Cerebrovascular Disease

Question 1

What are the 2 key features of a stroke

Answer 1

1. Sudden onset of symptoms

2. Focal neurology

Question 2

Causes of Strokes

Answer 2

1. Ischaemic (vaso-occlusive_
   - 85% of cases
   - Thromboembolic
   - In situ blockage (small vessel - lacunar)
2. Haemorrhagic
   - Considered in: Marked HTN, anticoagulants, prominent headache

Question 3

What is a TIA

Answer 3

Cerebrovascular incident lasting <24 hours

Question 4

What artery is occluded to cause Amaurosis Fugax

Answer 4

Ophthalmic branch of internal carotid

Question 5

What is the significance of a TIA

Answer 5

Suggests active plaque

• High risk of subsequent stroke
• 50% of strokes after TIA are within a week

Question 6

TIA - Investigations

Answer 6

Determine source

• Carotid ultrasound
• Echo

Question 7

What level of artery occlusion indicates endarterectomy

Answer 7

> 70%

Question 8

What are the clinical features of an Anterior Circulation stroke

Answer 8

1. Contralateral Hemiplegia
2. Homonymous Heminaopia
3. Higher cerebral dysfunction
   - dysphagia/motor neglect depending on hemisphere

Question 9

Difference between TACS + PACS

Answer 9

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

Question 10

Clinical features of a Posterior circulation stroke

Answer 10

Vague, any combination is suggestive

• Diplopia
• Dysarthria
• Dysphagia
• Unsteadiness
• Unilateral weakness
• Bilateral vision loss
• Amnesia

Question 11

Posterior Circulation stroke prognosis

Answer 11

Tends to be catastrophic

Can lead to
- coma, pinpoint pupils, paresis, pyrexia

Can also lead to death

Question 12

What is a Lacunar stroke

Answer 12

Small vessel occlusion

May cause internal capsule strokes
- pure motor or pure sensory deficits

Tends not to have ocular involvement

Better recovery

Question 13

What is the gold standard investigation for suspected stroke

Answer 13

CT head

- determines whether ischaemic or haemorrhagic

Question 14

What additional imaging can be done for ischaemic strokes

Answer 14

• Carotid ultrasound
• Echo

To determine cause

Question 15

What additional imaging can be done for haemorrhagic strokes

Answer 15

Angiography

• if clinical picture poor
• if suspected subarachnoid haemorrhage

Question 16

What is the acute management of ischaemic strokes

Answer 16

Thrombolysis (alteplase)
- if within 4 hours

Aspirin 300mg
- then 75-100mg for subsequent days

Question 17

What is the acute management for haemorrhagic strokes

Answer 17

Lower BP
Stop anticoagulants
Consider neurosurgical input
- for surgical drainage

Question 18

What is the additional acute management for both type of strokes

Answer 18

• Move to stroke ward: appropriate nursing
• Assess swallow: potentially NG tube
• Physiotherapy: prevent contracture

Question 19

What is the long term management of strokes

Answer 19

• Address cardiovascular risk factors
• Carotid endarterectomy (occlusion >70%)
• Managment/Prevention of disability: MDT

Question 20

What are the main causes of Subarachnoid Haemorrhages

Answer 20

• Ruptured berry aneurysm (70%)

- AV malformation (10%)

Question 21

Subarachnoid Haemorrhage - Clinical Features

Answer 21

• Thunderclap headache (classic)
• Signs: none > meningism > coma
• No focal neurology

Question 22

Subarachnoid Haemorrhage - Investigations

Answer 22

• CT head (usually diagnostic)
• Lumbar puncture >12hr after onset (if CT unclear)
• Angiogram (locate aneurysm)

Question 23

What will a lumbar puncture show with a subarachnoid haemorrhage

Answer 23

Xanthochromia (presence of bilirubin)

Question 24

Subarachnoid Haemorrhage - Management

Answer 24

BP control

• acutely maintain at 150
• long term lower

Endovascular occlusion/Open surgical clipping

Question 25

Subarachnoid Haemorrhage - Prognosis

Answer 25

Poor | <40% have a good outcome

Question 26

Main causes of brain shrinkage

Answer 26

- Old age - Dementia - Alcohol excess

Question 27

What is the pathophysiology of a Subdural haemorrhage

Answer 27

- Venous blood leaks into subdural space - Osmotic effect: sucks fluid from extracellular space - Creates space-occupying lesion effect - Expands slowly over several weeks

Question 28

Subdural Haemorrhage - Clinical Features

Answer 28

- History of trauma - Slow progression of focal neurology - Older patients less specific: 'off-legs'

Question 29

Subdural Haemorrhage - Investigations

Answer 29

``` CT head (diagnostic) - remember old blood looks different ```

Question 30

Subdural Haemorrhage - Management

Answer 30

Surgical Drainage | - even in older patients

Question 31

Venous Sinus Thrombosis - Demographics

Answer 31

- 75% are female | - Typically younger patients

Question 32

What are the 2 causes of Venous Sinus Thrombosis

Answer 32

1. Local cerebral vein occlusion - Focal neurology - Highly epileptogenic 2. Cerebral sinus occlusion - Focal neurology - Raised ICP (headaches)

Question 33

Venous Sinus Thrombosis - Clinical features

Answer 33

- Wide variation - depends on which vein - Can be acute or subacute - Headache/papiloedema (sinus) - Seizures (vein) - Disorders of consciousness

Question 34

What is the diagnostic investigation for Venous Sinus Thrombosis

Answer 34

MRI with contrast angiography

Question 35

Management

Answer 35

- Heparin - Local thrombolysis - Mannitol +/- acetazolamide (raised ICP) - Surgical removal