Cerebrovascular Disease- Stroke :) Flashcards
What is a stroke?
A stroke is a cerebrovascular event caused by disruption of blood supply to the brain.
What does a disruption of blood supply result in?
It results in damage and death of brain tissue because cells can no longer retrieve oxygen & nutrients from the blood.
What is a stroke characterised by?
- Rapidly developing signs of focal or global disturbance of cerebral functions
- Symptoms lasting for more than 24 hours.
In the UK it’s estimated _____________ people have a stroke and its the cause of ____________ deaths each year.
150,000
53,000 deaths
A further 20,000 people have a _______.
TIA.
What does TIA stand for and what is it?
Transient Ischemic Attack
Its a mini stroke, it can act as a warning sign for a future stroke.
Stroke is the largest cause of ________ and the third largest cause of ______.
Disability
Death.
What are the risk factors of stroke (why might a stroke happen)?
Alcohol use Obesity Old age Atrial fibliration High Blood Pressure Diabetes Poor Diet High Cholesterol Lack of physical activity Smoking.
What does FAST stand for?
Face
Arms
Speech
Time to call 999.
What are the signs of stroke?
- difficulty speaking
- trouble seeing in one or both eyes
- severe headache with no known cause
- Sudden weakness in limbs/face, most often on one side of the body
- Numbness of face/arm/leg on one side of the body
- confusion or understanding speech.
- trouble walking, dizziness, loss of balance or coordination.
What are the 4 that must be determined in triage?
- Time and Nature of Onset (when did symptoms start)
- Differential Diagnosis (is it a stroke?)
- Aetiology (what caused it?)
- Treatment Plan (what can we do to help)
Treatment plans aim to minimise ________ of _______________ and ________ future strokes.
Risk
Complications
Prevent
How do they determine the factors in triage?
They assess the patient’s clinical presentation
Image the brain
Run blood,heart and blood vessel tests
Symptoms depend on what?
- part of brain affected
- size of damaged area
Name the symptoms of a stroke affecting the posterior frontal, temporal, parietal lobes.
(contralateral - on other side of body from stroke ) Face and arm Leg weakness Sensory loss to all modalities Visual field cut Visua;-spatial neglect
ipsilateral (same side as stroke)
Gaze preference
dominant hemisphere affected: aphasia, alexia, agraphia, acalculia
The middle cerebral artery is the vasculatory territory supplying blood to where?
Posterior Frontal
Temporal
Parietal
Stroke affecting the _______ __________ ______________ causes aphasia.
Middle Cerebral Artery.
Stroke in what area can result in dysphagia?
Lateral Medulla.
Stroke affecting the lateral medulla is also known as what?
Wallenburg syndrome.
What artery supplies the lateral medulla?
Posterior Inferior Cerebral Artery.
Name symptoms of stroke affecting the lateral medulla.
Contralateral-
Loss of pain and temperatue sensation
Ipsilateral- Facial Pain Hemifacial pain and temperature loss ataxia nystagmus nausea/ vomitting vertigo
Hiccups
Can cause dysphagia.
What is used to confirm if an individual has had a stroke and the nature of the stroke?
Brainn Imaging (CT scan preferential).
Why is a CT scan normally used in these cases?
- Good at detecting acute bleeding and problems in bone eg. fractures or bone breaks
- It is quick (5-10 mins)
What is it difficult to do in the CT scan?
Image the brainstem.
When is an MRI scan performed?
If more information/detail is needed.
What is MRI best at detecting?
Small or subtle lesions.
The _____ scan takes about 45 mins to complete.
MRI
Why is a blood glucose test performed?
Low sugar levels may cause symptoms similar to those of a stroke.
Why do we measure platelet level?
Abnormal platelet levels may be a sign of:
- a bleeding disorder (not enough clotting)
- a thrombotic disorder (too much clotting)
What is an ECG?
Electrocardiogram
Records the heart’s electrical activity.
What does an ECG do?
It helps detect heart problems that may have led to a stroke.
eg. atrial fibrillation (irregular heart beat) or previous heart attack.
What uses sound waves to create pictures of your heart?
Echocardiography
What can echocardiography detect?
It can detect possible blood clots inside the heart and problems with the aorta.
What is the main supply of oxygen rich blood to the brain?
The carotid arteries.
Name this-
It uses sound waves to create pictures of the insides of the carotid arteries.
Carotid Ultrasound
What does a doppler ultrasound show?
The speed and direction of blood moving through the blood vessels.
What can a carotid ultrasound show?
It can show whether plaque has narrowed or blocked the carotid arteries.
If plaque in the carotid artery is untreated what can happen?
A blood clot can form and a piece of plaque breaks off which then goes to the brain.
Computed Tomography Arteriogram (CTA) and Magnetic Resonance Arteriogram (MRA) can show what?
It can show large blood vessels in the brain.
What can MRA and CTA give the doctor?
It can give the doctor more information about the site of a blood clot and the flow of blood through the brain.
CTA or MRA identifies where there’s issues with ______ _______.
blood flow.
What is a lumbar puncture?
A needle is inserted into the lower part of the spine.
It measure the pressure within the spinal canal and takes a sample of CSF to look for any traces of blood.
Why are all these tests so important?
Doctors must know what caused the stroke before they can choose the correct treatment.
Name the 2 Types of stroke.
Haemorrhagic Stroke
Ischaemic Stroke
What type of stroke is the most common?
Ischaemic
What is a haemorrhagic stroke?
A bleed in the brain.
A haemorrhagic results in high ____ and ___________. what is the outcome influenced by?
Morbidity
Mortality
Outcome influenced by the size of the bleed, its location, and the resultant complications.
Name the 2 main types of haemorrhagic stroke.
Intracerebral Haemorrhage
Subarachnoid Haemorrhage.
Explain what an intracerebral Haemorrhage is.
When an artery inside the brain bursts/ruptures.
Where do intracerebral haemorrhages most commonly occur?
In the basal ganglia.
Apart from the basal ganglia, where else can intracerebral haemorrhages occur?
In the cerebral lobes, cerebellum and pons.
What does the bursting and rupturing of the blood vessel result in?
Blood escaping into the brain tissue.
The escaped blood from the burst blood vessel collects forming a ______, putting ________ on surrounding tissue.
Haematoma
Pressure
Collecting blood has what sort of effects on surrounding tissue?
Toxic Effects.
ICH stands for what?
Intracerebral Haemorrhage.
The ICH may also extend into the ________.
Ventricles.
What produces CSF?
The ventricles.
What is the ultimate result of an intracerebral haemorrhage?
Damage to brain cells.
What is a SAH?
Subarachnoid Haemorrhage.
When does SAH occur?
When an aneurysm in an artery near the surface of the brain bursts.
What is an aneurysm?
An aneurysm is a localized, blood-filled balloon-like bulge in the wall of a blood vessel.
in a SAH-
Under pressure, the blood spills out into the __________ ________.
Subarachnoid space
A SAH results in- Acute rise in ______ pressure and a decrease in ____________ ______________ pressure.
Intracranial
Cerebral Perfusion
In a Subarachnoid Haemorrhage, what blood flow decreases?
Decrease in cerebral blood flow.
What does a SAH result in?
It results in ischaemia (reduction of blood flow to brain).
In addition to a SAH, what can happen?
Intracerebral and intraventricular extension of the haemorrhage.
What is the ultimate outcome of SAH?
Damage to brain cells.
Apart from haemorrhagic stroke, name the other type of stroke.
Ischeamic Stroke.
What is an ischaemic stroke?
The blockage of blood flow of part of brain.
______ stroke accounts for the majority of strokes.
Ischaemic.
Where can ischaemic strokes develop?
- They can develop in major blood vessels on brain surface
- or in smaller vessels deep within the brain.
Name the types of ischaemic stroke.
Embollic Infarct
Thrombotic Infarct
Lacunar Infarct
Infarct of unknown cause.
What is an embollic infarct?
A blood clot forms in one part of the body, travels through the bloodstream and lodges in and obstructs a blood vessel in the brain.
What is another word for blood clot?
embolism.
________ _______ account for 20-30% of ischaemic strokes.
Cardiac embolisms
Name this-
A blood clot forms in an artery that supplies the brain, causing tissue death.
Thrombotic Infarct.
How does a thrombotic infarct occur?
Usually occurs as a result of plaque build up in arteries and develops overtime.
_______ Infarcts account for 10-15% of ischaemic strokes.
Thrombotic.
Explain what a lacunar infarct is.
It usually occurs as a result of arterial blockage caused by high blood pressure (hypertension).
What type of stroke has the best prognosis?
Lacunar Infarct.
A Lacunar infarct makes up about _____ % of ischaemic cases.
20.
Infarcts of unknown causes account for ____% of ischaemic strokes.
30.
Name some rare causes of ischaemic stroke.
Trauma, infection and tumours.
What does TIA stand?
Transient Ischaemic Attack
In a TIA the symptoms resolve within ________ hours.
24
______ is a significant risk factor for stroke, what is it vital the individual does?
TIA
Vital that the individual seeks medical attention.
Prognosis depends on the _____ of the incident and how _______ medical care is accessed.
severity
quickly
What type of stroke (out of IS/HS) has a better outlook?
Ischaemic Stroke has a better outlook.
Do people survive a first stroke?
Yes, most people survive a first stroke, but often have significant morbidity.
After a stroke 75% of people survive after the ___ _________, ____% survive after 5 years.
first year
5 years
Describe how stroke can be managed.
Initial treatment and management in the Acute Stage (stabilising the patient)
Medical Management (get bleed to stop/break up clot)
Prevention of further strokes
Rehabilitation
Support
______ ____________ is ideally performed in a stroke unit.
Initial Treatment.
What does treating haemorrhagic stroke depend on?
The type and nature of the bleed.
What is an aim when treating haemorrhagic stroke?
To prevent potential complications.
How may a haemorrhagic stroke be treated?
Management of blood clotting levels
Intracranial pressure control
Treatment to help prevent Delayed Cerebral Ischaemia (blood irritates edges of blood vessels- SAH)
Craniotomy (removal of haematoma)
Repair of aneurysm (coiling and clipping)
What would be the most common ways of treating a haemorrhagic stroke?
Coiling (insert coil to stop bleeding)
Clipping (clip blood vessel to stop bleeding out)
In what type of stroke does treatment involve trying to get blood flowing again?
Ischaemic Stroke
What is the act of giving medication that can break down and disperse a clot?
Thrombolysis
What does a clot prevent?
It prevents blood reaching the brain.
What is tPA (tissue Plasminogen Activator)?
A clot-dissolving/clot-busting medication.
How and when is tPA given?
- tPA is injected into a vien in the arm
- Ideally it’s given as soon as possible
- Usually it’s given within 4 hours of symptom onset (at a push 6 hours in some circumstances.
What is a problem with Thrombolysis?
- Doesn’t work every time (only 1 in 7 people who recieve it benefit)
- Risk that it can cause harmful bleeding in your brain
- Not everybody is suitable.
Why may thrombolysis not be suitable?
- May have bleed in brain (haemorrhagic stroke)
- Don’t know when symptoms began
- Didn’t reach hospital in time
- Have a bleeding disorder
- Recent major surgery
- Stroke/ head injury within the past 3 months
- The medication they are on might not be compatible with tPA
What are other early treatments if thrombolysis isn’t possible?
- Antiplatelet medicine stops platelets clumping together and forming blood clots (aspirin)
- Anticoagulant medicine makes blood thinner preventing blood clots from getting any larger
- Intra-arterial thrombolysis
- Penumbra clot removal
- Mechanical Clot Removal in Cerebral Ischemia
What is intra-arterial thrombolysis?
- catheter put into the groin and threaded into tiny arteries of brain
- clot busting medicine is delivered through the catheter to break up the clot.
What is penumbra clot removal?
A catheter is threaded into the arteries of the brain and the clot is directly aspirated out.
Name this-
- device that removes blood clots from an artery
- catheter threaded through carotid artery to the affected artery in the brain
- device then pulls the blood clot out through the catheter.
Mechanical Clot Removal in Cerebral Ischaemia (MeRCI)
After either stopping the bleeding or getting the blood flowing, what must be maintained/restored?
Homeostasis must be restored/maintained.
How is homeostasis maintained?
- Oxygen Therapy
- Blood Sugar control
- Blood Pressure control
- Temperature
- Water Balance
- Ion Balance (Na, K+)
Name the 4 types of drugs given to people post stroke.
Anti-platelets
Anti-coagulants
Anti-hypertensives
Statins
Name the drug:
Makes platelets less sticky, reducing the chances of another clot forming. e.g. aspirin.
Anti-platelets
What drug changes the chemical composition of the blood to prevent clots?
Anti-coagulants
What are Anti-hypertensives?
Medication to lower high blood pressure. e.g. beta-blockers.
What do statins do?
They lower the level of cholesterol. (blocking an enzyme in the liver that produces cholesterol).
Within 7 days there can be many ______ ____________ of stroke.
Early complications.
Name some complications after an initial stroke.
- Expansion of infarct/ recurrent infarction
- Re-bleeding (SAH)
- Delayed Cerebral Ischaemia (SAH)
- Cerebral oedema and herniation
- Seizure
- Aspiration Pneumonitis (food gets into lungs)
- Myocardial Infarction
- Fever
- Hyperglycaemia
Name some late complications post stroke.
- seizure
- aspiration pneumonitis
- deep vein thrombosis and pulmonary embolism
- decubitus ulcer (pressure sore from staying in same position too long)
- spasticity
- delayed cerebral ischaemia (SAH)
- Recurrent Stroke
What is an infarct?
a small localized area of dead tissue resulting from failure of blood supply.
Name some ways to prevent future strokes.
- carotid endarterectomy
- carotid artery stent placement
- medications (Antiplatelets, Anti-coagulants, Anti-hypertensives and Statins)
What is a carotid endarterectomy?
A surgical procedure to unblock a carotid artery (remove build up of plaque).
Why is carotid endarterectomy performed?
To significantly reduce the risk of a stroke.
Around a quarter of strokes are caused by what?
The narrowing of the carotid arteries (from build up of plaque).
What is carotid artery stent replacement?
A catheter is inserted into and artery in your groin, threaded up into the carotid artery using x-rays to guide it into place.
A small inflated balloon is at the end of the catheter and the small mesh cylinder (stent) is then inserted.
The balloon is deflated and removed, leaving the stent in place.
What does a stent do?
It keeps the artery open and allows blood to flow through it.
Name a pro and con of carotid artery stent replacement.
pro= less invasive than a carotid endarterectomy- doesn't involve a cut being made at the neck con= doesn't remove the plaque.
Name what stroke can be caused by these risk factors:
- hypertension
- diabetes
- male
- over age 55
- lack of physical activity
- atrial fibrilation
Ischaemic stroke.
Name what stroke can be caused by these risk factors:
- illegal drug use
- hypertension
- tumour
- acute ischaemic stroke
- vascular malformation
Intracerebral stroke.
Name what stroke can be caused by these risk factors:
- hypertension
- smoking
- black
- female
- aneurysm
- alcohol abuse
Subarachnoid stroke.
What can the SLT help with?
- motor speech disorders (dysarthria, apraxia of speech)
- Language (aphasia)
- Communication (cognitive communication impairments)
- Swallowing (dysphagia)
Name some additional supports for patients post-stroke.
- Communication Partners (buddy system)
- Charities offer lots of services and support
- Carer support groups
Often people can have hemiplegia as a result of their stroke, what is this?
Half Paralysis.
Stroke can cause problems with balance and ______.
coordination.
as well as physical problems stroke can cause _____________ and _____________ problems.
cognitive and emotional.
Stroke can often cause _____, we must bear this in mind whilst working with patients.
fatigue.
