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CP3 @ UoN - Medicine & Surgery > Cerebrovascular Disease > Flashcards

Cerebrovascular Disease Flashcards

1
Q

What is a stroke?

A

An acute, focal, neurological deficit of cerebrovascular origin that persists >24hrs or leads to death

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2
Q

What is a transient ischaemic attack (TIA)?

A

An acute, focal, neurological deficit of cerebrovascular origin that persists <1hr, w/o signs of cerebral infarction on MRI scanning

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3
Q

What is the main complication of a TIA?

A

High risk of stroke w/i 4wks

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4
Q

What is amaurosis fugax?

A

Sudden, transient loss of vision in one eye
Often occurring w/ TIAs/ICA stenosis
Also found in ocular disease/migraine

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5
Q

What are the irreversible risk factors contributing to ischaemic stroke?

A

Age
Personal/family hx
Hyper-coagulable states
AF

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6
Q

What are the reversible risk factors contributing to ischaemic stroke?

A 
HTN
Hypercholesterolemia
DM
Smoking/alcohol
Poor diet/low exercise/obesity
Oestrogen containing contraceptives
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7
Q

What are some of the less common risk factors contributing to ischaemic stroke?

A 
Endocarditis
Migraine
Polycythaemia
APL syndomre
Vasculitis
Amyloidosis
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8
Q

What are the risk factors for haemorrhagic stroke?

A 
Family hx
Uncontrolled HTN
Vascular abnormalities
Coagulopathies/anticoag therapy
Heavy, recent alcohol intake
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9
Q

What are the two main types of stroke?

A

Infarction (85%) - thrombosis or embolus

Haemorrhagic (15%)

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10
Q

What are the common sites of arterial thrombosis in infarction strokes?

A

Carotid
Vertebral
Basilar

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11
Q

What are the two common types of haemorrhagic stroke?

A

Sub-arachnoid haemorrhage (5%)

Intra-cerebral haemorrhage (10%)

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12
Q

What are the different types of cerebral ischaemia?

A

Regional infarction
Lacunar infarction
Global ischaemia

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13
Q

Describe regional infarction

A

Thrombosis/embolus in large vessels

Affects cortical areas

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14
Q

Describe lacunar infarctions

A

Microinfarcts caused by small vessel disease
Affects subcortical areas
Can be asymptomatic

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15
Q

What are the potential long term complications of a lacunar infarct?

A

Vascular pseudo-Parkinsonism

Vascular dementia

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16
Q

Describe global ischaemia?

A

Infarcts at arterial boundary zone due to global reduction in blood flow due to severe hypotension

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17
Q

What is the main acute complication of global ischaemia?

A

Cortical laminar necrosis

  • death of majority of neurons 24hrs after insult
  • pt remains in vegetative state
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18
Q

What are the three zones of areas of cerebral ischaemic damage?

A 
Infarct core (tissue certain to die)
Oligaemic periphery (tissue that will survive)
Ischaemic penumbra (tissue in b/w, either outcome possible)
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19
Q

What infarct changes can be seen >24hrs?

A

Focal swelling

Loss of normal grey-white differentiation

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20
Q

In what way may large cerebral infarcts cause death?

A

Associated tissue oedema –> herniation –> brainstem compression
Infarcts in critical sites incompatible w/ life

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21
Q

What is the most common cause of 2o death in stroke patients?

A

Pneumonia, 2o to aspiration/immobility

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22
Q

What are the clinical features of ischaemic stroke?

A

Contralateral limb weakness/hemiplegia
-at first flaccid, reflexes then return and become brisk w/ extensor plantar
-weakness maximal at first, returns over wks/mo
Facial weakness
Higher dysfunction
Visual disturbances
Epileptic fit

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23
Q

What are the common sx of higher dysfunction present in ischaemic stroke?

A 
Expressive aphasia
Receptive aphasia
Apraxia
Asterognosis
Agnosia
Inattention (neglect)
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24
Q

What is expressive aphasia?

A

Inability to express language despite intact comprehension

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25
Q

What is receptive aphasia?

A

Inability to understand commands/world

Fluent but meaningless speech

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26
Q

What is apraxia?

A

Difficulty performing tasks despite intact motor function

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27
Q

What is asterognosis?

A

Inability to identify objects in both hands by touch alone despite intact sensation

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28
Q

What is agnosia?

A

Inability to recognise objects, persons, sounds, shapes or smells despite the specific sense being intact and no memory loss

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29
Q

What is inattention (neglect)?

A

Inability to attend to stimuli despite intact senses

30
Q

What is the Oxford (Bamford) classification of Stroke?

A

Simple bedside method of classifying acute strokes using pts sx to identify the region affected
Allows prognostic prediction

31
Q

What are the four types of Bamford stroke?

A

TACS
PACS
LACS
POCS

32
Q

What is a TACS, and which vessel is affected?

A

Total Anterior Circulation Syndrome

-proximal MCA occlusion

33
Q

What is a PACS and which vessel is affected?

A

Partial Anterior Circulation Syndrome

-distal MCA OR ACA occlusion

34
Q

What is a LACS and which vessel is affected?

A

Lacunar Anterior Circulation Syndrome

-occlusion of lacunar branch of MCA

35
Q

What is a POCS and which vessel is affected?

A

Posterior Circulation Syndrome

-occlusion of PCA

36
Q

What are the diagnostic criteria for a TACS?

A

ALL OF

  • higher dysfunction
  • homonymous hemianopia
  • contralateral hemiplegia/sensory loss
    • > 2 of face/arm/leg involvement
37
Q

What are the diagnostic criteria for a PACS?

A 
2/3 OF TACS CRITERIA
   -higher dysfunction
   -homonymous hemianopia 
   -hemiplegia/sensory loss
OR
Higher dysfunction alone w/ spared vision
38
Q

What are the diagnostic criteria for a LACS?

A

Pure motor sx (>2/3 face/arm/leg) OR
Pure sensory sx (>2/3 face/arm/leg) OR
Pure sensorimotor sx (>2/3 face/arm/leg) OR
Ataxic hemiparesis

39
Q

What are the diagnostic criteria for a POCS?

A 
Cranial nerve palsy AND contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement problems
Cerebellar dysfunction
Isolated homonymous hemianopia
40
Q

What is the 1yr prognosis for a TACS?

A

Dead - 60%
Dependent - 25%
Independent - 5%
Recurrence 1 yr - 5%

41
Q

What is the 1yr prognosis for a PACS?

A

Dead - 15%
Dependent - 30%
Independent - 55%
Recurrence 1 yr - 20%

42
Q

What is the 1yr prognosis for a LACS?

A

Dead - 10%
Dependent - 30%
Independent - 60%
Recurrence 1 yr - 10%

43
Q

What is the 1yr prognosis for a POCS?

A

Dead - 20%
Dependent - 30%
Independent - 50%
Recurrence 1 yr - 20%

44
Q

What is the NHISS?

A

National institute of health stroke scale

  • 15 item neurological exam
  • gives insight into location of stroke/severity
45
Q

What investigations are appropriate in a suspected stroke?

A 
Bloods --> FBCs, U&amp;Es, G6, HbA1c, lipids, coag, ESR
Brain imaging w/i 1hr
   -if considering thrombolysis
   -if bleeding risk/headache at onset
   -if decreased consciousness
   -if neck stiffness
ECG
46
Q

What is the aim of brain imaging in a suspected stroke?

A

Define arterial territory
Exclude stroke mimics
Determine haemorrhagic/thrombo-embolic pathology

47
Q

What imaging modalities are used in suspected stroke?

A

MRI - gold standard, high resolution, less available

CT - rapid, used to exclude haemorrhage

48
Q

What are the signs of an infarct on CT?

A 
Early signs
   -loss of grey-white differentiation
   -sulcal effacement
   -loss of insular ribbon
Lesions visible by day 7 (50%)
49
Q

What is the emergency management of acute stroke?

A

ABCDE (exclude hypoglycaemia)
Withhold antiplatelet therapy until haemorrhage excluded
-if excluded give aspirin 300mg
Thrombolysis

50
Q

What is the time limit for thromboylsis?

A

<4.5hrs

51
Q

What medication is used for thrombolysis?

A

Alteplase 0.9mg/kg

10% bolus over 1min, remainder over 60mins

52
Q

What is the ward management of an acute stroke?

A

SALT assessment w/i 2hrs
Physiotherapy –> To relieve spasticity/contractures (baclofen)
Occupational therapy –> Limb splinting, ward groups
Nutrition
LMWH anticoagulation (3/7 post ischaemic stroke)

53
Q

What are the absolute contraindications to thrombolysis?

A 
Intracranial haemorrhage on CT
SAH
Neurosurgery/head trauma/stroke in past 3mo
Uncontrolled HTN
Active internal bleeding
Known AV malformation
Suspected/confirmed endocarditis
54
Q

What steps should be taken post-thrombolysis?

A

Pt closely monitored over 24hrs
Avoid catheterisation during infusion
Avoid aspirin/heparin for 24hrs
Avoid NG tube insertion for 24hrs

55
Q

What sx indicate the need for an emergency CT post-thrombolysis?

A

Severe headache
Acute HTN
N/V

56
Q

What treatment should be given if thrombolysis is contraindicated?

A

Manage supportively on ward
Continue 300mg aspirin OD
2o prevention measures

57
Q

What 2o prevention measures should be taken post stroke?

A

Identify/tackle lifestyle risk factors (smoking/alcohol/exercise)
Antihypertensive therapy –> Start w/i 2wks, lower slowly
Antiplatelet therapy –> Aspirin 300mg OD, clopidogrel 75mg
Statin –> 48hrs post-stroke
Manage co-morbidities (AF, carotid USS)

58
Q

What legislation surrounds driving and strokes?

A

Pts w/ normal license must not drive for 4wks

If clinical improvement then may return to driving

59
Q

What are the potential post-stroke complications?

A 
Malignant MCA syndrome
DVT/PE
Aspiration/hydrostatic pneumonia
Pressure sores
Depression
Seizures
Incontinence
Post-stroke pain
60
Q

What is malignant MCA syndrome?

A

Rapid neurological deterioration due to effects of cerebral oedema following MCA stroke
High morbidity/mortality

61
Q

What is the presentation of malignant MCA syndrome?

A

Increased agitation/restlessness
Reducing GCS
Haemodynamic/thermal instability
Signs of raised ICP

62
Q

What is the management of malignant MCA syndrome?

A

Decompressive hemicraniectomy

63
Q

What is the indication for decompressive hemicraniectomy in malignant MCA syndrome?

A

CT/MRI showing infarct >50% of MCA territory in a pt <60yrs w/ any decrease in consciousness

64
Q

What are the high-risk features of TIAs?

A 
Recurrent TIAs w/i short period of time
AF/TIA whilst anticoagulated
ABCD2 score >4
   -Age (>60, 1 point)
   -BP (>140/90, 1 point)
   -Clinical features (Unilateral weakness, 2 points. Speech disturbance w/o weakness, 1 point)
   -Duration of sx (>60mins, 2 points. 10-59 mins, 1 point)
   -Diabetes (Pre-existing DM, 1 point)
65
Q

What is the management of TIA if high-risk features are present?

A

Statin (40mg)
300mg Aspirin
Referral to specialist clinic w/i 24hrs
Advise pt not to drive until seen by specialist

66
Q

What is the management of low-risk TIA?

A

Same as high risk but referral w/i 1wk instead of 24hrs

67
Q

How is carotid artery stenosis assessed?

A

Carotid artery doppler

68
Q

When should carotid endarterectomy be offered?

A

Stenosis >50%

69
Q

What are the benefits of carotid endarterectomy?

A

Reduces risk of further stroke/TIA by 75%

Reduces mortality

70
Q

What is available as an alternative to carotid endarterectomy?

A

Percutaneous luminal angioplasty +/- stenting

CP3 @ UoN - Medicine & Surgery (135 decks)

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