Cerebrovascular Disease (stroke and TIA) Flashcards
Aetiology
Interrupted BS to brain.
Stroke if over 24 hour symptoms. TIA if under.
Strokes- 70% cerebral infarction, 15% primary haemorrhage, 5% subarachnoid haemorrhage.
Can be caused by TE eg from CA atheroma.
RFS- HTN, smoking, DM, HD, hyperlidpidaemia, CF disorders, AF.
Causes-
-small vessel occlusion or thrombosis in situ.
-cardiac emboli (AF, endocarditis, MI).
-atherothromboembolism eg from carotids.
-CNS bleed eg HTN, trauma, aneurysm rupture, anticoagulation, thrombolysis.
-other- carotid dissection, vasculitis, SAH, venous sinus thrombosis etc.
Symptoms
Contralateral sensory and motor loss
Disturbed speech
Forehead sparing
Complications
Reoccurrence Loss independence of care Bladder and bowel dysfunction Dysphagia Altered mood and cognition Vascular dementia.
Diagnosis
Blood glucose! Haematological- FBC, INR Biochemical- UE, LFT, TFT, glucose, lipid. ECG Echocardiogram CXR Sickle cell Syphillis screen Carotid doppler CT in 4 hours, especially if eligible for thrombolysis. Most CT before 3 hours show no change if ischaemic stroke, would see bleeding. Maybe MRI.
Management
-ABCDE
-Oxygen
-Glucose control
-BP monitoring, HR, BP, ECG
-Urgent CT/MRI if thrombolysis considered, cerebellar signs, high risk haemorrhage. CT rules out primary haemorrhage. Diffusion weighted MRI shows acute infarct.
-Think about ability to swallow regarding route of administration.
NBM.
-Aspirin
-Anti platelet eg clopidogrel.
-IV thrombolysis if haemorrhage excluded, within 3 hours of onset (up to 4.5 if under 80), not on warfarin etc, independent self carer. Eg alteplase.
Contra indications- major infarct of haemorrhage on CT, mild deficit only, recent birth/ surgery/trauma, past CNS bleed, AVM or aneurysm, liver disease, seizures, anticoagulants, low platelets, very high BP
-Thrombectomy
-Surgery eg correct hydrocephalus, decrease ICP.
-Rehab, education, training, carer.
Differentials
Hypoglycaemia Head injury Migraines aura Epilepsy SOL Demyelination Labyrinthe disorders CNS tumour or lymphoma Wernickes or hepatic encephalopathy Subdural bleed Drug OD Bells plasy Abcess
Frontal lobe stroke symptoms
Pre and motor cortex
Broca’s (not fluent)
Prefrontal cortex (personality and behaviour)
Parietal lobe stroke symptoms
Primary sensory cortex (parasthesia)
Non dominant lesions- visuospatial issues
Superior optic radiation (inferior quadrantanopia/hemianopia)
Temporal lobe stroke symptoms
Central representation- auditory, vestibular, taste, smell function.
Wernicke’s (nonsense)
Memory circuits
Inferior optic radiation (superior quandrananopia)
Cerebellar and brainstem stroke symptoms
Motor and sensory tracts CN nuclei Balance and coordination. DANISH- Dysdiadokinesia and dysmetria Ataxia Nystagmus Intention tremor Slurred speech Hypotonia
Occipital lobe stroke symptoms
Visual cortex
Oxfordshire stroke classification
-TACS total anterior circulation stroke-
ICA or MCA, usually cardiac emboli. Contralateral hemiparesis, hemisensory loss and hemianopia. Higher cerebral dysfunction. High mortality.
PACS partial anterior-
MCS branch, usually large vessel disease eg carotids. 2 of above OR restricted motor deficit OR isolated cortical signs. High early recurrence.
LACS lacunar stroke-
Single perforating A eg basal ganglia/pons, small vessel disease ie atheroma in situ. Pure motor or sensory, sensorimotor, ataxic, hemiparesis. Silent and under diagnosed.
POCS posterior-
Brainstem, cerebellar or occipital involvement. Complex px. Thrombosis, can be anything.
Stroke history
Onset- when, speed, progression.
Neuro symptoms- body part, modalities, postive or negative?
Associated- headache, seizure (bleed), vomiting (RICP), drowsy, cardiac symptoms.
Atypical px- delirium, confusion, collapse, incontinence.
Neuro deficit patterns
Unilateral hemi or monoparesis
Unilateral facial N palsy (LMN vs UMN)
Unilateral sensory deficit and modalities
Dominant cortical (dysphagia, dysgraphia, dyslexia)
Non dominant cortical (visuospatial disorder, neglect)
Hemi and quadrantanopia both eyes
CN signs
Cerebellar signs
Prevention
Antithrombotic
RF tx eg HTN, hyperlipid, carotid surgery, DM tx.
Lifestyle.
Medication compliance.
