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neurology > Ischaemic Stroke > Flashcards

Ischaemic Stroke Flashcards

1
Q

what is the stroke classification system?

A

bamford/oxford classification

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2
Q

what is a total anterior infarct (TACI) defined by?

A

contralateral hemiplegia or hemiparesis
AND
contralateral homoymous hemianopia
AND
higher cerebral dysfunction (e.g. asphasia, neglect)

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3
Q

what does a total anterior circulation infarct (TACI) involve?

A

anterior and middle cerebral arteries

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4
Q

what is a partial anterior circulation infarct (PACI) defined by?

A

2 of:
contralateral hemiplegia or hemiparesis
contralateral homonymous hemianopia
higher cerebral dysfunction (e.g. asphaia, neglect)

OR
higher cerebral dysfunction alone

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5
Q

what does a partial anterior circulation infarct (PACI) involve?

A

anterior or middle cerebral artery

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6
Q

what is a lacunar infarct (LACI) defined by?

A
  • pure motor stroke
  • pure sensory stroke
  • sensorimotor stroke
  • ataxic hemiparesis

NO visual field defect, higher cerebral dysfunction or brainstem dysfunction

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7
Q

what does a lacunar infarct (LACI) involve?

A

small deep perforating arteries, typically supplying internal capsule or thalamus

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8
Q

what is a posterior circulation infarct (POCI) defined by?

A
  • cerebellar dysfunction
  • conjugate eye movement disorder
  • bilateral motor/sensory deficit
  • ipsilateral cranial nerve palsy with contralateral motor/sensory deficit
  • cortical blindness/isolated hemianopia
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9
Q

what does a posterior circulation infarct (POCI) involve?

A

vertebrobasilar arteries and associated branches (supplying the cerebrellum, brainstem and occipital lobe)

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10
Q

what area of the brain do the anterior cerebral arteries supply?

A

medial and supero-medial edge of the cortex, along the falx cerebri

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11
Q

what area of the brain does the middle cerebral artery supply?

A

hemisphere (cortex and white matter)

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12
Q

what is the typical presentation of the occulsion of the left middle cerebral artery?

A

dysphasia

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13
Q

what are the clinical features of an acute basilar artery occulsion?

A

‘locked-in syndrome

  • quadriparesis (complete loss of movement)
  • preserved consciousness
  • preserved ocular movements - typically only vertical gaze
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14
Q

name posterior stroke syndromes

A
  • locked-in syndrome
  • lateral pontine syndrome
  • lateral medullary syndrome/wallenberg’s syndrome
  • medial midbrain syndrome/weber’s syndrome
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15
Q

what artery occlusion leads to locked-in syndrome?

A

basilar artery

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16
Q

what artery occulsion leads to lateral pontine syndrome?

A

anterior inferior cerebellar artery

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17
Q

what artery occlusion leads to weber’s syndrome (medial midbrain syndrome)?

A

branches of the posterior cerebral artery that supply the midbrain

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18
Q

what are the clinical features of the wallenberg’s syndrome (lateral medullary syndrome)?

A

DANVAH
* Dysphasia
* ipsilateral Ataxia
* ipsilateral Nystagmus
* Vertigo
* Anaesthesia (ispilateral facial numbness and contralateral pain loss on the body)
* ipsilateral Horner’s syndrome

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19
Q

what are the clinical features of weber’s syndrome (medial midbrain syndrome)?

A
  • ipsilateral oculomotor nerve (CN III) palsy
  • contralateral hemiparesis
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20
Q

what is the scoring system used to recognise stroke in the emergency setting?

A

ROSIER

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21
Q

what is the most common artery infarct in thromboembolic strokes?

A

middle cerebral artery territory

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22
Q

what artery occulsion leads to wallenberg’s syndrome (lateral medullary syndrome)?

A

posterior inferior cerebral artery

23
Q

what are the clinical features of lateral pontine syndrome?

A
  • ataxia
  • dysarthria
  • dysphagia
  • ipsilateral horner’s syndrome
  • ipsilateral loss of pain and temperature sensation on the face
  • contralateral loss of pain and temperature sensation over the contralateral body

AND ipsilateral facial paralysis (CN VII) OR hearing loss (CN VIII)

wallenberg’s syndrome + facial paralysis or deafness

24
Q

what is wernicke’s area responsible for?

A

understanding of speech

25
Q

what is broca’s area responsible for?

A

fluent speech

26
Q

what type of dysphasia would an infarct in wernicke’s area lead to?

A

receptive dysphasia
typically present with a patient speaking in ‘word salad’ as a result of their impaired understanding

patient can express but not understand

27
Q

what type of dysphasia would an infarct in broca’s area lead to?

A

expressive dysphasia
patient retains their understanding of speech but is having difficulty producing words of their own

patient can understand but not express

28
Q

what is the definition of an ischaemic stroke?

A

sudden onset focal neurological deficit of vascular aetiology, with symptoms last >24 hours (or with evidence of infarction on imaging)

29
Q

what precentage of strokes are ischaemic?

A

85%

30
Q

what are the causes of an ischaemic stroke?

A
  • intracranial small vessel atherosclerosis
  • large vessel atherosclerosis (e.g. carotid artery stenosis)
  • cardio-embolic pathology (e.g. AF)
  • primary vascular causes (e.g. vasculitis and arterial dissection)
  • haematological causes (e.g. prothrombotic states)
31
Q

what are the risk factors for ischaemic stroke?

A
  • age
  • male sex
  • family history of ischaemic stroke
  • hypertension
  • smoking
  • diabetes mellitus
  • atrial fibrillation
  • weaker risk factors = hypercholesterolaemia, obesity, poor diet, oestrogen-containing therapy, migraine
32
Q

what is the mnemonic for acute management of ischaemic stroke?

A

DR ABCDE
airway protection and aspiration precautions are very important

33
Q

what should be performed with suspected stroke?

A

CT head should be performed on arrival to distinguish ischaemic from haemorrhagic stroke

34
Q

what is the most sensitive test for confirming ischaemic infarct?

A

diffusion weighted MRI - used if the diagnosis is unclear

35
Q

what is the medical management of acute stroke?

A

alteplase (tissue plasminogen activator)

36
Q

what is the criteria for giving alteplase?

A

within 4.5 hours of symptoms onset with no contraindications to thrombolysis

37
Q

what are the contraindications to thrombolysis?

A
  • recent head trauma
  • GI or intracranial haemorrhage
  • recent surgery
  • acceptable BP
  • platelet count
  • INR
38
Q

when can mechanical thromboectomy be performed?

A
  • within 6 hours of symptom onset in anterior circulation strokes
  • within 12 hours of symptom onset in posterior circulation strokes
39
Q

what is the recommended aspirin dosing?

A
  • no hyperacute treatment = aspirin 300mg OD for 2 weeks
  • hyperacute treatment = aspirin started 24 hours post-treatment following repeat CT head
40
Q

what investigations are commenced post-acute ischaemic stroke?

A
  • carotid ultrasound
  • CT/MRI angiography
  • echocariogram
  • serum glucose
  • serum lipids
41
Q

what is the mneumonic for chronic ischaemic stroke management?

A

HALTSS

42
Q

what is the management of chronic ischaemic stroke?

A

H = hypertension -initiate antihypertensives 2 weeks post-stroke
A = antiplatelet therapy - clopidogrel 75mg OD
L = lipid-lowering therapy - atorvastatin 20-80mg OD
T = tobacco - smoking cessation
S = sugar - screened for diabetes
S = surgery - ipsilateral carotid artery stensosi requires carotid endarterectomy

43
Q

what is an embolus?

A

anything that moves through the blood vessels until it reaches a vessel that is too small to let it pass

44
Q

what is a thrombus?

A

blood clot that forms in a vein

45
Q

what type of clot typically occurs in a large blood vessel occlusion?

A

embolus
as to have a clinical stroke event, occlusion has to be sudden and almost complete which is unlikely if it is a thrombotic occlusion

if a large artery occludes slowly with thrombosis, collaterals form and the acute occlusion goes unrecognised

46
Q

where does large vessel infarcts typically occur?

A

cortex - produces cortical signs

47
Q

what are cortical signs?

A
  • left hemisphere (usually the dominant hemisphere)
  • dysphasia
  • agnosia
48
Q

what conditions mimic strokes?

A
  • migraine
  • post seizure focal deficits
  • hypoglycaemia
  • acute presentations of subacute/chronic pathology like SOL
  • demylination
  • bell’s palsy
  • non-organic states
49
Q

what is amaurosis fugax?

A

form of stroke that affects the retinal/ophthalmic artery

50
Q

what adverse side-effect do antipsychotics increase the risk of in elderly patients?

A

increased risk of stroke and VTE

51
Q

what blood tests should be performed in patients >55 years who have no obvious cause of stroke?

A
  • thrombophilia
  • autoimmune screening
52
Q

anterior cerebral artery stroke presentation

A
  • contralateral hemiparesis and sensory loss
  • lower extremities > upper
53
Q

middle cerebral artery stroke presentation

A
  • contralateral hemiparesis and sensory loss
  • upper extremities > lower
  • contralateral homonymous hemianopia
  • aphasia
54
Q

posterior cerebral artery stroke presentation

A
  • contralateral homonymous hemianopia with macular sparing
  • visual agnosia

neurology (20 decks)

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