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Neurology + Psychiatry > Cerebrovascular Disease > Flashcards

Cerebrovascular Disease Flashcards

1
Q

What is a Transient Ischaemic Attack?

A
  • Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia
  • Without acute infarction
  • Also known as a mini stroke
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2
Q

What are the clinical features of a TIA?

A

=> Depends on the artery territory affected:

  • Anterior Cerebral Artery
  • Middle Cerebral Artery
  • Posterior Cerebral Artery
  • Branches of Posterior Cerebral Artery that supply midbrain
  • Posterior Inferior Cerebral Artery (PICA)
  • Anterior Inferior Cerebral Artery (AICA)
  • Ophthalmic Artery
  • Basilar Artery

=> Anterior Cerebral Artery occlusion:

  • Contralateral hemiparesis
  • Sensory loss, lower extremity > upper extremity

=> Middle Cerebral Artery occlusion:

  • Contralateral Hemiparesis
  • Sensory loss, upper extremity > lower extremity
  • Contralateral homonymous heminopia
  • Aphasia

=> Posterior Cerebral Artery occlusion:

  • Contralateral Homonymous Heminopia with macular sparing
  • Visual agnosia

=> Branches of PCA that supply midbrain (Webers syndrome):

  • Ipsilateral CN III palsy
  • Contralateral weakness of upper + lower extremities

=> PICA occlusion (Wallenberg syndrome):

  • Ipsilateral loss of facial pain and temp loss
  • Contralateral limb pain and temp loss
  • Ataxia
  • Nystagmus

=> AICA occlusion (Lateral pontine syndrome):
- Symptoms similar to PICA occlusion, but involves facial paralysis and deafness

=> Ophthalmic Artery occlusion:
- Amaurosis fugax (condition where person cannot see out of one or both eyes)

=> Basilar Artery occlusion:
- Locked in syndrome

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3
Q

What are the causes of TIAs?

A
  • Atherothromboembolism from carotid
  • Mural thrombus occlusion post MI and AF
  • Valve disease
  • Prosthetic valve
  • Hyperviscosity
  • Vasculitis
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4
Q

What are the investigations in suspected TIA cases?

A

=> Bloods

=> CXR

=> ECG

=> Carotid Doppler + angiography

=> Imaging - CT, MRI, Echo

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5
Q

What is the management of TIAs?

A
  1. Aspirin 300mg (unless patient has bleeding disorder, is already on aspirin or it is contraindicated)
  2. Add Clopidogrel (if clopidogrel contraindicated, consider aspirin + dipyridamole)
  3. Carotid artery endaterectomy considered in cases of carotid artery stenosis

=> If patient has > 1 TIA with cardioembolic source or severe cardiac stenosis:
- Discuss admission or urgent observation with stroke specialist

=> Suspected TIA in past 7 days:
- Urgent assessment (within 24 hours) with specialist

=> Suspected TIA more than a week ago:
- Referral ASAP within 7 days

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6
Q

What is the prognostic scoring system for TIAs?

A

=> ABCDD score

=> A - Age

Age ≥ 60 - 1 point

=> B - Blood pressure

BP ≥ 140/90 mmHg - 1 point

=> C - Clinical features

Unilateral weakness - 2 points
Speech disturbance without weakness - 1 point

=> D - Duration of symptoms

Symptoms ≥ 1 hour - 2 points
Symptoms 10-59 mins - 1 point

=> D - Diabetes - 1 point

Greater the score greater the risk

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7
Q

What is a stroke?

A

Sudden disruption in vascular supply to the brain

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8
Q

How is stroke catgoerised?

A

=> A stoke can be:

  • Ischaemic stroke
  • Haemorrhagic stroke

=> Ischaemic strokes can be categorised as:

  • Thrombotic strokes
  • Embolic strokes

=> Haemorrhagic strokes can be categorised as:

  • Intra-cerebral Haemorrhage
  • Subarachnoid Haemorrhage
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9
Q

What is an ischaemic stroke?

A

A blockage in a blood vessel which stops blood flow

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10
Q

What are the risk factors of an Ischaemic Stroke?

A
  • Age
  • Hypertension
  • Smoking
  • Hyperlipidemia
  • Diabetes
  • AF
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11
Q

What are the clinical features of an Ischaemic Stroke?

A

=> Depend on the region of infarction

=> Cerebral infarction:

  • Contralateral sensory loss
  • Contralateral hemiplegia
  • Dysphasia
  • Contralateral homomynous heminopia
  • Visuo-spatial defect

=> Brainstem infarction:

  • Lateral medullary syndrome
  • Locked in syndrome
  • Pseudobulbar palsy

=> Lacunar infarcts:

  • Pure motor
  • Pure sensory
  • Mixed motor and sensory signs
  • Ataxia
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12
Q

What is the difference between hemiperesis and hemiplegia?

A

Hemiperesis is slight paralysis or weakness of one side of the body where as hemiplegia is complete paralysis or weakness of one side

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13
Q

What is a Haemorrhagic stroke?

A
  • Caused by vascular rupture, followed by bleeding into the brain parrenchyma
  • This results in haematoma which expands and acts as a space occupying lesion
  • Expanding haematoma can also caused compression so increase in intracranial pressure

=> Hydrocephalus possible through block of CSF

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14
Q

How can you differentiate between a Haemorrhagic and Ischaemic stroke?

A

=> Haemorrhagic strokes are more likely to present with:

  • Decreased level of conciousness
  • Headache
  • Nausea and vomiting
  • Seizures
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15
Q

What are the risk factors of Haemorrhagic stroke?

A
  • Age
  • Hypertension
  • Arteriovenous malformation
  • Anticoagulation therapy
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16
Q

What are the risk factors of a Subarachnoid Haemorrhage?

A
  • Age
  • Hypertension
  • Arteriovenous malformation
  • Anticoagulation therapy
  • Family history of SAH
17
Q

What are the clinical features of Subarachnoid Haemorrhage?

A
  • Sudden onset headache
  • Nausea and vomiting
  • Photophobia + neck stiffness
  • Coma
  • Seizures
  • Sudden death
  • ECG changes

=> Typical presentation: Sudden onset of severe occiptal headache

18
Q

What tests are done to confirm the diagnosis of Subarachnoid Haemorrhage?

A
  • CT
  • If CT -ve, do a Lumbar Puncture after 12 hours following onset of symptoms. Look for Xanthachromia

LB CONTRAINDICATED IF RAISED ICP

19
Q

What are the investigations after confirming spontaneous Subarachnoid Haemorrhage?

A
  • CT

- MR Angiography to locate source and determine if surgery appropriate

20
Q

What is the management of Subarachnoid Haemorrhage?

A
  • Coiling or clipping depending on Berry Aneurysm size and accessibility
  • Strict bed rest and BP control
  • Nimadipine PO
  • External ventricular drain is cases of hydrocephalus
21
Q

What are some of the non-traumatic causes of Subarachnoid Haemorrhage?

A
  • Berry Aneurysm rupture
  • Arteriovenous malformation
  • Mycotic aneurysm
  • Pituitary apoplexy
  • Idiopathic
22
Q

What are the investigations in suspected Stroke?

A
  • CT scan within an hour
  • MRI better but limited availability
  • Lumbar Puncture if CT -ve (no raised ICP)
  • Doppler study in cases of Ischaemic stroke
  • Clotting screen in cases of haemorrhagic stroke
23
Q

What is the management of Stroke?

A
  1. Admit to stroke centre
  2. Exclude hypoglycaemia
  3. Immediate CT brain to exclude haemorrhage
  4. Aspirin 300mg cont for 2 weeks
  5. Thrombolysis with Alteplase (if within 4.5 hours of symptoms and haemorrhage excluded)
24
Q

What is Subarachnoid Haemorrhage?

A

=> Spontaneous non-traumatic bleed into the subarachnoid space

Most commonly as a result of the rupture of a Berry Aneurysm in non-traumatic cases

25
Q

What ares the different grades of Subarachnoid Haemorrhage?

A

=> Grade I
- No signs

=> Grade II
- Neck stiffness and cranial nerve palsies

=> Grade III
- Drowsiness

=> Grade IV
- Drowsy with hemiplegia

=> Grade V
- Prolonged coma

26
Q

What are the complications of a Subarachnoid Haemorrhage?

A
  • Re bleeding
  • Vasospasm leading to cerebral ischaemia
  • Hydrocephalus
  • Hyponatraemia
  • Seizure
  • Death

Neurology + Psychiatry (12 decks)

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