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.
Ischaemic types
Thrombus in situ (atheroma)- small vessel
Emboli- cardiac, large vessel (neck/aortic arch)
Rarities
Haemorrhagic types
Primary bleed usually HTN Secondary to anticoagulation Underlying vascular abnormality Underlying tumour Cerebral amyloid angiopathy
Signs
Sudden onset
Indicators of bleeding (unreliable)- meningism, severe headache, fast coma.
Indicators of ischaemia- carotid bruit, AF, TIA past, IHD.
-cerebral infarct 50%- site dependant. Contralateral sensory loss. Hemiplegia initially flacid then spastic. Dysphagia. Homonymous hemianopia. Visuospatial defect.
-brainstem infarct 25%- quadriplegia, gaze and visual disturbance, locked in.
-lacunar infarct 25% (basal ganglia, internal capsule, thalamus, pons)- 5 syndromes: ataxic hemiparesis, pure motor, pure sensory, sensorimotor, dysarthria.
TIA causes
Carotid atherothromboembolism
Cardio embolism- AF, MI, valve.
Hyperviscosity- SCD, polycythaemia, myeloma, high WBC.
SAH causes
Rupture aneurysm- berry aneurysm commonly btw ICA and posterior communicating, or ACA and anterior communicating, or MCA bifurcation.
AVM
SAH symptoms
Sudden thunderclap headache occipital Vomit Collapse Seizure Coma
SAH signs
Stiff neck
Retinal bleed
CN III palsy
SAH diagnosis
CT
Blood in CSF
SAH management
Regular CNS exam
Maintain hydration
Endovascular coiling
IC stents and balloon remodelling
Explanation
- a stroke happens when part of the brain is deprived of oxygen from the blood. It can be because a BV has been blocked or because one has burst. you get symptoms such as paralysis and loss of sensation because the damaged part of brain cannot control these things very well anymore.
- can cause difficulties in moving, eating, going to the toilet etc. There is a risk that it will happen again, give medicine to try to stop this.
- lifestyle- smoking, alcohol, diet, exercise. Compliance with CVS drugs.
- at the time may give drugs to break a clot or surgery to remove a cot. LT anti platelet clopidogrel, aspirin. Rehab, physio, support at home.
