Cerebrovascular Disease Flashcards
What are the 2 key features of a stroke
- Sudden onset of symptoms
2. Focal neurology
Causes of Strokes
- Ischaemic (vaso-occlusive_
- 85% of cases
- Thromboembolic
- In situ blockage (small vessel - lacunar) - Haemorrhagic
- Considered in: Marked HTN, anticoagulants, prominent headache
What is a TIA
Cerebrovascular incident lasting <24 hours
What artery is occluded to cause Amaurosis Fugax
Ophthalmic branch of internal carotid
What is the significance of a TIA
Suggests active plaque
- High risk of subsequent stroke
- 50% of strokes after TIA are within a week
TIA - Investigations
Determine source
- Carotid ultrasound
- Echo
What level of artery occlusion indicates endarterectomy
> 70%
What are the clinical features of an Anterior Circulation stroke
- Contralateral Hemiplegia
- Homonymous Heminaopia
- Higher cerebral dysfunction
- dysphagia/motor neglect depending on hemisphere
Difference between TACS + PACS
TACs
- Occlusion of anterior + middle cerebral arteries
- All 3 clinical features of an anterior stroke
PACs
- Occlusion of anterior/middle cerebral artery
- 2/3 clinical features of an anterior stroke
Clinical features of a Posterior circulation stroke
Vague, any combination is suggestive
- Diplopia
- Dysarthria
- Dysphagia
- Unsteadiness
- Unilateral weakness
- Bilateral vision loss
- Amnesia
Posterior Circulation stroke prognosis
Tends to be catastrophic
Can lead to
- coma, pinpoint pupils, paresis, pyrexia
Can also lead to death
What is a Lacunar stroke
Small vessel occlusion
May cause internal capsule strokes
- pure motor or pure sensory deficits
Tends not to have ocular involvement
Better recovery
What is the gold standard investigation for suspected stroke
CT head
- determines whether ischaemic or haemorrhagic
What additional imaging can be done for ischaemic strokes
- Carotid ultrasound
- Echo
To determine cause
What additional imaging can be done for haemorrhagic strokes
Angiography
- if clinical picture poor
- if suspected subarachnoid haemorrhage
What is the acute management of ischaemic strokes
Thrombolysis (alteplase)
- if within 4 hours
Aspirin 300mg
- then 75-100mg for subsequent days
What is the acute management for haemorrhagic strokes
Lower BP
Stop anticoagulants
Consider neurosurgical input
- for surgical drainage
What is the additional acute management for both type of strokes
- Move to stroke ward: appropriate nursing
- Assess swallow: potentially NG tube
- Physiotherapy: prevent contracture
What is the long term management of strokes
- Address cardiovascular risk factors
- Carotid endarterectomy (occlusion >70%)
- Managment/Prevention of disability: MDT
What are the main causes of Subarachnoid Haemorrhages
- Ruptured berry aneurysm (70%)
- AV malformation (10%)
Subarachnoid Haemorrhage - Clinical Features
- Thunderclap headache (classic)
- Signs: none > meningism > coma
- No focal neurology
Subarachnoid Haemorrhage - Investigations
- CT head (usually diagnostic)
- Lumbar puncture >12hr after onset (if CT unclear)
- Angiogram (locate aneurysm)
What will a lumbar puncture show with a subarachnoid haemorrhage
Xanthochromia (presence of bilirubin)
Subarachnoid Haemorrhage - Management
BP control
- acutely maintain at 150
- long term lower
Endovascular occlusion/Open surgical clipping
Subarachnoid Haemorrhage - Prognosis
Poor
<40% have a good outcome
Main causes of brain shrinkage
- Old age
- Dementia
- Alcohol excess
What is the pathophysiology of a Subdural haemorrhage
- Venous blood leaks into subdural space
- Osmotic effect: sucks fluid from extracellular space
- Creates space-occupying lesion effect
- Expands slowly over several weeks
Subdural Haemorrhage - Clinical Features
- History of trauma
- Slow progression of focal neurology
- Older patients less specific: ‘off-legs’
Subdural Haemorrhage - Investigations
CT head (diagnostic) - remember old blood looks different
Subdural Haemorrhage - Management
Surgical Drainage
- even in older patients
Venous Sinus Thrombosis - Demographics
- 75% are female
- Typically younger patients
What are the 2 causes of Venous Sinus Thrombosis
- Local cerebral vein occlusion
- Focal neurology
- Highly epileptogenic - Cerebral sinus occlusion
- Focal neurology
- Raised ICP (headaches)
Venous Sinus Thrombosis - Clinical features
- Wide variation - depends on which vein
- Can be acute or subacute
- Headache/papiloedema (sinus)
- Seizures (vein)
- Disorders of consciousness
What is the diagnostic investigation for Venous Sinus Thrombosis
MRI with contrast angiography
Management
- Heparin
- Local thrombolysis
- Mannitol +/- acetazolamide (raised ICP)
- Surgical removal
