and medium-seized arteries in normotensive patients - particularly over 60

22
Q

Example of a cause of haemorrhagic stroke in young adults

A

1/5th strokes are due to carotid/vertebral artery dissection - can occur due to recent neck pain, trauma or neck manipulation

23
Q

General clinical presentation of ischaemic stroke

A

Depends on the location of the infarct. Cerebal hemisphere (most common):
Signs contralateral to the affected side. Hemiplegia, hemisensory loss, upper motor neurone facial weakness and hemianopia
Brainstem:
Complex, depending on location
Multi-infarct:
Multiple steps progressing to dementia

24
Q

Clinical presentation of haemorrhagic stroke

A

Severe headache, nausea/vomiting.
Sudden loss of consciousness -> Stroke
(similar to ischaemic)

25
Q

Clinical presentation of stroke of Anterior Cerebral Artery (ACA) Territory

A 
Leg weakness and leg sensory disturbances
Gait apraxia
Truncal ataxia
Incontinence
Drowsiness
Akinetic mutism
26
Q

What is apraxia and ataxia

A

(Gait) Apraxia = Loss of ability to have normal function of lower limbs such as walking
(Truncal) Ataxia = patients cant sit or stand unsupported and tend to fall backwards

27
Q

Why does stroke affecting the ACA cause drowsiness

A

since part of consciousness is in the frontal lobe (which the ACA supplies)

28
Q

What is akinetic mutism

A

Decrease in spontaneous speech

Stuporous state

29
Q

Clinical presentation of stroke of Middle Cerebral Artery (MCA) Territory

A 
CONTRALATERAL ARM & LEG WEAKNESS
CONTRALATERAL sensory loss
Hemianopia
Aphasia
Dysphasia
Facial droop
30
Q

What are aphasia and dysphasia

A

Aphasia - inability to understand or produce speech

Dysphasia - deficiency in speech generation

31
Q

Clinical presentation of stroke of Posterior Cerebral Artery (PCA) Territory

A 
CONTRALATERAL HOMONYMOUS HEMIANOPIA
Cortical blindness
Visual agnosia
Prosopagnosia
Colour naming and discriminate problems
Unilateral headache (*RARE in ischaemic stroke, so if you see headache then think PCA)
32
Q

Describe contralateral homonymous hemianopia

A

loss of half the vision of the same side in both eyes

33
Q

What is meant by cortical blindness

A

eye healthy, but brain issue causing blindness

34
Q

What are:
Visual agnosia
Prosopagnosia

A

Visual agnosia - cannot interpret visual information, but can see
Prosopagnosia - cannot see faces

35
Q

Clinical presentation of stroke of Posterior circulation territory such as vertebrobasilar artery

A

Motor deficits such as hemiparesis or tetraparesis and facial paralysis
Dysarthria (unclear speech articulation) & speech impairment
Vertigo, nausea & vomiting
Visual disturbance
Altered consciousness

36
Q

Why are posterior circulation stroke more catastrophic

A

Due to wide region supplied by it

37
Q

Describe lacunar stroke

A

Small subcortical strokes e.g. midbrain, internal capsule

38
Q

Clinical presentation of lacunar stroke

A 
Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three
Pure sensory loss
Ataxic hemiparesis (cerebellar and motor symptoms)

In general only 1 modality tends to be affected

39
Q

True or False:
No reliable way of distinguishing between haemorrhage and ischaemic infarcts

When could you assume otherwise

A

True

  • Intracerebral haemorrhage is more often associated with severe headache or coma (signs of raised intracranial pressure (ICP) i.e. due to blood forming space-occupying lesion)
  • Patients on oral anticoagulants should be assumed to have had a haemorrhage unless it is proved otherwise
40
Q

Differential diagnosis

A

Always EXCLUDE hypoglycaemia as a cause of sudden onset neurological syndrome
Hypoglycaemia
Migraine aura (symptoms spread and intensify over minutes, often with visual scintillations (sparkling/blinking))
Focal epilepsy
Intracranial lesion - tumour or subdural haemotoma
Syncope due to arrhythmia

41
Q

What is syncope

A

Temporary loss of consciousness usually related to insufficient blood flow to the brain
(AKA fainting)

42
Q

Diagnosis

A

Urgent CT head/MRI head BEFORE TREATMENT (CT to confirm ischaemic)
Pulse, BP and ECG - look for AF
Bloods - FBC, Glucose

43
Q

Why is it important to be careful in treating high BP

A

Even a 20% fall in BP may compromise cerebral perfusion

44
Q

Why are bloods done in diagnosis (FBC and glucose)

A

FBC - look for thrombocytopenia and polycythaemia

Blood glucose - to rule out hypoglycaemia

45
Q

When is CT head/MRI urgent

A

If suspected cerebellar stroke, unusual presentation (i.e. alternative diagnosis likely), high risk of haemorrhage (low GCS and signs of raised ICP)
Rule out haemorrhagic stroke before starting thrombolysis

46
Q

Treatment

A

Aspirin
IV alteplase in at least 4.5 hours (thrombolytic; IV tissue plasminogen activator)
Antiplatelet (aspirin -> Lifelong Clopidogrel)
Maintain glucose
NBM (Nil By Mouth)
Ensure hydration and keep O2 stats > 95%

Stop anticoagulants (Haemorrhagic)

47
Q

Describe risk factor management for stroke prevention

A

Platelet treatment (lifelong if already had stroke) e.g. ASPIRIN + DIPYRIDAMOLE or CLOPIDOGREL
Cholesterol treatment like statins e.g. SIMVASTATIN
Atrial fibrillation treatment e.g. WARFARIN or new oral anticoagulants e.g. PIXIBAN
Blood pressure treatment e.g. ACE-inhibitor e.g. RAMIPRIL

48
Q

Why is it important to ensure hydration and keep O2 stats > 95%

A

Maximise reversible ischaemic tissue

49
Q

Haemorrhagic treatment

A

Frequent GCS monitoring
Antiplatelets contraindicated
Any anticoagulants should be reversed for Warfarin reversal use BERIPLEX and VITAMIN K
Control hypertension
Manual decompression of raised ICP, can also reduce ICP by giving
diuretic e.g. MANNITOL
Surgery may be required

50
Q

Called by paramedics to inform you there is a 65 yr old RIGHT HANDED man who presents with a RIGHT SIDED WEAKNESS of BOTH ARMS & LEGS, DYSARTHRIA, LOSS OF VISION and DIFFICULTY SPEAKING
- Paramedics say symptoms came on SUDDENLY at 13:30
- Time is now 15:00
Diagnosis and treatment?

A

Diagnosis:
Likely to be MCA stroke since BOTH arms & legs involved

Treatment:
Within the 4.5 hour time frame for thrombolysis (alteplase) as long as CT head confirms ischaemic and no contraindications

51
Q

What is Clopidogrel

A

P2Y12 inhibitor

Antiplatelet drug

Medicine Phase 2a Neuro (28 decks)

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