Introduction to Stroke Flashcards
What is a stroke?
- a sudden loss of focal (meaning a specific location) cerebral function
- symptoms last >24 hours or death
In a stroke how long do the symptoms generally present for?
1 - 1-2 hours
2 - 6-8 hours
3 - 12-16 hours
4 - >24 hours or death
4 - >24 hours or death
What are the 2 most common causes of a stroke?
1 - spontaneous haemorrhage (blood vessel bursts)
2 - Ischemia (inadequate blood flow(
The 2 most common causes of a stroke are
1 - spontaneous haemorrhage
2 - Ischemia (inadequate blood flow)
What are the 2 main causes of an ischemia stroke?
- thrombosis = blood clot, or thrombus, grows in blood vessels of the brain
- embolus (referred to as an embolism) = blood clot develops elsewhere in the body and travels to the brain, blocking blood vessels
A transient Ischemia attack (TIA) differs to a stroke, how is this different?
- acute with symptoms for <24 hours
- loss of function can be focal (specific part of brain) cerebral for ocular (eye) and then relieve itself
A transient Ischemia attack (TIA) is an acute attack with symptoms lasting for <24 hours. It causes a loss of function that can be focal (specific part of brain) cerebral or ocular (eye). This is thought to be caused by an acute loss of blood flow. What are the 2 most common causes?
1 - thrombosis (growing blood clot)
2 - embolism (clot broken off in body and gets trapped in blood vessels in the brain)
- both could cause reduced blood flow on and off until blood vessels become completely blocked
Does a transient ischaemic attack (TIA) occur in isolation with no risks?
1 - yes just a mini stroke with no consequences
2 - increases the risk of a stroke
3 - increases risk of dementia
4 - increases the risk of vasculitis
2 - increases the risk of a stroke
- highest risk within days of TIA
- risk reduces only 3 months following subsidence of the symptoms
What does acute stroke syndrome refer to?
- period where it is not possible to distinguish between TIA and stroke
How many people a year are affected by strokes?
1 - 10,000
2 - 100,000
3 - 150,000
4 - 200,000
3 - 150,000
What % of people who have a stroke is fatal within the year of the stroke?
1 - 10%
2 - 25%
3 - 45%
4 - 75%
2 - 25%
What % of people who have a stroke then live with severe disability?
1 - 10%
2 - 25%
3 - 33%
4 - 75%
3 - 33.3%
What % of people who have a stroke are <65 years of age?
1 - 10%
2 - 25%
3 - 50%
4 - 75%
2 - 25%
What % of people who have a stroke has previously been preceded by a transient ischemic attack?
1 - 10%
2 - 20%
3 - 50%
4 - 75%
2 - 20%
What are the costs of stroke to the UK per year?
- £9 billion
What % of <65 year old survivors of a stroke are unable to return to work?
- nearly 70%
Are ischemic or haemorrhage strokes more common?
- ischemic accounts for aprox 85%
- far and above leading cause
What % of strokes are intracranial haemorrhage?
1 - 10%
2 - 20%
3 - 50%
4 - 75%
1 - 10%
What % of strokes are subarachnoid (bleeding in space around the brain) haemorrhage?
1 - 10%
2 - 5%
3 - 50%
4 - 75%
2 - 5%
- sub = below
- between subarachnoid and pia mater
What are the 3 most common causes of an ischemic attack?
1 - Large vessel-vessel thromboembolism (50%)
2 - Cardioembolic events (20%) (AF, endocarditis)
3 - Small vessel disease (25%) (diabetes, hypertension)
What is an Intracranial hemorrhage (ICH), also known as a intracranial bleed?
- bleeding within the skull
- not within the brain though
An intracranial hemorrhage (ICH), also known as a intracranial bleed is bleeding within the skill and not the brain specifically. What group of patients is most at risk to an ICH?
1 - diabetics
2 - hypertensives
3 - obese
4 - previous cancer
2 - hypertensives
- vessels under high pressure are more likely to rupture
What is an subarachnoid hemorrhage (ICH), which comes under the umbrella term of intracranial bleed?
- bleeding between subarachnoid and pia mater
- not in the brain though
What is a septic emboli?
- an infected blood clot
- such as sinusitis (swollen and inflamed sinuses)
Subarachnoid haemorrhage is bleeding into the space between the arachnoid and pia mater meninges. What is one of the most common causes of this?
1 - intracranial aneurysm
2 - head trauma
3 - infection
4 - medication
1 - intracranial aneurysm
- rupture of an intracranial aneurysm (weak blood vessel that bursts) or vascular malformation
Subarachnoid haemorrhage is bleeding into the space between the brain and the skull. The most common causes are a rupture of an intracranial aneurysm (weak blood vessel that bursts) or vascular malformation. What is the most common symptom of a subarachnoid haemorrhage?
1 - muscle weakness on one side of the body
2 - paralysis
3 - fever
4 - intense headache
4 - intense headache
Subarachnoid haemorrhage is bleeding into the space between the arachnoid and pia mater ;ayers of the meninges. One of the most common causes is a rupture of an intracranial aneurysm (weak blood vessel that bursts) or vascular malformation. The most common symptom of a subarachnoid haemorrhage is a severe acute headache. What can happen if this is missed?
- increased blood in brain increases intracranial pressure (ICP)
- increased ICP can damage and kill brain cells
- permanent brain damage
Why is addressing hypertension an important modification of risk stroke?
- patients with hypertension are at increased risk of intracranial haemorrhage
How can being aware and treating atrial fibrillation reduce the risk of a stroke?
- AF = a common heart rhythm disorder and increases the risk of virchow’s triad
- blood can pool in the atria forming blood clots
- if blood clot breaks away, forming an embolism it could travel to your brain and block it
Why is addressing carotid artery disease (CAD) (stenosis) an important modification of risk stroke?
- stenosis due to CAD can reduced blood flow
- internal coronary artery supplies the brain, so this would reduce blood flow
Why is addressing diabetes an important modification of risk stroke?
- increased sugar in your blood damages the blood vessels
- blood vessels can become stiff causing atherosclerosis
- this can then lead to blockage of blood vessels
Why is addressing obesity an important modification of risk stroke?
- increased risk of CVD, diabetes and hypertension
- all increase the risk of stroke
Why is addressing obesity an important modification of risk stroke?
- can lead to atrial fibrillation (AF) and virchow’s triad
- AF = a common heart rhythm disorder
- blood can pool in the atria forming blood clots
- if blood clot breaks away, forming an embolism it could travel to your brain and block it
- causing ischaemic stroke (most common 85%)
Why is addressing smoking an important modification of risk stroke?
- hypertension, CVD, atherosclerosis
- all increase risk of strokes
When you suspect a stroke, what imaging modality must be used and what are we imaging?
1 - 1st CT and/or MRI imaging
2 - ultrasound
3 - PET scan
1 - 1st CT and/or MRI imaging
When you suspect a stroke, what imaging modality must be used when we would want to investigate vascular pathology?
1 - CT
2 - MRI imaging
3 - MRI angiogram
4 - ultrasound
3 - MRI angiogram
- MRI that focusses on blood vessels
When you suspect a stroke, what imaging modality must be used if we suspect carotid stenosis due to a potential thrombosis?
1 - CT
2 - MRI imaging
3 - MRI angiogram
4 - carotid doppler
4 - carotid doppler
- doppler would identify a blockage of an blood vessel
When you suspect a stroke, what modality must be used if we suspect atrial fibrillation?
1 - ECG
2 - MRI imaging
3 - MRI angiogram
4 - carotid doppler
1 - ECG and cardiac monitoring
- blood pressure monitoring
- full blood counts
What is the Oxfordshire Community Stroke Project (OCSP) Classification for strokes?
- practical method for assessing management options for patients who have had a stroke
- understanding the pathophysiology of a stroke will drive treatment options
The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). What does total anterior circulation syndrome mean?
- a type of cerebral infarction
- entire anterior circulation supplying one side of the brain affected
- very serious affect on carotid artery
The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). A total anterior circulation syndrome (TACS) mean is a type of cerebral infarction. It affects the entire anterior circulation supplying one side of the brain. It is very serious and is affected by the carotid artery. What 3 presentations must be present for a diagnosis of TACS?
1 - unilateral motor weakness, higher cortical deficit, systemic visual field defects
2 - bilateral motor weakness, higher cortical deficit, homonymous visual field defect
3 - unilateral motor weakness, higher cortical deficit, homonymous visual field defect
4 - unilateral motor weakness, lower cortical deficit, homonymous visual field defect
homonymous visual = vision lost in one eye
3 - unilateral motor weakness, higher cortical deficit, homonymous visual field defect
The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). In order for a patient to be diagnosed with partial circulation syndrome (PACS) mean, how many of the following criteria must be met?
- unilateral motor weakness
- higher cortical deficit
- homonymous (one side of eye cannot see) visual field defect
- 2 of these features
The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). What does a lacunar stroke (LACS) mean?
1 - stroke affecting tissue, resembling a lacuna
2 - stroke affecting the lacunae blood vessels
3 - occlusion of blood vessels in the penetrating arteries in deep brain structures
3 - occlusion of blood vessels in the penetrating arteries in deep brain structures
- common type of ischaemic stroke
- can affect the basal ganglia
The Oxfordshire Community Stroke Project (OCSP) Classification for strokes is a classification system that is a simple clinical classification method that predicts the site and size of the infarct on cerebral tomography (CT). What does posterior circulation stroke syndrome (POCS) mean?
- damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem)
There are some salient points in Acute Stroke Management, which essentially means the faster a stroke is treated the better the clinical outcome. Plasminogen activators (tPA) are one key treatment that should be used acutely. What are tPAa?
1 - serine protease catalysing the activation of plasmin
2 - degrading embolisms
3 - degrading fibrinogen directly
4 - inhibiting coagulation of blood
1 - serine protease catalysing the activation of plasmin
- plasmin is important fibrinolysis, breakdown of fibrin, component of blood clots
- essentially stops blood embolism forming
There are some salient points in Acute Stroke Management, which essentially means the faster a stroke is treated the better the clinical outcome. Plasminogen activators (tPA) are one key treatment that should be used acutely. tPAa’s are serine proteases that catalyze the activation of plasmin, which is important fibrinolysis, breakdown of fibrin, component of blood clots, reducing the risk of an embolism. In acute ischaemic stoke presentation, how soon does this need to be given to reduce disability?
1 - <1 hour from stroke
2 - <2 hours from stroke
3 - <3 hours from stroke
4 - <4.5 hours from stroke
4 - <4.5 hours from stroke
Where should all patients with a suspected stroke be admitted to?
1 - GP
2 - emergency department
3 - ICU
4 - stroke ward
4 - stroke ward
In a subset (10%) of acute ischaemic stroke patients who demonstrate radiographic evidence of a proximal anterior circulation large vessel occlusion (proximal middle cerebral or distal internal carotid) within 6 hours of symptom onset, what treatment can offer distinct benefit?
1 - Plasminogen activators (tPA
2 - aspirin
3 - MRI angiogram
4 - mechanical thrombectomy
4 - mechanical thrombectomy
- minimally invasive technique to remove the blood clot
What are the 4 most common differentials that could present as a stroke, but are not a stroke?
1 - Space occupying lesion
2 - Seizure
3 - Migraine (e.g. hemiplegic)
4 - Functional neurological disorder
What is bells palsy?
- an unexplained episode of facial muscle weakness or paralysis
- sudden onset affecting whole side of the face
- damage or infection to the CN VII (7) the facial nerve
In addition to addressing the physical aspects of a stroke, what else must be taken into account in a patient who has had a stroke?
- post-stroke psychiatric co-morbidities
- associated with decreased likelihood of returning to work, poorer quality of life and long term disability
Patients who have suffered a stroke are more likely to suffer from phobic anxiety disorders. What are these?
- specific phobic disorders involve persistent, unrealistic, intense anxiety about and fear of specific situations, circumstances, or objects
Management of Neuropsychiatric Manifestations is important. Why is rehabilitation important?
- to return people back to previous level
- reduce atrophy, neural degeneration
Management of Neuropsychiatric Manifestations is important. Why are multidisciplinary collaborations important?
- it is a comorbidity affecting multiple parts of the body
What is homonymous hemianopia?
- hemi = greek for half
- an = greek for without
- opsia = greek for seeing
- loss of visual field side of the vertical midline
Homonymous hemianopia has greek origins in its name: hemi = greek for half, an = greek for without, opsia = greek for seeing. So loss of visual field side of the vertical midline. If the right or left side of the hemisphere is affected, which side will the loss of sight be on?
1 - right hemisphere damaged
left side of left eye and left side of right eye loss
2 - left hemisphere damaged
right side of left and right side of right eye loss
What does dysphasia mean?
- dys = greek for difficult
- phaots = spoken
- language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage
Dysphasia means difficulty speaking. Which 2 parts of the brain is crucial for speech?
1 - brodmann areas 22, 44 and 45
2 - brodmann areas 1, 2 and 3
3 - brodmann areas 4 and 17
4 - brodmann area 6
1 - brodmann areas 22, 44 and 45
- Wernicke’s area = brodmann area 22
- Brocas area = brodmann areas 44 and 45
A patient presents with sudden onset right sided weakness and dysphasia, dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous. Out of the following, which diagnosis would she have?
- Total anterior circulation syndrome (TACS)
- Partial anterior circulation stroke (PACS)
- Lacunar strokes (LACS)
- Posterior Circulation Stroke Syndromes (POCS)
- TACS because she has all 3 clinical presentations
1 = unilateral motor weakness 2 = higher cortical deficit 3 = homonymous visual field defect
A patient presents with sudden onset right sided weakness and dysphasia, dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous and is diagnosed with Total anterior circulation syndrome (TACS). She attends A&E within an hour of the symptoms starting, from the following treatments, which would be most appropriate?
1 - Aspirin and IV fluids and admit to stroke ward
2 - Thrombolysis only (plasminogen activator (tPA))
3 - Thrombectomy only
4 - Thrombolysis and thrombectomy
2 - Thrombolysis only with plasminogen activator (tPA)
- only good if within the first 4.5 hours of symptoms starting
Does the image below show an ischaemic or haemorrhagic stroke?
- haemorrhagic stroke
- white area is a bleed
Does the image below show an ischaemic or haemorrhagic stroke?
- blood clot so ischaemic
A patient presents with a left temporoparietal haemorrhage, and presents with speech disturbance, loss of balance on the right side and right homonymous hemianopia. She also has a history of hypertension, atrial fibrillation and is on warfarin. What is likely to be causing the haemorrhage?
1 - trauma from a fall
2 - hypertension
3 - obesity
4 - infection
2 - hypertension
- increased pressure in brain due to hypertension
- bleed made worse by blood thinning (warfarin)
A patient presents with a left temporoparietal haemorrhage, and presents with speech disturbance, loss of balance on the right side and right homonymous hemianopia. She also has a history of hypertension, atrial fibrillation and is on warfarin. Increased pressure in brain due to hypertension has likely made the blood vessels weak, hence the haemorrhage, and the bleed is made worse by blood thinning (warfarin). What are 2 important treatment options must be used on this patient?
1 - Aspirin and IV fluids and admit to stroke ward
2 - Thrombolysis only (plasminogen activator (tPA))
3 - prothrombin complex, vitamin K and surgery
4 - Thrombectomy
3 - prothrombin complex, vitamin K and surgery
- surgery to relieve the pressure
In the image below, we can see an embolism. Which of the following would this be based on the image below?
1 - Total anterior circulation syndrome (TACS)
2 - Partial anterior circulation stroke (PACS)
3 - Lacunar strokes (LACS)
4 - Posterior Circulation Stroke Syndromes (POCS)
3 - LACS as its small in deep brain tissue
- pure motor function would be affected
- deep brain tissue affected
In the image below, we can see an embolism due to a Lacunar strokes (LACS). We know this because the presenting patient only had motor function affected and we can see it is in the deep brain tissue that is affected. The patient was fine the night before but found collapsed the next day, what would be his initial treatment option?
1 - Aspirin and IV fluids and admit to stroke ward
2 - Thrombolysis only (plasminogen activator (tPA))
3 - prothrombin complex, vitamin K and surgery
4 - Thrombectomy
1 - Aspirin and IV fluids and admit to stroke ward
- beyond the 4.5 hours for Thrombolysis plasminogen activator (tPA)
- not proximal anterior circulation large vessel occlusion and beyond 6 hours for thrombectomy
What does photophobic mean?
- photo = light
- phobia = fear of
- sensitivity to light
What can we see on the head CT-scan below?
- migraine
What is a collateral history?
- information about the patient from the patient’s known contacts
If a patient presents with dysphasia (speech difficulty) and sensitivity to light, and has been off work previously due to severe headaches, is this likely to be a stroke or migraine?
- migraine
- can mimic a stroke
- can be triggered by stress, change of diet, hormonal changes, weather, alcohol etc
A 45 year old patient presents with left facial weakness involving the whole of left side of face, including the forehead and with incomplete closure of left eye. Has had a recent infection of sinuses and symptoms have been present for a few days. Is the diagnosis likely to be some form of a stroke or bells palsy?
- bells palsy
- affects CN VII (7) the facial nerve
- damage to or in infection of CN VII can cause bells palsy
- we can distinguish because bells palsy is a lower motor neuron problem
A 45 year old patient presents with eft facial weakness involving the whole of left side of face, including the forehead and with incomplete closure of left eye. Has had a recent infection of sinuses and symptoms have been present for a few days. The diagnosis is bells palsy. What is bells palsy?
- unexplained episode of facial muscle weakness or paralysis
- acute onset and worsens over 48 hours
- due to damage to CN VII the facial nerve
- key feature is that the lower motor neuron is affected
Although the cause of bells palsy is unknown, what is the most common precipitating factor that it has been linked with it?
1 - viral infection of sinuses
2 - trauma
3 - stroke
4 - hypertension
1 - viral infection of the sinuses
What does the image below show?
1 - TACS
2 - PACs
3 - left occipital tumour
4 - haemorrhage
3 - left occipital tumour
- can see different structure in occipital region
What are some of the most common things that can mimic a stroke that we need to be aware of?
- Seizures
- Tumour
- Migraine
- Bells palsy
- Hypoglycaemia
- Infection (and cerebral hypoperfusion)
- Subdural haemorrhage
- Functional disorder
