Cerebrovascular Disease Flashcards
Risk factors for intracranial haemorrhage
Head injury
Hypertension
Aneurysms
Ischaemic stroke can progress to haemorrhage
Brain tumours
Anticoagulants e.g. warfarin
Presentation of intracranial haemorrhage
Sudden onset headache is key feature
Seizures
Weakness
Vomiting
Reduced consciousness
Other sudden onset neurological symptoms
What is a transient ischaemic attack?
Sudden onset focal neurological deficit of vascular aetiology, with symptoms typically lasting less than 1 hour, and no evidence of acute infarct on imaging
Risk factors for TIA
Diabetes mellitus
High cholesterol
Hypertension
Smoking
Family history of cardiovascular disease/stroke
Atrial fibrillation is a risk factor for cardio-embolic TIAs
Presentation of TIA
Sudden onset, focal neurological deficit
Features resolve typically within 1 hour
Unilateral weakness or sensory loss
Aphasia or dysarthria
Ataxia, vertigo, or loss of balance
Visual problems (amaurosis fugax, diplopia, homonymous hemianopia)
Absence of headache
Investigations in TIA
MRI to assess territory
Carotid imaging
Management of TIA
Immediate antithrombotic therapy - 300mg aspirin
Secondary prevention for CV disease
Refer to stroke specialist
Advise not to drive until they have seen specialist
Define cerebral infarction (stroke)
Sudden onset focal neurological deficit of vascular aetiology, with symptoms lasting >24 hours (or with evidence of infarction on imaging)
Risk factors for stroke
Cardiovascular disease
Previous stroke or TIA
Atrial fibrillation
Carotid artery disease
Hypertension
Diabetes
Smoking
Vasculitis
Thrombophilia
Combined contraceptive pill
Aetiology of stroke
85% ischaemia/infarction
15% intracranial haemorrhage
Clinical features of stroke
Typically asymmetrical
Sudden weakness of limbs
Sudden facial weakness
Sudden onset dysphasia (speech disturbance)
Sudden onset visual or sensory loss
Which areas do total anterior circulation infarcts involve?
Middle and anterior cerebral arteries
Which areas do partial anterior circulation infarcts involve?
Smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
Which areas do lacunar anterior circulation infarcts involve?
Perforating arteries around the internal capsule, thalamus and basal ganglia
Which areas do posterior anterior circulation infarcts involve?
Vertebrobasilar arteries
How do LACIs present?
One of:
Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg, or all three
Pure sensory stroke
Ataxic hemiparesis
How do POCIs present?
One of:
Cerebellar or brainstem syndromes
Loss of consciousness
Isolated homonymous hemianopia
Investigations in stroke
Diffusion-weighted MRI
Carotid USS
Management of stroke
Admit to specialist stroke centre
Exclude hypoglycaemia
Immediate CT brain to exclude intracerebral haemorrhage
Aspirin 300mg stat (continue for 2 weeks)
Thrombolysis with alteplase
Thrombolysis vs. thrombectomy
Within 4.5hrs - thrombolysis with alteplase
> 4.5hrs and within 24hrs - thrombectomy
Thrombolysis contraindications
Previous intracranial haemorrhage
Seizure at onset of stroke
Intracranial neoplasm
Suspected subarachnoid haemorrhage
Stroke/traumatic brain injury in last 3 months
LP in last 7 days
GI bleed in last 3 days
Active bleeding
Pregnancy
Oesophageal varices
Uncontrolled HTN
Stroke secondary prevention
Clopidogrel 75mg OD
Anti-hypertensive 2 weeks post-stroke
Atorvastatin 20-80mg OD
Treat modifiable risk factors
Surgery if ipsilateral carotid artery stenosis
Causes of subarachnoid haemorrhage
Intracranial aneurysm
Arteriovenous malformation
Pituitary apoplexy
Arterial dissection
Mycotic (infective) aneurysms
Perimesencephalic (an idiopathic venous bleed)
Clinical features of subarachnoid haemorrhage
Sudden onset thunderclap (or baseball bat) occipital headache
Nausea and vomiting
Meningism(photophobia, neck stiffness)
Coma
Seizures
Sudden death
ECG changes includingST elevationmay be seen
Investigations in subarachnoid haemorrhage
CT head
LP - used to confirm if CT negative
What will LP show in subarachnoid haemorrhage?
Xanthochromia
Management of subarachnoid haemorrhage
Refer to neurosurgery
Bed rest, well-controlled BP
Coil/clip
Complications of subarachnoid haemorrhage
Re-bleeding (10%)
Vasospasm
Hyponatraemia
Seizures
Hydrocephalus
Death
