Group work scenarios Flashcards
Total Anterior Circulation Stroke - TACs
- Occlusion of a large cerebral artery (Internal carotid or middle cerebral)
- High mortality (60% at 1 year)
- All three of:
- Hemiplegia contralateral to the cerebral lesion, usually with contralateral hemi sensory loss
- Hemianopia Contralateral to cerebral lesion
- New disturbance of higher cerebral function (aphasia, visuospatial problems - neglect)
Lacunar Stroke - LACs
- Occlusion of a single deep perforating artery (lenticulatestriate)
- High recurrence rate and often missed
- Pure motor loss, OR pure sensory loss, OR ataxic hemiparesis i.e. a single deficit
Partial Anterior Circulation Stroke - PACs
Occlusion of a branch of the middle cerebral artery
High recurrence rate. 16% mortality at 1 year
Diagnosis requires 2 out of 3 TACS deficits, OR higher cerebral dysfunction alone, OR monoparesis, for example:
- Motor/sensory deficit + Hemianopia
- Motor/sensory deficit + new higher cerebral dysfunction
- New higher cerebral dysfunction alone
Posterior Circulation Stroke - POCs
- Occlusion of a posterior vessel (basilar/ vertebral/posterior cerebral) leading to cerebella/ brainstem/ occipital infarcts
- Complex presentation due if brainstem involved due to decussation of various tracts e.g.
- Ipsilateral cranial nerve palsy (single/multiple) with contralateral motor and /or sensory deficit
- Disorders of conjugate eye movement (horizontal/vertical)
- Cerebellar dysfunction without ipsilateral long tract sign
- Isolated hemianopia or cortical blindness
Causes of ischaemic stroke
- Cardioembolism (30%). Atrial fibrillation, myocardial infarction, prosthetic heart values, cardiac surgery, cardioversion, infectious endocarditis,
- Atherothrombosis in large vessels (15%). In situ (intracerebral vessels) , OR embolism from atherosclerotic plaques in extracerebral vessels (carotids, aortic arch, vertebral etc).
- Lacunar (20%). Caused by occlusion of deep penetrating arterial branches, especially the lentulastriate braches of the middle cerebral artery (MCA).
- Other ischaemic/crptogenic (15-20%). Venous sinus thrombosis, vasculitis, thrombophilia, carotid artery dissection,
- Intracerebral Haemorrhage (ICH) (10-15%). Bleeding into the brain parenchyma. Most common cause by far = hypertension. Others include cerebral amyloid angiopathy, arteriovenous malformation rupture, secondary ICH e.g. from tumours.
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
1) Are Mrs R’s symptoms likely to have an underlying vascular cause?
- risk factors
- sudden onset
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
1c) Has Mrs R had a TIA or a stroke?
probably TIA
ACA- think leg homonculus
*TIA- 24hrs symptoms*
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
2a) could anything else of caused her symptoms? List common stroke mimics
slipped disc
LMN lesion
seizure
migraine
pre-syncope
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
2a) which lobes of the brain have been affected?
frontal (motor cortex)- think medial homonculus
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
3) which blood vessel may have been occluded?
ACA–> branch of the internal carotid
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
4) What further investigations should be considered and why?
head CT, FBC, BM, ECG, cartotid US, MRI can be helpful
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
5) What type of brain imaging is most useful in TIA?
MRI (CT no longer suggested)
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker.
?6) What is the likely aetiology and pathophysiology of Mrs R’s event?
atherosclerotic plaque - occlusion
Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker
7) What immediate treatments should be considered to prevent stroke?
- antiplatelet (aspirin, apixiban)
- carotid endarectomy
- lipid- lowering- statin
- smoking cessation
- diet advice
Case Study 2 (Mr A): 65-year-old gentleman. Keen gardener. Found collapsed by wife. Drowsy with a dense left sided weakness, left homonymous hemianopia, and a fixed gaze palsy (to the right). Not attentive to his left side. Only past medical history is of Type 2 DM.
1) What is the most likely diagnosis?
stroke - ischamia, haemorrhagic
Case Study 2 (Mr A): 65-year-old gentleman. Keen gardener. Found collapsed by wife. Drowsy with a dense left sided weakness, left homonymous hemianopia, and a fixed gaze palsy (to the right). Not attentive to his left side. Only past medical history is of Type 2 DM.
2) What investigation should be performed immediately and why?
CT head- rule out haemorrhagic stroke (white)
Case Study 2 (Mr A): 65-year-old gentleman. Keen gardener. Found collapsed by wife. Drowsy with a dense left sided weakness, left homonymous hemianopia, and a fixed gaze palsy (to the right). Not attentive to his left side. Only past medical history is of Type 2 DM.
3) What is the likely Oxford classification (OSCP)?
TACS- right
Case Study 2 (Mr A): 65-year-old gentleman. Keen gardener. Found collapsed by wife. Drowsy with a dense left sided weakness, left homonymous hemianopia, and a fixed gaze palsy (to the right). Not attentive to his left side. Only past medical history is of Type 2 DM.
5) Which lobes of the brain have been affected? B) Which blood vessel has been occluded?
frontal
- internal carotid
- MCA
Case Study 2 (Mr A): 65-year-old gentleman. Keen gardener. Found collapsed by wife. Drowsy with a dense left sided weakness, left homonymous hemianopia, and a fixed gaze palsy (to the right). Not attentive to his left side. Only past medical history is of Type 2 DM.
6) Should thrombolysis be given?
yes if within 4.5 hours
Case Study 2 (Mr A): 65-year-old gentleman. Keen gardener. Found collapsed by wife. Drowsy with a dense left sided weakness, left homonymous hemianopia, and a fixed gaze palsy (to the right). Not attentive to his left side. Only past medical history is of Type 2 DM.
7) Should any further urgent imaging be considered?
CT angiogram
Case Study 2 (Mr A): 65-year-old gentleman. Keen gardener. Found collapsed by wife. Drowsy with a dense left sided weakness, left homonymous hemianopia, and a fixed gaze palsy (to the right). Not attentive to his left side. Only past medical history is of Type 2 DM.
8) What investigations should be done prior to discharge from hospital?
ECG
carotid US
BP
HbA1C
cholesterol
h your facilitator. For each patient, address the questions (in red) in turn as they appear on the slides, and feedback to the group via the discussion on blackboard, or by writing text on the slide and as directed by you moderator.. Patient Case 1 (Mrs R): 80-year-old lady. Normally independent. Presents with sudden onset of right leg weakness. Resolves in 30 minutes. Past medical history of hypertension, and type 2 DM. Ex-smoker. 1) Are Mrs R’s symptoms likely to have an underlying vascular cause? 1b) Why? 1c) Has Mrs R had a TIA or a stroke? 2a) could anything else of caused her symptoms? List common stroke mimics 2a) which lobes of the brain have been affected? 3) which blood vessel may have been occluded? 4) What further investigations should be considered and why? 5) What type of brain imaging is most useful in TIA?6) What is the likely aetiology and pathophysiology of Mrs R’s event? 7) What immediate treatments should be considered to prevent stroke? Case Study 2 (Mr A): 65-year-old gentleman. Keen gardener. Found collapsed by wife. Drowsy with a dense left sided weakness, left homonymous hemianopia, and a fixed gaze palsy (to the right). Not attentive to his left side. Only past medical history is of Type 2 DM.
9) What medical treatment options should be considered prior to discharge?
thrombolysis and thrombectomy
