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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
What is receptive aphasia?
Inability to understand commands/world | Fluent but meaningless speech
26
What is apraxia?
Difficulty performing tasks despite intact motor function
27
What is asterognosis?
Inability to identify objects in both hands by touch alone despite intact sensation
28
What is agnosia?
Inability to recognise objects, persons, sounds, shapes or smells despite the specific sense being intact and no memory loss
29
What is inattention (neglect)?
Inability to attend to stimuli despite intact senses
30
What is the Oxford (Bamford) classification of Stroke?
Simple bedside method of classifying acute strokes using pts sx to identify the region affected Allows prognostic prediction
31
What are the four types of Bamford stroke?
TACS PACS LACS POCS
32
What is a TACS, and which vessel is affected?
Total Anterior Circulation Syndrome | -proximal MCA occlusion
33
What is a PACS and which vessel is affected?
Partial Anterior Circulation Syndrome | -distal MCA OR ACA occlusion
34
What is a LACS and which vessel is affected?
Lacunar Anterior Circulation Syndrome | -occlusion of lacunar branch of MCA
35
What is a POCS and which vessel is affected?
Posterior Circulation Syndrome | -occlusion of PCA
36
What are the diagnostic criteria for a TACS?
ALL OF - higher dysfunction - homonymous hemianopia - contralateral hemiplegia/sensory loss - >2 of face/arm/leg involvement
37
What are the diagnostic criteria for a PACS?
``` 2/3 OF TACS CRITERIA -higher dysfunction -homonymous hemianopia -hemiplegia/sensory loss OR Higher dysfunction alone w/ spared vision ```
38
What are the diagnostic criteria for a LACS?
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
What are the diagnostic criteria for a POCS?
``` Cranial nerve palsy AND contralateral motor/sensory deficit Bilateral motor/sensory deficit Conjugate eye movement problems Cerebellar dysfunction Isolated homonymous hemianopia ```
40
What is the 1yr prognosis for a TACS?
Dead - 60% Dependent - 25% Independent - 5% Recurrence 1 yr - 5%
41
What is the 1yr prognosis for a PACS?
Dead - 15% Dependent - 30% Independent - 55% Recurrence 1 yr - 20%
42
What is the 1yr prognosis for a LACS?
Dead - 10% Dependent - 30% Independent - 60% Recurrence 1 yr - 10%
43
What is the 1yr prognosis for a POCS?
Dead - 20% Dependent - 30% Independent - 50% Recurrence 1 yr - 20%
44
What is the NHISS?
National institute of health stroke scale - 15 item neurological exam - gives insight into location of stroke/severity
45
What investigations are appropriate in a suspected stroke?
``` Bloods --> FBCs, U&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
What is the aim of brain imaging in a suspected stroke?
Define arterial territory Exclude stroke mimics Determine haemorrhagic/thrombo-embolic pathology
47
What imaging modalities are used in suspected stroke?
MRI - gold standard, high resolution, less available | CT - rapid, used to exclude haemorrhage
48
What are the signs of an infarct on CT?
``` Early signs -loss of grey-white differentiation -sulcal effacement -loss of insular ribbon Lesions visible by day 7 (50%) ```
49
What is the emergency management of acute stroke?
ABCDE (exclude hypoglycaemia) Withhold antiplatelet therapy until haemorrhage excluded -if excluded give aspirin 300mg Thrombolysis
50
What is the time limit for thromboylsis?
<4.5hrs
51
What medication is used for thrombolysis?
Alteplase 0.9mg/kg | 10% bolus over 1min, remainder over 60mins
52
What is the ward management of an acute stroke?
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
What are the absolute contraindications to thrombolysis?
``` Intracranial haemorrhage on CT SAH Neurosurgery/head trauma/stroke in past 3mo Uncontrolled HTN Active internal bleeding Known AV malformation Suspected/confirmed endocarditis ```
54
What steps should be taken post-thrombolysis?
Pt closely monitored over 24hrs Avoid catheterisation during infusion Avoid aspirin/heparin for 24hrs Avoid NG tube insertion for 24hrs
55
What sx indicate the need for an emergency CT post-thrombolysis?
Severe headache Acute HTN N/V
56
What treatment should be given if thrombolysis is contraindicated?
Manage supportively on ward Continue 300mg aspirin OD 2o prevention measures
57
What 2o prevention measures should be taken post stroke?
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
What legislation surrounds driving and strokes?
Pts w/ normal license must not drive for 4wks | If clinical improvement then may return to driving
59
What are the potential post-stroke complications?
``` Malignant MCA syndrome DVT/PE Aspiration/hydrostatic pneumonia Pressure sores Depression Seizures Incontinence Post-stroke pain ```
60
What is malignant MCA syndrome?
Rapid neurological deterioration due to effects of cerebral oedema following MCA stroke High morbidity/mortality
61
What is the presentation of malignant MCA syndrome?
Increased agitation/restlessness Reducing GCS Haemodynamic/thermal instability Signs of raised ICP
62
What is the management of malignant MCA syndrome?
Decompressive hemicraniectomy
63
What is the indication for decompressive hemicraniectomy in malignant MCA syndrome?
CT/MRI showing infarct >50% of MCA territory in a pt <60yrs w/ any decrease in consciousness
64
What are the high-risk features of TIAs?
``` 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
What is the management of TIA if high-risk features are present?
Statin (40mg) 300mg Aspirin Referral to specialist clinic w/i 24hrs Advise pt not to drive until seen by specialist
66
What is the management of low-risk TIA?
Same as high risk but referral w/i 1wk instead of 24hrs
67
How is carotid artery stenosis assessed?
Carotid artery doppler
68
When should carotid endarterectomy be offered?
Stenosis >50%
69
What are the benefits of carotid endarterectomy?
Reduces risk of further stroke/TIA by 75% | Reduces mortality
70
What is available as an alternative to carotid endarterectomy?
Percutaneous luminal angioplasty +/- stenting

CP3 @ UoN - Medicine & Surgery (135 decks)

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